Developing a survey to measure nursing students' knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study.

BACKGROUND: Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada's legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses' (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students' knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. METHODS: The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada. RESULTS: During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies. DISCUSSION: Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students' attitudes toward MAiD in a Canadian context. CONCLUSION: The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

An exploration of service use pattern changes and cost analysis following implementation of community perinatal mental health teams in pregnant women with a history of specialist mental healthcare in England: a national population-based cohort study.

BACKGROUND: The National Health Service in England pledged >£365 million to improve access to mental healthcare services via Community Perinatal Mental Health Teams (CPMHTs) and reduce the rate of perinatal relapse in women with severe mental illness. This study aimed to explore changes in service use patterns following the implementation of CPMHTs in pregnant women with a history of specialist mental healthcare in England, and conduct a cost-analysis on these changes. METHODS: This study used a longitudinal cohort design based on existing routine administrative data. The study population was all women residing in England with an onset of pregnancy on or after 1st April 2016 and who gave birth on or before 31st March 2018 with pre-existing mental illness (N = 70,323). Resource use and costs were compared before and after the implementation of CPMHTs. The economic perspective was limited to secondary mental health services, and the time horizon was the perinatal period (from the start of pregnancy to 1-year post-birth, ~ 21 months). RESULTS: The percentage of women using community mental healthcare services over the perinatal period was higher for areas with CPMHTs (30.96%, n=9,653) compared to areas without CPMHTs (24.72%, n=9,615). The overall percentage of women using acute care services (inpatient and crisis resolution teams) over the perinatal period was lower for areas with CPMHTs (4.94%, n=1,540 vs. 5.58%, n=2,171), comprising reduced crisis resolution team contacts (4.41%, n=1,375 vs. 5.23%, n=2,035) but increased psychiatric admissions (1.43%, n=445 vs. 1.13%, n=441). Total mental healthcare costs over the perinatal period were significantly higher for areas with CPMHTs (fully adjusted incremental cost £111, 95% CI £29 to £192, p-value 0.008). CONCLUSIONS: Following implementation of CPMHTs, the percentage of women using acute care decreased while the percentage of women using community care increased. However, the greater use of inpatient admissions alongside greater use of community care resulted in a significantly higher mean cost of secondary mental health service use for women in the CPMHT group compared with no CPMHT. Increased costs must be considered with caution as no data was available on relevant outcomes such as quality of life or satisfaction with services.

Community perinatal mental health teams and associations with perinatal mental health and obstetric and neonatal outcomes in pregnant women with a history of secondary mental health care in England: a national population-based cohort study.

BACKGROUND: Women with a pre-existing severe mental disorder have an increased risk of relapse after giving birth. We aimed to evaluate associations of the gradual regional implementation of community perinatal mental health teams in England from April, 2016, with access to mental health care and with mental health, obstetric, and neonatal outcomes. METHODS: For this cohort study, we used the national dataset of secondary mental health care provided by National Health Service England, including mental health-care episodes from April 1, 2006, to March 31, 2019, linked at patient level to the Hospital Episode Statistics, and birth notifications from the Personal Demographic Service. We included women (aged ≥18 years) with an onset of pregnancy from April 1, 2016, who had given birth to a singleton baby up to March 31, 2018, and who had a pre-existing mental disorder, defined as contacts with secondary mental health care in the 10 years immediately before pregnancy. The primary outcome was acute relapse, defined as psychiatric hospital admission or crisis resolution team contact in the postnatal period (first year after birth). Secondary outcomes included any secondary mental health care in the perinatal period (pregnancy and postnatal period) and obstetric and neonatal outcomes. Outcomes were compared according to whether a community perinatal mental health team was available before pregnancy, with odds ratios (ORs) adjusted for time trends and maternal characteristics (adjORs). FINDINGS: Of 807 798 maternity episodes in England, we identified 780 026 eligible women with a singleton birth, of whom 70 323 (9·0%) had a pre-existing mental disorder. A postnatal acute relapse was found in 1117 (3·6%) of 31 276 women where a community perinatal mental health team was available and in 1745 (4·5%) of 39 047 women where one was unavailable (adjOR 0·77, 95% CI 0·64-0·92; p=0·0038). Perinatal access to any secondary mental health care was found in 9888 (31·6%) of 31 276 women where a community perinatal mental health team was available and 10 033 (25·7%) of 39 047 women where one was not (adjOR 1·35, 95% CI 1·23-1·49; p<0·0001). Risk of stillbirth and neonatal death was higher where a community perinatal mental health team was available (165 [0·5%] of 30 980 women) than where it was not (151 [0·4%] of 38 693 women; adjOR 1·34, 95% CI 1·09-1·66; p=0·0063), as was the risk of a baby small for gestational age (2227 [7·2%] of 31 030 women vs 2542 [6·6%] of 38 762 women; adjOR 1·10, 1·02-1·20; p=0·016), whereas preterm birth risk was lower (3167 [10·1%] of 31 206 women vs 4341 [11·1%] of 38 961; adjOR 0·86, 0·74-0·99; p=0·032). INTERPRETATION: The regional availability of community perinatal mental health teams reduced the postnatal risk of acute relapse and increased the overall use of secondary mental health care. Community perinatal mental health teams should have close links with maternity services to avoid intensive psychiatric support overshadowing obstetric and neonatal risks. FUNDING: The National Institute for Health and Care Research.

Experience and Reporting of Postnatal Depression Across Cultures: A Comparison Using Anchoring Vignettes of Mothers in the United Kingdom and India.

Postnatal mental health is often assessed using self-assessment questionnaires in epidemiologic research. Differences in response style, influenced by language, culture, and experience, may mean that the same response may not have the same meaning in different settings. These differences need to be identified and accounted for in cross-cultural comparisons. Here we describe the development and application of anchoring vignettes to investigate the cross-cultural functioning of the Edinburgh Postnatal Depression Scale (EPDS) in urban community samples in India (n = 549) and the United Kingdom (n = 828), alongside a UK calibration sample (n = 226). Participants completed the EPDS and anchoring vignettes when their children were 12-24 months old. In an unadjusted item-response theory model, UK mothers reported higher depressive symptoms than Indian mothers (d = 0.48, 95% confidence interval: 0.358, 0.599). Following adjustment for differences in response style, these positions were reversed (d = -0.25, 95% confidence interval: -0.391, -0.103). Response styles vary between India and the United Kingdom, indicating a need to take these differences into account when making cross-cultural comparisons. Anchoring vignettes offer a valid and feasible method for global data harmonization.

Obstetric and neonatal outcomes in pregnant women with and without a history of specialist mental health care: a national population-based cohort study using linked routinely collected data in England.

BACKGROUND: Pregnant women with pre-existing mental illnesses have increased risks of adverse obstetric and neonatal outcomes compared with pregnant women without pre-existing mental illnesses. We aimed to estimate these differences in risks according to the highest level of pre-pregnancy specialist mental health care, defined as psychiatric hospital admission, crisis resolution team (CRT) contact, or specialist community care only, and the timing of the most recent care episode in the 7 years before pregnancy. METHODS: Hospital and birth registration records of women with singleton births between April 1, 2014, and March 31, 2018 in England were linked to records of babies and records from specialist mental health services provided by the England National Health Service, a publicly funded health-care system. We compared the risks of adverse pregnancy outcomes, including fetal and neonatal death, preterm birth, and babies being born small for gestational age (SGA; birthweight <10th percentile), and composite indicators for neonatal adverse outcomes and maternal morbidity, between women with and without a history of contact with specialist mental health care. We calculated odds ratios adjusted for maternal characteristics (aORs), using logistic regression. FINDINGS: Of 2 081 043 included women (mean age 30·0 years; range 18-55 years; 77·7% White, 11·4% South Asian, 4·7% Black, and 6·2% mixed or other ethnic background), 151 770 (7·3%) had at least one pre-pregnancy specialist mental health-care contact. 7247 (0·3%) had been admitted to a psychiatric hospital, 29 770 (1·4%) had CRT contact, and 114 753 (5·5%) had community care only. With a pre-pregnancy mental health-care contact, risk of stillbirth or neonatal death within 7 days of birth was not significantly increased (0·45-0·49%; aOR 1·11, 95% CI 0·99-1·24): risk of preterm birth (<37 weeks) increased (6·5-9·8%; aOR 1·53, 1·35-1·73), as did risk of SGA (6·2- 7·5%; aOR 1·34, 1·30-1·37) and neonatal adverse outcomes (6·4-8·4%; aOR 1·37, 1·21-1·55). With a pre-pregnancy mental health-care contact, risk of maternal morbidity increased slightly from 0·9% to 1·0% (aOR 1·18, 1·12-1·25). Overall, risks were highest for women who had a psychiatric hospital admission any time or a mental health-care contact in the year before pregnancy. INTERPRETATION: Information about the level and timing of pre-pregnancy specialist mental health-care contacts helps to identify women at increased risk of adverse obstetric and neonatal outcomes. These women are most likely to benefit from dedicated community perinatal mental health teams working closely with maternity services to provide integrated care. FUNDING: National Institute for Health Research.

What do software startups need from UX work?

Empirical research on software development practices in startups is growing. However, little has been investigated about how User eXperience (UX) work has been carried out in software startups. The primary objective of this paper is to investigate what software startups need from UX work. To achieve this goal, we conducted open-ended interviews and retrospective meetings with 16 software professionals from two software startups in Brazil. We analysed the data qualitatively using different coding approaches: initial coding, focused coding, and theoretical coding. We found 14 UX work-related needs which emerged from the daily practices used for software development in the two startups studied. Based on our findings, we propose an initial theoretical framework that highlights two theoretical themes and four groups underlying the needs identified. Our study reveals several relationships between UX work-related needs which are helpful to understand in order to identify what startups need from UX work in practice and to focus startup teams' efforts on the most urgent needs. As future work, we plan to explore ways in which these needs may be addressed so that UX work may be put into practice in software startups.

A Comparison of Non-verbal Maternal Care of Male and Female Infants in India and the United Kingdom: The Parent-Infant Caregiving Touch Scale in Two Cultures.

Differences in infant caregiving behavior between cultures have long been noted, although the quantified comparison of touch-based caregiving using uniform standardized methodology has been much more limited. The Parent-Infant Caregiving Touch scale (PICTS) was developed for this purpose and programming effects of early parental tactile stimulation (stroking) on infant hypothalamic-pituitary adrenal (HPA)-axis functioning (stress-response system), cardiovascular regulation and behavioral outcomes, similar to that reported in animals, have now been demonstrated. In order to inform future studies examining such programming effects in India, we first aimed to describe and examine, using parametric and non-parametric item-response methods, the item-response frequencies and characteristics of responses on the PICTS, and evidence for cross-cultural differential item functioning (DIF) in the United Kingdom (UK) and India. Second, in the context of a cultural favoring of male children in India, we also aimed to test the association between the sex of the infant and infant "stroking" in both cultural settings. The PICTS was administered at 8-12 weeks postpartum to mothers in two-cohort studies: The Wirral Child Health and Development Study, United Kingdom (n = 874) and the Bangalore Child Health and Development Study, India (n = 395). Mokken scale analysis, parametric item-response analysis, and structural equation modeling for categorical items were used. Items for two dimensions, one for stroking behavior and one for holding behavior, could be identified as meeting many of the criteria required for Mokken scales in the United Kingdom, only the stroking scale met these criteria in the sample from India. Thus, while a comparison between the two cultures was possible for the stroking construct, comparisons for the other non-verbal parenting constructs within PICTS were not. Analyses revealed higher rates of early stroking being reported for the United Kingdom than India, but no sex differences in rates in either country and no differential sex difference by culture. We conclude that PICTS items can be used reliably in both countries to conduct further research on the role of early tactile stimulation in shaping important child development outcomes.

Breast may not always be best: moderation of effects of postnatal depression by breastfeeding and infant sex.

BACKGROUND: There is good evidence that female infants are particularly vulnerable to poor emotional outcomes following in utero glucocorticoid exposure. It is currently unclear whether such effects might persist into the postnatal period for breastfed infants, as maternal cortisol is expressed in breastmilk and is influenced by maternal psychological distress. We pre-registered hypotheses that maternal postnatal depression would be associated with infant negative emotionality, and that this effect would be moderated by breastfeeding status and infant sex. METHODS: We analysed data from the Wirral Child Health and Development Study (WCHADS), a prospective epidemiological study starting in pregnancy. Nine weeks after birth mothers self-reported depressive symptoms and breastfeeding status, and reported infant negative emotionality using the distress to limits subscale of the infant behaviour questionnaire (IBQ-R) when their infant was aged 9 weeks and 14 months. Maximum likelihood estimations made use of data from 857 mother-infant pairs. RESULTS: At 9 weeks of age, maternal postnatal depressive symptoms were positively associated with infant distress to limits; however, this effect was not moderated by infant sex or breastfeeding. At age 14 months, the association between postnatal depression symptoms and distress to limits was greatest in the breastfed females, whereas the association was smaller, but still significant, in the non-breastfed females. For males, the association was non-significant in both the breastfed and non-breastfed groups. A test of sex difference between breastfed males and females was significant. CONCLUSIONS: We provide evidence that effects of maternal postnatal depression on child emotional outcomes are moderated by breastfeeding status and differ by infant sex. Female vulnerability to elevated maternal breastmilk glucocorticoids may, at least in part, explain these effects.

Interplay between long-term vulnerability and new risk: Young adolescent and maternal mental health immediately before and during the COVID-19 pandemic.

BACKGROUND: We examine whether there has been an increase in young adolescent and maternal mental health problems from pre- to post-onset of the COVID-19 pandemic. METHODS: Children aged 11-12 years and their mothers participating in a UK population-based birth cohort (Wirral Child Health and Development Study) provided mental health data between December 2019 and March 2020, and again 3 months after lockdown, 89% (N = 202) of 226 assessed pre-COVID-19. Emotional and behavioural problems were assessed by self- and maternal reports, and long-term vulnerability by maternal report of prior child adjustment, and maternal prenatal depression. RESULTS: The young adolescents reported a 44% (95% confidence interval [CI: 23%-65%]) increase in symptoms of depression and 26% (95% CI [12%-40%]) for post-traumatic stress disorder, with corresponding maternal reports of child symptoms of 71% (95% CI [44%-99%]) and 43% (95% CI 29%-86%). Disruptive behaviour problem symptoms increased by 76% (95% CI [43%-109%]) particularly in children without previous externalising symptoms. Both female gender and having had high internalising symptoms earlier in childhood were associated with elevated rates of depression pre-pandemic, and with greater absolute increases during COVID-19. Mothers' own depression symptoms increased by 42% (95% CI [20%-65%]), and this change was greater among mothers who had prenatal depression. No change in anxiety was observed among children or mothers. None of these increases were moderated by COVID-19-related experiences such as frontline worker status of a parent. Prior to the pandemic, rates of maternal and child depression were greater in families experiencing higher deprivation, but changed only in less deprived families, raising their rates to those of the high deprivation group. CONCLUSIONS: COVID-19 has led to a marked increase in mental health problems in young adolescents and their mothers with concomitant requirements for mental health services to have the resources to adapt to meet the level and nature of the needs.

A systematic review of the association between perinatal depression and cognitive development in infancy in low and middle-income countries.

The association between perinatal depression and infant cognitive development has been well documented in research based in high-income contexts, but the literature regarding the same relationship in low and middle-income countries (LMICs) is less developed. The aim of this study is to systematically review what is known in this area in order to inform priorities for early intervention and future research in LMICs. The review protocol was pre-registered on Prospero (CRD42018108589) and relevant electronic databases were searched using a consistent set of keywords and 1473 articles were screened against the eligibility criteria. Sixteen articles were included in the review, seven focusing on the antenatal period, eight on the postnatal period, and one which included both. Five out of eight studies found a significant association between antenatal depression (d = .21-.93) and infant cognitive development, while four out of nine studies found a significant association with postnatal depression (d = .17-.47). Although the evidence suggests that LMICs should prioritise antenatal mental health care, many of the studies did not adequately isolate the effects of depression in each period. Furthermore, very few studies explored more complex interactions that may exist between perinatal depression and other relevant factors. More high-quality studies are needed in LMIC settings, driven by current theory, that test main effects and examine moderating or mediating pathways to cognitive development.

Anxiety and depressive symptoms in pregnancy predict low birth weight differentially in male and female infants-findings from an urban pregnancy cohort in India.

PURPOSE: This study examined the contributions of antenatal anxiety, depression, and partner violence to low birth weight (LBW) in infants and to sex-specific birth weight outcomes among mothers from a cohort in urban India. METHODS: Data from 700 mothers from the PRAMMS cohort (Prospective Assessment of Maternal Mental Health Study) were used. Pregnant women were assessed in each trimester-T1, T2 and T3, for symptoms of anxiety, and depression as well as partner violence. Multivariate analyses were performed for the whole sample and then for male and female infants separately. The final multivariable logistic regression models were each built using a backward selection procedure and controlling for confounders. To accommodate longitudinally measured data, change in scores (T2-T1 and T3-T2) of anxiety and depression were included in the model. RESULTS: Of the 583 women with a singleton live birth, birth weight was available for 514 infants  and LBW was recorded in 80 infants (15.6%). Of these, 23 infants were preterm. Overall, higher T1 Depression scores (OR: 1.11; 95% CI 1.040, 1.187) and an increase in both Depression scores (OR: 1.12; 95% CI 1.047, 1.195) from T1 to T2 and Anxiety scores (OR: 1.32; 95% CI 1.079, 1.603) between T2 and T3 were predictors of LBW. Female infants had a higher chance of LBW with increase in maternal anxiety between T1-T2 (OR: 1.69; 95% CI 1.053, 2.708) and T2-T3 (OR: 1.49; 95% CI 1.058, 2.086); partner violence during pregnancy just failed to reach conventional statistical significance (OR: 2.48; 95% CI 0.810, 7.581) in girls. Male infants had a higher chance of LBW with higher baseline depression scores at T1 (OR: 1.23; 95% CI 1.042, 1.452) and an increase in depression scores (OR: 1.25; 95% CI 1.060, 1.472) from T1 to T2. CONCLUSION: Increasing prenatal anxiety and depressive symptoms in different trimesters of pregnancy were associated with LBW with sex-specific patterns of association in this sample from a Low and Middle Income Country.

The feasibility of using videos to assess maternal sensitivity in low income urban settings in India - The researcher's perspective.

Maternal sensitivity is one of the parenting dimensions associated with optimal child outcomes. Video-recording mother-child interactions is an objective and methodologically accurate way to assess maternal sensitivity. This research method is widely used in Western settings, but data is lacking in low-and-middle-income countries. We present findings drawn from the Bangalore Child Health and Development Study on the feasibility of video-recording interactions in low income home settings in India. Cultural, personal and practical advantages reported by researchers and strategies implemented to overcome barriers are described in the present letter to inform researchers who intend to use this method in non-Western populations.

A psychometric and validity study of callous-unemotional traits in 2.5 year old children.

Callous-unemotional (CU) traits are associated with severe and stable antisocial behaviour in childhood and adolescence. In order to understand the earliest origins of CU traits we need first to know whether measurement is reliable and valid in young children. This study evaluated the psychometric properties and validity of a CU traits measure generated from existing child problem behaviour scales at age 2.5 years. The participants were members of an epidemiological longitudinal study starting in pregnancy. Items from the Antisocial Process Screening Device and other problem behaviour scales were subjected to exploratory and confirmatory factor analysis. Structural equation modelling was used to test whether age 2.5 CU traits showed incremental validity in predicting aggression at age 5. The CU measure showed acceptable psychometric properties, factorial invariance by sex and good stability. Incremental prediction to later aggression was evident in girls, whereas boys showed strong continuity in aggression not found for girls.

Do stress and anxiety in early pregnancy affect the progress of labor: Evidence from the Wirral Child Health and Development Study.

INTRODUCTION: Despite widespread belief that anxiety causes longer labor, evidence of association is inconsistent. Data gathered as part of a prospective epidemiological longitudinal study were used to investigate associations between antenatal anxiety and pregnancy-specific stress, and labor progression was assessed by duration and use of augmentation. MATERIAL AND METHODS: Pregnant primiparous women completed measures for anxiety and pregnancy-specific stress at 20 weeks' gestation (n = 1145). Birth outcome data were extracted from medical records. Regression analyses and a path analysis assessed associations between antenatal anxiety and pregnancy-specific stress, and indices of labor progression (labor duration and augmentation). RESULTS: Anxiety/pregnancy-specific stress were not directly associated with duration of stage 1 labor (HIGH/LOW anxiety: mean difference = 13.94 minutes, SD = 20.66, 95% CI -26.60 to 54.49, P < .50)/(HIGH/LOW pregnancy-specific stress: mean difference = 12.05 minutes, SD = 16.09, 95% CI -19.52 to 43.63, P < .45). However, anxiety/pregnancy-specific stress were associated with epidural use (HIGH/LOW anxiety: 39% vs 31%, P < .042; HIGH/LOW pregnancy-specific stress: 38% vs 29%, P < .001), which was itself associated with longer labor (mean difference: 158.79 minutes, SD = 16.76, 95% CI 125.89-191.68, P < .001). Anxiety and pregnancy-specific stress were associated with increased likelihood of augmentation but these associations were nonsignificant after accounting for epidural, which was itself highly associated with augmentation. However, path analysis indicated an indirect effect linking pregnancy-specific stress, but not general anxiety, to labor duration and augmentation: elevated pregnancy-specific stress led to greater use of epidural, which was linked to both increased rates of augmentation, and increased labor duration. CONCLUSIONS: Contrary to general belief, general anxiety and specific pregnancy stress were not directly linked to longer duration of stage one labor. However specific pregnancy stress was associated with epidural use, which in turn was significantly associated with risk of augmentation, and longer stage one labor. Identification of pregnancy-specific stress could help to identify women for whom psychological interventions could improve birth experience.

Emotion Recognition Performance in Children with Callous Unemotional Traits is Modulated by Co-occurring Autistic Traits.

OBJECTIVE: Atypical emotion recognition (ER) is characteristic of children with high callous unemotional (CU) traits. The current study aims to 1) replicate studies showing ER difficulties for static faces in relation to high CU-traits; 2) test whether ER difficulties remain when more naturalistic dynamic stimuli are used; 3) test whether ER performance for dynamic stimuli is moderated by eye-gaze direction and 4) assess the impact of co-occurring autistic traits on the association between CU and ER. METHODS: Participants were 292 (152 male) 7-year-olds from the Wirral Child Health and Development Study (WCHADS). Children completed a static and dynamic ER eye-tracking task, and accuracy, reaction time and attention to the eyes were recorded. RESULTS: Higher parent-reported CU-traits were significantly associated with reduced ER for static expressions, with lower accuracy for angry and happy faces. No association was found for dynamic expressions. However, parent-reported autistic traits were associated with ER difficulties for both static and dynamic expressions, and after controlling for autistic traits, the association between CU-traits and ER for static expressions became non-significant. CU-traits and looking to the eyes were not associated in either paradigm. CONCLUSION: The finding that CU-traits and ER are associated for static but not naturalistic dynamic expressions may be because motion cues in the dynamic stimuli draw attention to emotion-relevant features such as eyes and mouth. Further, results suggest that ER difficulties in CU-traits may be due, in part, to co-occurring autistic traits. Future developmental studies are required to tease apart pathways toward the apparently overlapping cognitive phenotype.

Governing the second deep transition towards a circular economy: How rules emerge, align and diffuse.

The recently developed Deep Transitions framework has so far been mainly used to explore the first deep transition towards industrial modernity. This paper looks at a potential second deep transition towards a circular economy, which is hoped to lead to a more sustainable global economic system. Our focus is on exploring the role of the EU in developing and diffusing this emerging set of rules. We draw on ideas from the international relations literature to explain why and how the EU adopted the idea of a circular economy, helped formulate it into a set of rules and how it promoted its international diffusion. The paper concludes with lessons about the case and critical reflections about the Deep Transitions framework. In particular, we argue for taking a more actor-based approach when researching the unfolding second deep transition.

Sex differences in foetal origins of child emotional symptoms: a test of evolutionary hypotheses in a large, general population cohort.

BACKGROUND: Based on previous findings from the Wirral Child Health and Development Study (WCHADS), and on evolutionary hypotheses, we preregistered analyses of data from a large epidemiological sample (https://osf.io/fn5g9/register/564d31db8c5e4a7c9694b2be), to test for sex-dependent moderation by prenatal maternal depressive symptoms of the association between postnatal maternal depressive symptoms and child emotional problems. METHODS: A total of 8,354 mothers and children were followed from pregnancy to 3.5 years in the Avon Longitudinal Study of Parents and Children (ALSPAC). Self-report measures of prenatal and postnatal maternal depressive symptoms, and maternal report of child emotional symptoms were administered. RESULTS: There was a three-way interaction between maternal prenatal and postnatal depression, and child sex (Coeff .042 95% CI 0.015 to 0.068, p = .002). This arose from moderation by prenatal depression, in opposite directions in boys and in girls. In boys, the association between postnatal depression and child emotional symptoms was weaker following lower prenatal depressive symptoms (interaction term coeff = .030, p = .001), and in girls, to a lesser extent, the association was stronger following lower prenatal depressive symptoms (interaction term coeff = -.012, p = .221). CONCLUSIONS: We replicated the finding from the WCHADS that prenatal depression modifies the association between postnatal depression and children's emotional problems in a sex-dependent fashion. In ALSPAC, the sex difference was explained mainly by a protective effect of low prenatal depression in boys, while in WCHADS, it arose from greater vulnerability of girls to postnatal depression following low prenatal depression. In the light of these findings, in evaluating and implementing early interventions, there is need to consider that risks associated with postnatal depression may vary depending on maternal mood during pregnancy and may differ between boys and girls.

Mismatched Prenatal and Postnatal Maternal Depressive Symptoms and Child Behaviours: A Sex-Dependent Role for NR3C1 DNA Methylation in the Wirral Child Health and Development Study.

Evolutionary hypotheses predict that male fetuses are more vulnerable to poor maternal conditions (Sex-biased Maternal Investment), but female fetuses are at greater risk of glucocorticoid-mediated disorders where there is a mismatch between fetal and postnatal environments (Predictive Adaptive Response). Self-reported prenatal and postnatal depression and maternal report of child anxious-depressed symptoms at 2.5, 3.5 and 5.0 years were obtained from an 'extensive' sample of first-time mothers (N = 794). Salivary NR3C1 1-F promoter methylation was assayed at 14 months in an 'intensive' subsample (n = 176) and stratified by psychosocial risk. Generalised structural equation models were fitted and estimated by maximum likelihood to allow the inclusion of participants from both intensive and extensive samples. Postnatal depression was associated with NR3C1 methylation and anxious-depressed symptoms in daughters of mothers with low prenatal depression (prenatal-postnatal depression interaction for methylation, p < 0.001; for child symptoms, p = 0.011). In girls, NR3C1 methylation mediated the association between maternal depression and child anxious-depressed symptoms. The effects were greater in girls than boys: the test of sex differences in the effect of the prenatal-postnatal depression interaction on both outcomes gave X2 (2) = 5.95 (p = 0.051). This was the first human study to show that epigenetic and early behavioural outcomes may arise through different mechanisms in males and females.

Sex-dependent associations between maternal prenatal cortisol and child callous-unemotional traits: Findings from the Wirral Child Health and Development Study.

BACKGROUND: Elevated maternal glucocorticoids during pregnancy may impact on fetal development in a sex-dependent way, leading to increased amygdala activation and increased risk for internalising disorders in females. Based on evidence implicating reduced amygdala activation in callous-unemotional (CU) traits, we predicted that elevated maternal cortisol in pregnancy would be associated with lower CU traits and elevated anxious-depressed symptoms, only in girls. METHODS: Participants were 225 members of a stratified subsample within an epidemiological longitudinal cohort (WCHADS). Salivary cortisol was measured over two days at 32 weeks gestation (on waking, 30-min post-waking and during the evening) and the log of the area under the curve (LogAUC) was calculated as an index of diurnal cortisol. Mothers reported on child CU traits and anxious-depressed symptoms at 2.5, 3.5 and 5.0 years of age. RESULTS: As predicted there was a sex of child by cortisol interaction (p < .001) whereby elevated maternal cortisol was associated with lower child CU traits, explaining 25% of the variance, in girls, but not in boys. This effect remained when controlling for relevant confounders and anxious-depressed symptoms. By contrast, elevated maternal cortisol did not predict higher anxious-depressed symptoms in girls. CONCLUSIONS: The study adds to growing evidence for sex-dependent effects of elevated maternal cortisol during pregnancy on early child psychopathology, consistent with mediation by elevated amygdala activation. The conditions under which, in girls, this is associated with heightened responsiveness to others' distress characteristic of low CU traits, or with increased affective symptoms, require further study.