The Relationship Between Time Spent on Social Media and Adolescent Cigarette, E-cigarette, and Dual Use: A Longitudinal Analysis of the UK Millennium Cohort Study.

INTRODUCTION: To estimate the effect of social media use in 14 year olds on risk of and inequalities in cigarette, e-cigarette, and dual use at 17 years, using the UK-representative Millennium Cohort Study (born 2000-2002). AIMS AND METHODS: The relationship of time spent on social media (using questionnaires [n = 8987] and time-use-diaries [n = 2520]) with cigarette, e-cigarette, and dual use was estimated using adjusted odds ratios (AORs) or relative risk ratios (ARRRs). Effect modification was examined (using parental education as an indicator for socioeconomic circumstances) by comparing adjusted risk differences within low and high-parental education groups. Analyses accounted for prespecified confounders (identified via directed acyclic graphs), baseline outcome measures (to address reverse causality), sample design, attrition, and item-missingness (through multiple imputation). RESULTS: Time spent on social media was associated with increased risk of cigarette, e-cigarette, and dual use in a dose-response manner. Social media use for ≥2 hours/day (vs. 1-<30 minutes) was associated with increased cigarette (AOR 2.76 [95% confidence interval 2.19 to 3.48]), e-cigarette (3.24 [2.59 to 4.05]), and dual use (ARRR 4.11 [2.77 to 6.08]). The risk of cigarette use among 30 minutes-<1 hour/day users (vs. non-users) were smaller in those with high versus low parental education (ARDs 1.4% vs. 12.4%). Similar findings were observed across the higher time categories. Analyses using time-use-diaries, in complete case samples, and with additional adjustment for baseline outcome measures generally revealed similar findings. CONCLUSIONS: After accounting for observed confounders and potential reverse causality, findings suggest social media use increases the risk of cigarette, e-cigarette, and dual use in a dose-response manner. Guidance addressing adolescent online safety should be prioritized. IMPLICATIONS: This study's identification of a dose-response relationship and differential effects across socioeconomic groups, could assist in the development of guidance on time spent on social media. The adverse effects of social media use on adolescent cigarette, e-cigarette, and dual use supports legislation aimed at promoting adolescent online safety. Study findings strengthen calls to prohibit social media marketing of nicotine-related products and importantly highlight the need to increase awareness and understanding of the underlying algorithms which drive adolescent exposure to nicotine-related content on social media to ensure they are functioning in a way that best serves the adolescent population.

Association between care experience and mental health hospitalisation among children in Scotland, with a focus on chronic conditions (CHiCS): a population-wide longitudinal study using administrative data.

BACKGROUND: Chronic conditions in children are associated with an increased risk of mental health problems. However, not much is known about the nature of this association among care experienced children. We explore the association between three chronic conditions (epilepsy, asthma, and diabetes) and mental health hospitalisation in children with or without care experience. METHODS: The Children's Health in Care in Scotland (CHiCS) is a population-wide longitudinal study that links health and social care data for 13 830 care-experienced children (6274 [45%] female, 7556 [55%] male) and 649 771 general population children (319 438 [49%] female, 330 333 [51%] male). Hospitalisations were followed up from birth between 1990 and 2004, up to July 31, 2016 (when children were aged 12-27 years). We used Cox proportional hazards models with age as timescale to estimate hazard ratios (HR) and 95% CIs for first mental health hospitalisation separately among care-experienced children and general population children. FINDINGS: Among general population children, 3152 (0·49%) children had epilepsy, 94 700 (14·57%) had asthma, and 5501 (0·85%) had diabetes. In comparison, among care-experienced children, 160 (1·16%) children had epilepsy, 2242 (16·21%) had asthma, and 142 (1·03%) had diabetes. Care-experienced children were more likely to have mental health hospitalisations than general population children, with 701 cases (5·1%) versus 5225 cases (0·8%), respectively. Among general population children, out of all three chronic conditions, epilepsy showed the highest risk (HR 2·61, 95% CI 2·20-3·09) for first mental health hospitalisation, followed by diabetes (1·93, 1·62-2·31), and asthma (1·25, 1·16-1·34). Among care-experienced children, asthma showed an HR of 1·43 (1·17-1·74) for first mental health hospitalisation, whereas epilepsy (1·33, 0·70-2·52) and diabetes (1·71, 0·96-3·05) had no association with first mental health hospitalisation in this subgroup. INTERPRETATION: The study highlights the associations between chronic conditions and risk of mental health hospitalisation among children with or without care experience. One limitation of the study is the small number of care experienced children with a chronic condition and mental health hospitalisation, which might have contributed to the lack of association found among care-experienced children between epilepsy and mental health, and diabetes and mental health. Nevertheless, one of its strengths is contributing to the limited knowledge regarding this association. FUNDING: Economic and Social Research Council, Medical Research Council, Scottish Government Chief Scientist Office.

Social media use and health risk behaviours in young people: systematic review and meta-analysis.

OBJECTIVES: To examine the association between social media use and health risk behaviours in adolescents (defined as those 10-19 years). DESIGN: Systematic review and meta-analysis. DATA SOURCES: EMBASE, Medline, APA PsycINFO, SocINDEX, CINAHL, SSRN, SocArXic, PsyArXiv, medRxiv, and Google Scholar (1 January 1997 to 6 June 2022). METHODS: Health risk behaviours were defined as use of alcohol, drugs, tobacco, electronic nicotine delivery systems, unhealthy dietary behaviour, inadequate physical activity, gambling, and anti-social, sexual risk, and multiple risk behaviours. Included studies reported a social media variable (ie, time spent, frequency of use, exposure to health risk behaviour content, or other social media activities) and one or more relevant outcomes. Screening and risk of bias assessments were completed independently by two reviewers. Synthesis without meta-analysis based on effect direction and random-effects meta-analyses was used. Effect modification was explored using meta-regression and stratification. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluations). RESULTS: Of 17 077 studies screened, 126 were included (73 included in meta-analyses). The final sample included 1 431 534 adolescents (mean age 15.0 years). Synthesis without meta-analysis indicated harmful associations between social media and all health risk behaviours in most included studies, except inadequate physical activity where beneficial associations were reported in 63.6% of studies. Frequent (v infrequent) social media use was associated with increased alcohol consumption (odds ratio 1.48 (95% confidence interval 1.35 to 1.62); n=383 068), drug use (1.28 (1.05 to 1.56); n=117 646), tobacco use (1.85, 1.49 to 2.30; n=424 326), sexual risk behaviours (1.77 (1.48 to 2.12); n=47 280), anti-social behaviour (1.73 (1.44 to 2.06); n=54 993), multiple risk behaviours (1.75 (1.30 to 2.35); n=43 571), and gambling (2.84 (2.04 to 3.97); n=26 537). Exposure to content showcasing health risk behaviours on social media (v no exposure) was associated with increased odds of use of electronic nicotine delivery systems (1.73 (1.34 to 2.23); n=721 322), unhealthy dietary behaviours (2.48 (2.08 to 2.97); n=9892), and alcohol consumption (2.43 (1.25 to 4.71); n=14 731). For alcohol consumption, stronger associations were identified for exposure to user generated content (3.21 (2.37 to 4.33)) versus marketer generated content (2.12 (1.06 to 4.24)). For time spent on social media, use for at least 2 h per day (v <2 h) increased odds of alcohol consumption (2.12 (1.53 to 2.95); n=12 390). GRADE certainty was moderate for unhealthy dietary behaviour, low for alcohol use, and very low for other investigated outcomes. CONCLUSIONS: Social media use is associated with adverse health risk behaviours in young people, but further high quality research is needed to establish causality, understand effects on health inequalities, and determine which aspects of social media are most harmful. STUDY REGISTRATION: PROSPERO, CRD42020179766.

The relationship between time spent on social media and adolescent alcohol use: a longitudinal analysis of the UK Millennium Cohort Study.

BACKGROUND: To estimate the effect of social media use in 14 year olds on risk of and inequalities in alcohol use and binge drinking at 17 years. METHODS: Using the UK-representative Millennium Cohort Study, the relationship between time spent on social media (assessed using questionnaires [n = 8987] and time-use-diaries [n = 2520]) with frequency of alcohol use in the past month and binge drinking was estimated using adjusted odds ratios (AORs) or adjusted relative risk ratios (ARRRs). Associations within low and high parental education groups were compared to examine effect modification. Analyses accounted for pre-specified confounders, baseline outcome measures (to address reverse causality), sample design, attrition and item-missingness (through multiple imputation). RESULTS: Questionnaire-reported time spent on social media was associated with increased risk of alcohol use and binge drinking in a dose-response manner. Compared to 1-< 30 min/day social media users, 30 min-<1 h/day users were more likely to report alcohol use ≥6 times/month (ARRR 1.62 [95% confidence interval 1.20 to 2.20]) and binge drinking (AOR 1.51 [1.22 to 1.87]), as were 1-<2 h/day users (ARRR 2.61 [1.90 to 3.58]; AOR 2.06 [1.69 to 2.52]) and ≥2 h/day users (ARRR 4.80 [3.65 to 6.32]; AOR 3.07 [2.54 to 3.70]). Social media measured by time-use-diary was associated with higher risks, although not always demonstrating a dose-response relationship. The effect of social media use (vs no-use) on binge drinking was larger in the higher (vs lower) parental education groups. Analyses repeated in complete case samples, and with adjustment for baseline outcome measures revealed consistent findings. CONCLUSIONS: Findings suggest social media use may increase risk of alcohol use and binge drinking. Regulatory action protecting adolescents from harmful alcohol-related social media content is necessary.

Mapping Geographic Trends in Early Childhood Social, Emotional, and Behavioural Difficulties in Glasgow: 2010-2017.

Measuring variation in childhood mental health supports the development of local early intervention strategies. The methodological approach used to investigate mental health trends (often determined by the availability of individual level data) can affect decision making. We apply two approaches to identify geographic trends in childhood social, emotional, and behavioural difficulties using the Strengths and Difficulties Questionnaire (SDQ). SDQ forms were analysed for 35,171 children aged 4-6 years old across 180 preschools in Glasgow, UK, between 2010 and 2017 as part of routine monitoring. The number of children in each electoral ward and year with a high SDQ total difficulties score (≥15), indicating a high risk of psychopathology, was modelled using a disease mapping model. The total difficulties score for an individual child nested in their preschool and electoral ward was modelled using a multilevel model. For each approach, linear time trends and unstructured spatial random effects were estimated. The disease mapping model estimated a yearly rise in the relative rate (RR) of high scores of 1.5-5.0%. The multilevel model estimated an RR increase of 0.3-1.2% in average total scores across the years, with higher variation between preschools than between electoral wards. Rising temporal trends may indicate worsening social, emotional, and behavioural difficulties over time, with a faster rate for the proportion with high scores than for the average total scores. Preschool and ward variation, although minimal, highlight potential priority areas for local service provision. Both methodological approaches have utility in estimating and predicting children's difficulties and local areas requiring greater intervention.

The Best Services Trial (BeST?): a cluster randomised controlled trial comparing the clinical and cost-effectiveness of New Orleans Intervention Model with services as usual (SAU) for infants and young children entering care.

BACKGROUND: Abused and neglected children are at increased risk of health problems throughout life, but negative effects may be ameliorated by nurturing family care. It is not known whether it is better to place these children permanently with substitute (foster or adoptive) families or to attempt to reform their birth families. Previously, we conducted a feasibility randomised controlled trial (RCT) of the New Orleans Intervention Model (NIM) for children aged 0-60 months coming into foster care in Glasgow. NIM is delivered by a multidisciplinary health and social care team and offers families, whose child has been taken into foster care, a structured assessment of family relationships followed by a trial of treatment aiming to improve family functioning. A recommendation is then made for the child to return home or for adoption. In the feasibility RCT, families were willing to be randomised to NIM or optimised social work services as usual and equipoise was maintained. Here we present the protocol of a substantive RCT of NIM including a new London site. METHODS: The study is a multi-site, pragmatic, single-blind, parallel group, cluster randomised controlled superiority trial with an allocation ratio of 1:1. We plan to recruit approximately 390 families across the sites, including those recruited in our feasibility RCT. They will be randomly allocated to NIM or optimised services as usual and followed up to 2.5 years post-randomisation. The principal outcome measure will be child mental health, and secondary outcomes will be child quality of life, the time taken for the child to be placed in permanent care (rehabilitation home or adoption) and the quality of the relationship with the primary caregiver. DISCUSSION: The study is novel in that infant mental health professionals rarely have a role in judicial decisions about children's care placements, and RCTs are rare in the judicial context. The trial will allow us to determine whether NIM is clinically and cost-effective in the UK and findings may have important implications for the use of mental health assessment and treatment as part of the decision-making about children in the care system.

How do Pregnant Women with Additional Health or Social Care Needs Experience Parenting Groups: Evidence from Delivery of Enhanced Triple P for Baby and Mellow Bumps as Part of the Trial of Healthy Relationships Initiatives in the Very Early Years (THRIVE).

There is still relatively little known about when, why, how and in what circumstances parenting interventions are effective. Support within the group context has been theorised as a key mechanism. This paper explores how pregnant women with additional health or social care needs participating in two group parenting interventions-Mellow Bumps or Enhanced Triple P for Babies-experienced being in a parenting group, and how this shaped how they engaged with the interventions; and it examines how group delivery may have facilitated or inhibited the effectiveness of the interventions, and for whom it did so. Session evaluation forms (n = 708) and a post-intervention questionnaire (n = 117) were completed by participants. In-depth interviews were conducted following the MB/ETPB antenatal sessions (n = 19), and 6-12 months after the birth of their baby (n = 15). Group delivery of these parenting interventions had the potential to support participants, particularly those with multiple additional health and social care needs. There are, however, important caveats including patchy attendance reducing the supportiveness of the groups, and few discernible longer terms changes. More group sessions, less patchy attendance, and more encouragement from facilitators for the women to keep in touch, and to join other community parent-child groups after the birth of their baby are likely to have increased feelings of support and connectedness.

Cohort profile: The 'Children's Health in Care in Scotland' (CHiCS) study-a longitudinal dataset to compare health outcomes for care experienced children and general population children.

PURPOSE: The Children's Health in Care in Scotland Cohorts were set up to provide first population-wide evidence on the health outcomes of care experienced children (CEC) compared with children in the general population (CGP). To date, there are no data on how objective health outcomes, mortality and pregnancies for CEC are different from CGP in Scotland. PARTICIPANTS: The CEC cohort includes school-aged children who were on the 2009/2010 Scottish Government's Children Looked After Statistics (CLAS) return and on the 2009 Pupil Census (PC). The children in the general population cohort includes those who were on the 2009 PC and not on any of the CLAS returns between 1 April 2007 and 31 July 2016. FINDINGS TO DATE: Data on a variety of health outcomes, including mortality, prescriptions, hospitalisations, pregnancies, and Accident & Emergency attendances, were obtained for the period 1 August 2009 to 31 July 2016 for both cohorts. Data on socioeconomic status (SES) for both cohorts were available from the Birth Registrations and a small area deprivation measure was available from the PC. CEC have, on average, lower SES at birth and live in areas of higher deprivation compared with CGP. A higher proportion of CEC have recorded events across all health data sets, and they experienced higher average rates of mortality, prescriptions and hospitalisations during the study period. The reasons for contacting health services vary between cohorts. FUTURE PLANS: Age-standardised rates for the two cohorts by sex and area deprivation will be calculated to provide evidence on population-wide prevalence of main causes of death, reasons for hospitalisation and types of prescription. Event history analysis will be used on matched cohorts to investigate the impact of placement histories and socioeconomic factors on health.

Recruiting hard-to-reach pregnant women at high psychosocial risk: strategies and costs from a randomised controlled trial.

BACKGROUND: Recruiting participants to randomised controlled trials (RCTs) is often challenging, particularly when working with socially disadvantaged populations who are often termed 'hard-to-reach' in research. Here we report the recruitment strategies and costs for the Trial for Healthy Relationship Initiatives in the Very Early years (THRIVE), an RCT evaluating two group-based parenting interventions for pregnant women. METHODS: THRIVE aimed to recruit 500 pregnant women with additional health and social care needs in Scotland between 2014 and 2018. Three recruitment strategies were employed: (1) referrals from a health or social care practitioner or voluntary/community organisation (practitioner-led referral), (2) direct engagement with potential participants by research staff (researcher-led recruitment) and (3) self-referral in response to study advertising (self-referral). The number of referrals and recruited participants from each strategy is reported along with the overall cost of recruitment. The impact of recruitment activities and the changes in maternity policy/context on recruitment throughout the study are examined. RESULTS: THRIVE received 973 referrals: 684 (70%) from practitioners (mainly specialist and general midwives), 273 (28%) from research nurses and 16 (2%) self-referrals. The time spent in antenatal clinics by research nurses each month was positively correlated with the number of referrals received (r = 0.57; p < 0.001). Changes in maternity policies and contexts were reflected in the number of referrals received each month, with both positive and negative impacts throughout the trial. Overall, 50% of referred women were recruited to the trial. Women referred via self-referral, THRIVE research nurses and specialist midwives were most likely to go on to be recruited (81%, 58% and 57%, respectively). Key contributors to recruitment included engaging key groups of referrers, establishing a large flexible workforce to enable recruitment activities to adapt to changes in context throughout the study and identifying the most appropriate setting to engage with potential participants. The overall cost of recruitment was £377 per randomised participant. CONCLUSIONS: Recruitment resulted from a combination of all three strategies. Our reflections on the successes and challenges of these strategies highlight the need for recruitment strategies to be flexible to adapt to complex interventions and real-world challenges. These findings will inform future research in similar hard-to-reach populations. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number Registry ISRCTN21656568 . Retrospectively registered on 28 February 2014.

Correction to: Trial of healthy relationship initiatives for the very early years (THRIVE), evaluating Enhanced Triple P for Baby and Mellow Bumps for those with additional social and care needs during pregnancy and their infants who are at higher risk of maltreatment: study protocol for a randomised controlled trial.

Following publication of the original article [1], it has been brought to our attention that an error was slipped into the article's title.

Trial of healthy relationship initiatives for the very early years (THRIVE), evaluating Enhanced Triple P for Baby and Mellow Bumps additional social and care needs during pregnancy and their infants who are at higher risk of maltreatment: study protocol for a randomised controlled trial.

BACKGROUND: Growing evidence suggests that experiences in the early years play a major role in children's development in terms of health, wellbeing and educational attainment. The Trial of healthy relationship initiatives for the very early years (THRIVE) aims to evaluate two antenatal group interventions, Enhanced Triple P for Baby and Mellow Bumps, designed for those with additional health or social care needs in pregnancy. As both interventions aim to improve maternal mental health and parenting skills, we hypothesise that in the longer term, participation may lead to an improvement in children's life trajectories. METHODS: THRIVE is a three-arm, longitudinal, randomised controlled trial aiming to recruit 500 pregnant women with additional health or social care needs. Participants will be referred by health and social care professionals, predominately midwives. Consenting participants will be block randomised to one of the three arms: Enhanced Triple P for Baby plus care as usual, Mellow Bumps plus care as usual or care as usual. Groups will commence when participants are between 20 and 34 weeks pregnant. DISCUSSION: The population we aim to recruit are traditionally referred to as "hard to reach", therefore we will monitor referrals received from maternity and social care pathways and will be open to innovation to boost referral rates. We will set geographically acceptable group locations for participants, to limit challenges we foresee for group participation and retention. We anticipate the results of the trial will help inform policy and practice in supporting women with additional health and social care needs during antenatal and early postnatal periods. This is currently a high priority for the Scottish and UK Governments. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) Registry, ISRCTN:21656568 . Registered on 28 February 2014 (registered retrospectively (by 3 months)).

A realist process evaluation of Enhanced Triple P for Baby and Mellow Bumps, within a Trial of Healthy Relationship Initiatives for the Very Early years (THRIVE): study protocol for a randomized controlled trial.

BACKGROUND: THRIVE is a three-arm randomised controlled trial (RCT) that aims to evaluate whether antenatal and early postnatal interventions, Enhanced Triple B for Baby (ETPB) plus care as usual (CAU) or Mellow Bumps (MB) plus CAU (versus CAU alone), can: 1) improve the mental health and well-being of pregnant women with complex health and social care needs; 2) improve mother-infant bonding and interaction; 3) reduce child maltreatment; and 4) improve child language acquisition. This paper focuses on THRIVE's realist process evaluation, which is carefully monitoring what is happening in the RCT. METHODS: Realistic evaluation provides the theoretical rationale for the process evaluation. We question: 1) how faithfully are MB and ETPB implemented? 2) What are the mechanisms by which they work, if they do, and who do they work for and how? 3) What contextual factors are necessary for the programmes to function, or might prevent them functioning? The mixed-methods design includes quantitative measures, which are pre- and post-training/intervention questionnaires for facilitators and mothers-to-be, and post-session evaluation forms. Qualitative data collection methods include participant observation of facilitator training and the delivery of a series of antenatal sessions in selected intervention groups (n = 3 for ETPB and n = 3 for MB), semi-structured interviews with facilitators, pregnant women, partners, and referring facilitators, and telephone interviews examining the content of the postnatal components of ETPB and MB. DISCUSSION: The findings of this process evaluation will help researchers and decision makers interpret the outcomes of THRIVE. It will provide a greater understanding of: how the interventions work (if they do); the extent and quality of their implementation; contextual factors facilitating and constraining intervention functioning; variations in response within and between subgroups of vulnerable parents; and benefits or unintended consequences of either intervention. Few studies to date have published detailed research protocols illustrating how realist process evaluation is designed and conducted as an integral part of a randomised controlled trial. TRIAL REGISTRATION: ISRCTN, ISRCTN21656568 . Registered on 8 November 2013.

Poly-substance use and sexual risk behaviours: a cross-sectional comparison of adolescents in mainstream and alternative education settings.

BACKGROUND: Surveys of young people under-represent those in alternative education settings (AES), potentially disguising health inequalities. We present the first quantitative UK evidence of health inequalities between AES and mainstream education school (MES) pupils, assessing whether observed inequalities are attributable to socioeconomic, familial, educational and peer factors. METHODS: Cross-sectional, self-reported data on individual- and poly-substance use (PSU: combined tobacco, alcohol and cannabis use) and sexual risk-taking from 219 pupils in AES (mean age 15.9 years) were compared with data from 4024 pupils in MES (mean age 15.5 years). Data were collected from 2008 to 2009 as part of the quasi-experimental evaluation of Healthy Respect 2 (HR2). RESULTS: AES pupils reported higher levels of substance use, including tobacco use, weekly drunkenness, using cannabis at least once a week and engaging in PSU at least once a week. AES pupils also reported higher levels of sexual health risk behaviours than their MES counterparts, including: earlier sexual activity; less protection against sexually transmitted infections (STIs); and having 3+ lifetime sexual partners. In multivariate analyses, inequalities in sexual risk-taking were fully explained after adjusting for higher deprivation, lower parental monitoring, lower parent-child connectedness, school disengagement and heightened intentions towards early parenthood among AES vs MES pupils. However, an increased risk (OR = 1.73, 95% CI 1.15, 2.60) of weekly PSU was found for AES vs MES pupils after adjusting for these factors and the influence of peer behaviours. CONCLUSION: AES pupils are more likely to engage in health risk behaviours, including PSU and sexual risk-taking, compared with MES pupils. AES pupils are a vulnerable group who may not be easily targeted by conventional population-level public health programmes. Health promotion interventions need to be tailored and contextualised for AES pupils, in particular for sexual health and PSU. These could be included within interventions designed to promote broader outcomes such as mental wellbeing, educational engagement, raise future aspirations and promote resilience.

Providing sex and relationships education for looked-after children: a qualitative exploration of how personal and institutional factors promote or limit the experience of role ambiguity, conflict and overload among caregivers.

OBJECTIVES: To explore how personal and institutional factors promote or limit caregivers promoting sexual health and relationships (SHR) among looked-after children (LAC). In so doing, develop existing research dominated by atheoretical accounts of the facilitators and barriers of SHR promotion in care settings. DESIGN: Qualitative semistructured interview study. SETTING: UK social services, residential children's homes and foster care. PARTICIPANTS: 22 caregivers of LAC, including 9 foster carers, 8 residential carers and 5 social workers; half of whom had received SHR training. METHODS: In-depth interviews explored barriers/facilitators to SHR discussions, and how these shaped caregivers' experiences of discussing SHR with LAC. Data were systematically analysed using predetermined research questions and themes identified from reading transcripts. Role theory was used to explore caregivers' understanding of their role. RESULTS: SHR policies clarified role expectations and increased acceptability of discussing SHR. Training increased knowledge and confidence, and supported caregivers to reflect on how personally held values impacted practice. Identified training gaps were how to: (1) Discuss SHR with LAC demonstrating problematic sexual behaviours. (2) Record the SHR discussions that had occurred in LAC's health plans. Contrary to previous findings, caregivers regularly discussed SHR with LAC. Competing demands on time resulted in prioritisation of discussions for sexually active LAC and those 'at risk' of sexual exploitation/harm. Interagency working addressed gaps in SHR provision. SHR discussions placed emotional burdens on caregivers. Caregivers worried about allegations being made against them by LAC. Managerial/pastoral support and 'safe care' procedures minimised these harms. CONCLUSIONS: While acknowledging the existing level of SHR promotion for LAC there is scope to more firmly embed this into the role of caregivers. Care needs to be taken to avoid role ambiguity and tension when doing so. Providing SHR policies and training, promoting interagency working and providing pastoral support are important steps towards achieving this.

The reflective component of the Mellow Bumps parenting intervention: Implementation, engagement and mechanisms of change.

Understanding why parenting programmes work or do not work, and for whom, is crucial for development of more effective parenting interventions. In this paper we focus on a specific component of Mellow Bumps: reflection on one's own childhood/past/life. We explore how this component was implemented, how participants engaged with it, the facilitating and constraining factors shaping this, whether and how it appeared to work, or not, and for whom. The paper analyses data from the Process Evaluation of the Trial of Healthy Relationships Initiatives for the Very Early years, which is evaluating two antenatal interventions delivered to vulnerable women, one of which is Mellow Bumps. Data were collected from January 2014 to June 2018 for 28 groups, 108 participants and 24 facilitators in a comprehensive and rigorous Process Evaluation designed to complement the Outcome Evaluation. Data were gathered at various time points using multiple methods, and were synthesised to triangulate findings. The reflective component was implemented with fidelity and participants engaged with it to varying degrees, dependent largely on the coherence of the group. Patchy attendance compromised the coherence of some groups, with the development of rapport, which is key to delivering reflective exercises, more difficult when group composition varied from week to week. Where there was a coherent group, powerful mechanisms of change, leading to stress reduction, included: relief through unburdening, empowerment through support given and received, reduced isolation through sharing anxieties, and control through self-care advice. A minority of highly vulnerable mothers seemed not to benefit from the reflective exercises and were marginalised within their groups. In order to minimise potential harmful effects of such exercises, allocation of participants to groups should strive to maximise group homogeneity. More research is needed to explore how very vulnerable parents can be supported in attending parenting interventions from start to finish.

Enhancing Outcomes of Low-Intensity Parenting Groups Through Sufficient Exemplar Training: A Randomized Control Trial.

Low-intensity parenting groups, such as the Triple P-Positive Parenting Program Discussion Groups, appear to be a cost-effective intervention for child conduct problems. Several studies evaluating a Triple P Discussion Group on disobedience found promising results for improving child and parent outcomes. However, a sufficient exemplar training approach that incorporates generalization promotion strategies may assist parents to more flexibly apply positive parenting principles to a broader range of child target behaviors and settings, leading to greater change. We compared the effects of sufficient exemplar training to an existing narrowly focused low-intensity intervention. Participants were 78 families with a 5-8 year-old child. Sufficient exemplar training resulted in more robust changes in child behavior and superior outcomes for mothers on measures of parenting behavior, parenting self-efficacy, mental health, and perceptions of partner support at post-intervention and 6-month follow-up. These results indicate that teaching sufficient exemplars may promote generalization leading to enhanced intervention outcomes.

Mental health promotion for young people - the case for yoga in schools.

BACKGROUND: Mental wellbeing among young people is deteriorating. Poor mental wellbeing can be related to unmanaged stress. Adverse Childhood Experiences are widespread and result in young people having stressful lives. Stress has many manifestations, and coping with it can lead to risky health-related behaviours. MAIN BODY: A safe, scientifically-supported, efficient and effective set of stress-reduction skills is provided by the practice of yoga. At present, yoga is available privately, not publicly. After appropriately designed and evaluated interventions, the public provision of yoga could be integrated within the school curriculum, thereby reducing the high prevalence of prescription medication and offering a preventative strategy to promote positive mental health among young people. SHORT CONCLUSION: We suggest that the long-term benefits of an investment in a curriculum-embedded school-based yoga programme would do much to reduce stress both now for future generations.