Jacqueline Barnes

Effects of fully-established Sure Start Local Programmes on 3-year-old children and their families living in England: a quasi-experimental observational study

BACKGROUND Sure Start Local Programmes (SSLPs) are area-based interventions to improve services for young children and their families in deprived communities, promote health and development, and reduce inequalities. We therefore investigated whether SSLPs affect the wellbeing of 3-year-old children and their families. METHODS In a quasi-experimental observational study, we compared 5883 3-year-old children and their families from 93 disadvantaged SSLP areas with 1879 3-year-old children and their families from 72 similarly deprived areas in England who took part in the Millennium Cohort Study. We studied 14 outcomes-childrens immunisations, accidents, language development, positive and negative social behaviours, and independence; parenting risk; home-learning environment; fathers involvement; maternal smoking, body-mass index, and life satisfaction; familys service use; and mothers rating of area. FINDINGS After we controlled for background factors, we noted beneficial effects associated with the programmes for five of 14 outcomes. Children in the SSLP areas showed better social development than those in the non-SSLP areas, with more positive social behaviour (mean difference 0.45, 95% CI 0.09 to 0.80, p=0.01) and greater independence (0.32, 0.18 to 0.47, p<0.0001). Families in SSLP areas showed less negative parenting (-0.90, -1.11 to -0.69, p<0.0001) and provided a better home-learning environment (1.30, 0.75 to 1.86, p<0.0001). These families used more services for supporting child and family development than those not living in SSLP areas (0.98, 0.86 to 1.09, p<0.0001). Effects of SSLPs seemed to apply to all subpopulations and SSLP areas. INTERPRETATION Children and their families benefited from living in SSLP areas. The contrast between these and previous findings on the effect of SSLPs might indicate increased exposure to programmes that have become more effective. Early interventions can improve the life chances of young children living in deprived areas.

International Collaborative Study of Intracytoplasmic Sperm Injection–Conceived, In Vitro Fertilization–Conceived, and Naturally Conceived 5-Year-Old Child Outcomes: Cognitive and Motor Assessments

Objective. To date, very few studies have been conducted on the neurodevelopmental well-being of children conceived through intracytoplasmic sperm injection (ICSI). The limitations of these studies often include a lack of comparison with a demographically matched, naturally conceived (NC) group and the investigation of only very young children, with relatively small samples sizes. One study showed that there were no differences in IQ scores among ICSI-conceived, in vitro fertilization (IVF)-conceived, and NC children at 5 years of age. Unfortunately, psychomotor development was not assessed in that study. Because findings regarding these childrens cognitive and motor development are inconclusive, the aim of this study was to shed more light on the cognitive and motor development of 5-year-old ICSI-conceived children. Methods. A total of 511 ICSI-conceived children were compared with 424 IVF-conceived children and 488 NC controls. Children were recruited in 5 European countries, ie, Belgium, Denmark, Greece, Sweden, and the United Kingdom. Participation rates ranged from 45% to 96% in the ICSI and IVF groups and from 34% to 78% in the NC group. Cognitive and motor development was assessed with the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) and McCarthy Scales of Childrens Abilities (MSCA) Motor Scale, respectively. The WPPSI-R consists of 2 major scales, ie, Verbal and Performance, each including 6 subtests. The 6 Performance Scale subtests are object assembly, geometric design, block design, mazes, picture completion, and animal pegs. The 6 Verbal Scale subtests are information, comprehension, arithmetic, vocabulary, similarities, and sentences. Scores on the Performance and Verbal Scale subtests are summed to yield the performance IQ (PIQ) and verbal IQ (VIQ), respectively. Scores on both the Performance Scale and the Verbal Scale yield the full-scale IQ (FSIQ). IQ scales have a mean score of 100 and a SD of 15. Each subtest has a mean score of 10 and a SD of 3. The MSCA consists of 6 scales, ie, Verbal, Perceptual-Performance, Quantitative, General Cognitive, Memory, and Motor Scale. In this study, only the Motor Scale was administered. This scale assesses the childs coordination during performance of a variety of gross- and fine-motor tasks. Leg coordination, arm coordination, and imitative action tests provide measures of gross-motor ability. Draw-a-design and draw-a-child assess fine-motor coordination, as revealed by the levels of hand coordination and finger dexterity. The mean score for this test is 50, with a SD of 10. Results. No differences were identified among ICSI, IVF, and NC children with respect to VIQ, PIQ, or FSIQ scores of the WPPSI-R. Furthermore, there were no differences between groups regarding the discrepancy between VIQ and PIQ scores. These results were not influenced by gender, country, or maternal educational level. However, in the subgroup of firstborn children with mothers who gave birth at an older age (33–45 years), NC children obtained significantly better VIQ and FSIQ scores than did children conceived through assisted reproductive technologies. These differences in VIQ and FSIQ scores between ICSI/IVF and NC children were relative, because NC children scored <1 IQ point higher than ICSI/IVF children. Therefore, these scores show no clinical relevance. For Verbal Scale subtests, variables such as age of the mother at the time of the birth, educational level of the mother, and gender and nationality of the child interacted with mode of conception, resulting in clinically irrelevant differences between scores for the ICSI/IVF and NC groups on the arithmetic, vocabulary, and comprehension subtests. For Performance Scale subtests, these same demographic factors interacted with mode of conception for the block design, object assembly, and animal pegs subtests, again resulting in clinically irrelevant differences among groups. In the 3 groups (ICSI, IVF, and NC), we observed equal numbers of children scoring below 1 SD from the mean on the WPPSI-R and the MSCA. Conclusions. This study includes a substantial number of children from several European countries. Apart from a few interaction effects between mode of conception and demographic variables, no differences were found when ICSI, IVF, and NC scores on the WPPSI-R and MSCA Motor Scale were compared. Nevertheless, the aforementioned interaction effects could indicate that demographic variables such as maternal age at the time of the birth and maternal educational level play different roles in the cognitive development of IVF and ICSI children, compared with NC children. Additional research is needed to explore and verify this finding. Previous studies revealed that ICSI children, in comparison with NC children, more frequently obtained scores below 1 SD from the mean on 3 subtests of the Performance Scale (object assembly, block design, and mazes) or showed a trend of 5.2% of ICSI children, compared with 2.5% of IVF children and 0.9% of NC children, obtaining a score below 1 SD from the mean, but those findings were not confirmed in this study. Here no differences were found among the 3 groups in the numbers of children scoring below 1 SD from the mean on the VIQ, PIQ, and FSIQ tests and the Verbal and Performance Scale subtests. Motor development results were somewhat more conclusive. There were no differences between the scores of ICSI, IVF, and NC children on the MCSA Motor Scale. No interaction effects were found between mode of conception and demographic variables, indicating that these results are not influenced by gender, nationality, maternal educational level, or maternal age at the time of the birth. Furthermore, equal proportions of children in all 3 groups scored below 1 SD from the mean. The results of this study are reassuring for parents who conceived through ICSI (or IVF). The findings indicate that the motor and cognitive development of their offspring is very similar to that of NC children. However, demographic factors such as maternal educational level and maternal age at the time of the birth might play different roles in the cognitive development of ICSI and IVF children, compared with NC children.

The influence of maternal depression, caregiving, and socioeconomic status in the post-natal year on children's language development

BACKGROUND Post-natal depression is common and has been associated with adverse effects on childrens later emotional and behavioural development. The evidence for effects on childrens cognitive development is unclear but this could potentially be a major public health issue. The aim was to examine whether maternal depression and maternal caregiving during the first year of life are associated with childrens subsequent language development. METHODS One thousand two hundred and one women were recruited from antenatal and post-natal baby clinics in two areas in England, and followed up until their babies were 3 years. Mothers and children were assessed by questionnaire, interview and home observation; 999 childrens language was assessed at 36 months, although 55 were excluded principally because they had been exposed to insufficient English. RESULTS In bivariate analyses maternal depressive symptomatology in the post-natal year but not at 36 months was associated with poorer child language at 36 months; maternal caregiving, was positively associated with language. Structural Equation Modelling revealed that depression was associated with poorer caregiving but was not independently associated with language. Higher quality caregiving at 10 months was associated with better language. When the sample was split by socioeconomic factors the effects of depression on caregiving were stronger in the less advantaged group. In both groups poorer quality early caregiving predicted lower language outcome. CONCLUSIONS Post-natal depression had a negative effect on caregiving, which in turn affected language; post-natal depression did not have an additional direct effect on language. Socioeconomic factors moderated the effects of depression on caregiving. When targeting interventions at mothers with post-natal depression, it may be strategic to focus on lower socioeconomic groups at higher risk.

Psychological disorder amongst refugee and migrant schoolchildren in London

Abstract.Background:Refugee and migrant children are likely to be exposed to many of the risk factors for emotional and behavioural problems. These children form a significant proportion of the school population in London and other inner cities in the UK. However, there are very little epidemiological data available on their mental health. In this study, we aimed to examine the prevalence of psychological problems among refugee and migrant schoolchildren compared to their UK-born peers.Method:A cross-sectional investigation using the Strengths and Difficulties Questionnaire (SDQ) examined in association with socio-demographic variables including language preference.Results:Almost a quarter of schoolchildren might be described as having a need, with migrant and refugee children showing greater psychological distress on a number of the sub-scales of the SDQ. Language appears to be an important variable associated with distress.

The health and development of children born to older mothers in the United Kingdom: observational study using longitudinal cohort data

Objective To assess relations between children’s health and development and maternal age. Design Observational study of longitudinal cohorts. Setting Millennium Cohort Study (a random sample of UK children) and the National Evaluation of Sure Start study (a random sample of children in deprived areas in England), 2001 to 2007. Participants 31 257 children at age 9 months, 24 781 children at age 3 years, and 22 504 at age 5 years. Main outcome measures Childhood unintentional injuries and hospital admissions (aged 9 months, 3 years, and 5 years), immunisations (aged 9 months and 3 years), body mass index, language development, and difficulties with social development (aged 3 and 5 years). Results Associations were independent of personal and family characteristics and parity. The risk of children having unintentional injuries requiring medical attention or being admitted to hospital both declined with increasing maternal age. For example, at three years the risk of unintentional injuries declined from 36.6% for mothers aged 20 to 28.6% for mothers aged 40 and hospital admissions declined, respectively, from 27.1% to 21.6%. Immunisation rates at nine months increased with maternal age from 94.6% for mothers aged 20 to 98.1% for mothers aged 40. At three years, immunisation rates reached a maximum, at 81.3% for mothers aged 27, being lower for younger and older mothers. This was linked to rates for the combined measles, mumps, and rubella immunisation because excluding these resulted in no significant relation with maternal age. An increase in overweight children at ages 3 and 5 years associated with increasing maternal age was eliminated once maternal body mass index was included as a covariate. Language development was associated with improvements with increasing maternal age, with scores for children of mothers aged 20 being lower than those of children of mothers aged 40 by 0.21 to 0.22 standard deviations at ages 3 and 4 years. There were fewer social and emotional difficulties associated with increasing maternal age. Children of teenage mothers had more difficulties than children of mothers aged 40 (difference 0.28 SD at age 3 and 0.16 SD at age 5). Conclusion Increasing maternal age was associated with improved health and development for children up to 5 years of age.

Maternal Prepregnancy BMI and Child Cognition: A Longitudinal Cohort Study

OBJECTIVE: To examine the association between maternal prepregnancy BMI and cognitive performance in children at 5 and 7 years of age. METHODS: This is a secondary analysis of data from the Millennium Cohort Study, a prospective population based cohort of 19 517 children in the United Kingdom. Standardized cognitive assessments of children, involving components of the British Ability Scales, second edition and a number skills test, were performed at 5 and 7 years of age. Principal components analysis was used to identify a general cognitive ability factor (g) from individual test scores. Maternal prepregnancy BMI was retrospectively self-reported when children were 9 months old. Mixed-effects linear regression models were fitted, controlling for multiple socio-demographic factors, child’s birth weight, child’s BMI, maternal smoking, and maternal diabetes. Complete data were available for 11 025 children at 5 years, and 9882 children at 7 years. RESULTS: Maternal prepregnancy BMI was negatively associated with children’s cognitive performance (g) at age 5 (P = .0069) and age 7 (P < .0001). The overall effect size was modest: a 10-point increase in maternal BMI was associated with a decrease in cognitive performance of ∼1/10th of an SD at age 7. CONCLUSIONS: Maternal prepregnancy BMI is negatively associated with children’s cognitive performance, even after adjusting for multiple socio-demographic confounders and children’s BMI. The relationship appears to become stronger as children get older, although the overall effect size is modest. In utero fetal programming or residual confounding may explain these findings.

Health of children conceived after preimplantation genetic diagnosis: a preliminary outcome study.

A preliminary study was conducted on health of children conceived after preimplantation genetic screening and diagnosis (PGD). Forty-nine children were assessed with 66 matched naturally conceived (NC) controls. Primary outcome was neurodevelopmental screening, and secondary outcomes were evidence of other health problems and assessment of parent-child relationships. Study and control children were well matched across relevant socio-demographic variables. Growth parameters at mean age 18 months were normal. The mean Griffiths quotient was 102.7 (+/-13.1) (PGD) and 103.3 (+/-12.8) (NC), both of which were within the normal range, and did not differ significantly. PGD cases were more likely to be lighter, at <2500 g (12 children, 24.5% versus one child 1.5%, P < 0.0001) and born earlier than controls (38.2 +/- 2.6 versus 40.0 +/- 1.4 weeks; P < 0.0001), consistent with other similar studies. PGD families showed no evidence of excess stress in their relationship with their child. The PGD group had significantly higher scores on the warmth-affection sub-scale (P = 0.042), and significantly lower scores on the aggression-hostility and rejection sub-scales (P = 0.030) of the questionnaire. The study showed no major ill effects from PGD on the child health. A larger study is needed to confirm the validity of this conclusion.

Concerns about body shape and weight in the postpartum period and their relation to women's self‐identification

The purpose of this qualitative study was to examine how three groups of women, with different levels of eating disorder psychopathology, perceived and coped with changes in eating and body shape and weight following pregnancy and the birth of a baby. Furthermore, we aimed to find out how such changes influenced their identity as mothers. Twenty‐one mothers were selected from a large survey of womens eating habits and attitudes in the postnatal period: mothers with an eating disorder (n = 6), mothers who were at risk for eating disorder (n = 9) and a comparison group without such concerns (n = 6). They were interviewed in detail about their eating habits and attitudes to body shape and weight and a variety of related issues. Thematic analyses of the transcripts identified five themes: (i) loss of the pre‐pregnancy self; (ii) life transitions; (iii) feeding relationship with infant; (iv) new relationship with family members; and (v) role within wider society. Differences were identified between the groups. For example, mothers with eating disorders tended to perceive the external world as more negative and critical about their new maternal selves. Mothers in the comparison group seemed better able to ‘prioritize’ and tolerate their babys dependency on their bodies, discussing breastfeeding in relation to infant needs rather than their own body needs. Comparison mothers were also more able to reflect on the implications of the changes in shape (and loss of their former slim selves). The findings suggest that the postnatal period may be a vulnerable time for mothers with eating difficulties. Previous life transitions seemed to be relevant to this life‐changing transition.

Evaluation and value of Sure Start

A decade ago, the Cross-Departmental Review of Services for Young Children concluded that disadvantage among young children was increasing and it was more likely that poor outcomes could be prevented when early intervention was undertaken.1 The review also noted that current services were uncoordinated and patchy, and recommended that there should be a change in service design and delivery. It suggested that programmes should be jointly planned by all relevant bodies and be area based, with all children under 4 years old and their families in an area being clients. In July 1998, the then Chancellor of the Exchequer, Gordon Brown, introduced Sure Start, which is aimed at providing quality services for children under 4 years old and their parents.2 The original intent of the programme design was to focus on the 20% most deprived areas, which included around 51% of children in families with incomes 60% or less than the national median (official poverty line).3 Over 3 years, £542 million was made available, with £452 million designated for England. In England, 250 programmes were planned by 2001–2002to support 187 000 children, 18% of poor children under 4 years old. Typically, a programme was to include 800 children under 4 years old, with £1250 per annum per child at the peak of funding. Programmes were to run for at least 10 years with funding peaking at year 3 and declining from year 6 to none at year 10. Some funding would fall to local authorities, made available by “reshaping” services. This investment utterly transformed early-year services while representing a relatively small contribution from the perspective of treasury—just 0.05% of public expenditure. In this brief summary, we cover the history and impact of this ambitious initiative. While more than 40 reports and peer-reviewed publications have documented the different …

Evidence based medicine and evaluation of mental health services: methodological issues and future directions

It is becoming increasingly evident that paediatricians and general practitioners play a key role in assessing and treating children with mental health problems. A recent national survey in England and Wales found that paediatricians are probably treating more emotional and behavioural disorders in children and young people than any other single professional group and that, on average, this group of patients comprises one fifth of their referrals. 1 In one large survey in the UK, almost one quarter of 7‐12 year olds from a large urban area visiting their general practitioner had a psychiatric disorder, 2 and more than half of the children attending a child mental health clinic in a six month period had been referred by their general practitioner. 3 In the USA, a large study of 7‐11 year old children referred to paediatric clinics found that almost one quarter had a diagnosable mental health disorder, with a further 42% showing threshold disorders. 4