Access to and perceived unmet need for mental health services and support in a community sample of UK adolescents with and without experience of childhood adversity.

AIMS: Children and adolescents with a history of adverse childhood experiences (ACEs) are more likely than their peers to develop mental health difficulties, but not enough is known about their help-seeking behaviours and preferences. We aimed to determine whether ACEs are associated with access to and perceived unmet need for mental health services and support amongst secondary school students. METHODS: We used multi-level logistic regression with data from the 2020 OxWell Student Survey to assess whether ACEs were associated with (1) prior access to mental health support and (2) perceived unmet need for mental health services in a community sample of English secondary school students. We assessed ACEs as a cumulative score from the Center for Youth Wellness Adverse Childhood Experiences Questionnaire: Teen Self-Report version and accounted for current mental health difficulties as measured by the 25-item Revised Children's Anxiety and Depression Scale (RCADS). RESULTS: Our analysis included 2018 students across 64 schools, of whom 29.9% (598/2002) reported prior access to mental health support. Of those not reporting prior access, 34.1% (469/1377) reported a perceived unmet need for services. In the unadjusted models, cumulative ACE scores were significantly positively associated with both prior access to mental health support (odds ratio (OR) = 1.36; 95% confidence interval (CI): 1.29-1.43) and perceived unmet need for mental health services (OR = 1.47; 95% CI: 1.37-1.59), meaning that students who had experienced adversity had a greater chance of having previously accessed support as well as perceiving an unmet need for services. After adjusting for mental health difficulties and other sociodemographic variables, cumulative ACE scores were positively associated with prior access (adjusted OR (aOR) = 1.25; 95% CI: 1.17-1.34 with a significant interaction between RCADS and ACE scores, aOR = 0.88; 95% CI: 0.84-0.93) as well as perceived unmet need (aOR = 1.32; 95% CI: 1.21-1.43 with a significant interaction between RCADS and ACE scores, aOR = 0.85; 95% CI: 0.78-0.91). CONCLUSIONS: Although it is encouraging that adolescents with experience of adversity are more likely than their peers with similar levels of depression and anxiety symptoms to have accessed mental health support, there remains a concern that those who have not accessed support are more likely to perceive an as-yet unmet need for it. Mental health support must be available, accessible and acceptable to all who need it, especially for those groups that traditionally have not accessed services, including the more marginalised and vulnerable populations.

The use of teledentistry in clinical oral and maxillofacial pathology practice: an institutional experience.

Background: Although there has been a slight increase in dental professionals since 2011, 98 of North Carolina's 100 counties are designated as Dental Health Professional Shortage Areas by the Heath Resources and Service Administration. This shortage significantly increases disparities and access to primary and specialized oral health care. Also, dental professionals in these remote locations may feel the access and referrals to oral and maxillofacial pathologists cumbersome. In 2020, the COVID-19 pandemic prompted an inevitable surge in the use of digital technology due to the social distancing norms and lockdowns, which forced dental education institutions and practitioners to adjust to new ways of meeting, teaching, and providing dental care. In the present manuscript, we report our institutional experience delivering specialized dental care in rural areas. Materials and methods: We conducted a retrospective case series of diagnosis, management, and outcomes of patients who underwent synchronous or asynchronous virtual and remote examination of oral lesions at ECU School of Dental Medicine and one satellite clinic over seven years. For those cases that concluded on surgical sampling, the clinical impressions, differential diagnoses, and the final diagnosis were compared to assess the accuracy of the clinical exam through teledentistry. Results: The total study population consisted of 71 patients. Most of the remote consultations were done asynchronously. Also, most virtual clinical consultations were initiated due to clinical suspicion of malignancy and infectious/reactive conditions, accounting for 42% and 25.3% of all encounters. Conclusions: The presented data suggest how teledentistry can support clinical practice in rural areas to achieve optimal care for the patient in rural or remote communities. Also, it significantly decreases the travel required, the number of appointments, and increases the speed of diagnosis. Teledentistry is an excellent tool available to all clinicians and can dramatically aid in diagnosing oral mucosa lesions.

Relationship between ambient temperature at sampling and the interferon gamma test result for bovine tuberculosis in cattle.

Bovine tuberculosis (bTB) is a disease of significant economic and zoonotic importance, therefore, optimising tests for the identification of Mycobacterium bovis infected cattle is essential. The Interferon Gamma (IFN-γ) Release Assay (IGRA) can diagnose M. bovis infected cattle at an early stage, is easy to perform and can be used alongside skin tests for confirmatory purposes or to increase diagnostic sensitivity. It is known that IGRA performance is sensitive to environmental conditions under which samples are taken and transported. In this study, the association between the ambient temperature on the day of bleeding and the subsequent IGRA result for bTB was quantified using field samples from Northern Ireland (NI). Results of 106,434 IGRA results (2013-2018) were associated with temperature data extracted from weather stations near tested cattle herds. Model dependent variables were the levels of IFN-γ triggered by avian purified protein derivative (PPDa), M. bovis PPD (PPDb), their difference (PPD(b-a)) as well as the final binary outcome (positive or negative for M. bovis infection). IFN-γ levels after both PPDa and PPDb stimulation were lowest at the extremes of the temperature distribution for NI. The highest IGRA positive probability (above 6%) was found on days with moderate maximum temperatures (6-16 °C) or moderate minimum temperatures (4-7 °C). Adjustment for covariates did not lead to major changes in the model estimates. These data suggest that IGRA performance can be affected when samples are taken at high or low temperatures. Whilst it is difficult to exclude physiological factors, the data nonetheless supports the temperature control of samples from bleeding through to laboratory to help mitigate post-collection confounders.

Taking modern psychiatry into the metaverse: Integrating augmented, virtual, and mixed reality technologies into psychiatric care.

The landscape of psychiatry is ever evolving and has recently begun to be influenced more heavily by new technologies. One novel technology which may have particular application to psychiatry is the metaverse, a three-dimensional digital social platform accessed via augmented, virtual, and mixed reality (AR/VR/MR). The metaverse allows the interaction of users in a virtual world which can be measured and manipulated, posing at once exciting new possibilities and significant potential challenges and risks. While the final form of the nascent metaverse is not yet clear, the immersive simulation and holographic mixed reality-based worlds made possible by the metaverse have the potential to redefine neuropsychiatric care for both patients and their providers. While a number of applications for this technology can be envisioned, this article will focus on leveraging the metaverse in three specific domains: medical education, brain stimulation, and biofeedback. Within medical education, the metaverse could allow for more precise feedback to students performing patient interviews as well as the ability to more easily disseminate highly specialized technical skills, such as those used in advanced neurostimulation paradigms. Examples of potential applications in brain stimulation and biofeedback range from using AR to improve precision targeting of non-invasive neuromodulation modalities to more innovative practices, such as using physiological and behavioral measures derived from interactions in VR environments to directly inform and personalize treatment parameters for patients. Along with promising future applications, we also discuss ethical implications and data security concerns that arise when considering the introduction of the metaverse and related AR/VR technologies to psychiatric research and care.

Rural-Urban Differences in Use of Dental Services and Procedures Among Medicare Beneficiaries in 2018.

OBJECTIVE: Medicare beneficiaries in rural areas may face challenges in access to dental care. This study assessed rural-urban differences in the use of dental services and dental procedures by Medicare beneficiaries. METHODS: We obtained data from the 2018 Medicare Current Beneficiary Survey cost and use files. Outcome variables examined in this study were (1) dental visits (yes/no), whether the Medicare beneficiary had ≥1 dental visit in the past year, and (2) dental procedures-preventive (yes/no), restorative (yes/no), and surgical procedures (yes/no)-whether the beneficiary had the procedure in a dental visit. The independent variable was the beneficiary's residence (rural vs urban). We used multiple logistic regression to analyze data and accounted for the survey design of the Medicare Current Beneficiary Survey. The analytic sample included 7377 respondents aged ≥65 years. RESULTS: Approximately 57.0% (95% CI, 54.9%-59.0%) and 46.4% (95% CI, 41.6%-51.2%) of Medicare beneficiaries in urban and rural communities in the United States had a dental visit in 2018, respectively. Rural beneficiaries were significantly less likely than their urban counterparts to have preventive procedures (adjusted odds ratio = 0.51; 95% CI, 0.36-0.72) but significantly more likely to have restorative procedures (adjusted odds ratio = 1.30; 95% CI, 1.05-1.62). CONCLUSION: We found significant disparities in use of dental services by Medicare beneficiaries in rural communities. When Medicare beneficiaries in rural areas used dental care, they were less likely than beneficiaries in urban areas to have preventive procedures but more likely to have restorative procedures, suggesting a greater burden of oral health needs among them. Policy research is needed to identify models that can incentivize prevention and improve access to dental care for Medicare beneficiaries in rural communities.

Understanding the relationship between family income and conduct problems: findings from the mental health of children and young people survey.

BACKGROUND: Children from low-socioeconomic backgrounds exhibit more behavioural difficulties than those from more affluent families. Influential theoretical models specify family stress and child characteristics as mediating this effect. These accounts, however, have often been based on cross-sectional data or longitudinal analyses that do not capture all potential pathways, and therefore may not provide good policy guidance. METHODS: In a UK representative sample of 2399 children aged 5-15, we tested mediation of the effect of household income on parent and teacher reports of conduct problems (CP) via unhealthy family functioning, poor parental mental health, stressful life events, child physical health and reading ability. We applied cross-lagged longitudinal mediation models which allowed for testing of reciprocal effects whereby the hypothesised mediators were modelled as outcomes as well as predictors of CP. RESULTS: We found the predicted significant longitudinal effect of income on CP, but no evidence that it was mediated by the child and family factors included in the study. Instead, we found significant indirect paths from income to parental mental health, child physical health and stressful life events that were transmitted via child CP. CONCLUSION: The results confirm that income is associated with change in CP but do not support models that suggest this effect is transmitted via unhealthy family functioning, parental mental health, child physical health, stressful life events or reading difficulties. Instead, the results highlight that child CP may be a mediator of social inequalities in family psychosocial functioning.

A quality improvement study: Optimizing pneumococcal vaccination rates in children with cochlear implants.

Children with cochlear implants are at increased risk of invasive pneumococcal disease, with national and international guidelines recommending additional pneumococcal vaccines for these children. This study aimed to examine the pneumococcal immunization status and rate of invasive pneumococcal disease in children with cochlear implants at a tertiary paediatric hospital over a 12-year period. Additionally, the impacts of vaccination reminders and a dedicated immunization clinic on pneumococcal vaccination rates were assessed. This quality improvement study included 200 children who had received a cochlear implant through the Children's Hearing Implant Program at a tertiary paediatric hospital servicing the state of Western Australia. The majority of children (88%) were not up to date with additionally recommended pneumococcal vaccinations. Over the 12-year study period, 2% of children developed invasive pneumococcal disease associated with cochlear implant infections. Generic and personalized electronic immunization reminders improved pneumococcal vaccine up-take in this paediatric cochlear implant setting from 12% (19/153) at baseline to 49% (75/153, p < 0.0001) post implementation. The value of a nurse-led dedicated immunization clinic was also demonstrated with all children (42/42, 100%) up to date with Prevenar13 and the majority (34/42, 81%) up to date with Pneumovax23 post initiation of this referral pathway. These data support the expansion of this model to other medically-at-risk paediatric groups that have been highlighted consistently to be under-vaccinated.

Stratified medicine using invasive coronary function testing in angina: A cost-effectiveness analysis of the British Heart Foundation CorMicA trial.

AIM: Coronary angiography is indicated in many patients with known or suspected angina for the investigation of coronary artery disease (CAD). However, up to half of patients with symptoms of ischaemia have no obstructive coronary arteries (INOCA). This large subgroup includes patients with suspected microvascular angina (MVA) and/or vasospastic angina (VSA). Clinical guidelines relating to the management of patients with INOCA are limited. Uncertainty regarding the diagnosis of patients with INOCA presents a health economic challenge, both in terms of healthcare resource utilisation and of quality-of-life impact on patients. METHODS: A cost-effectiveness analysis of the introduction of stratified medicine into the invasive management of INOCA, based on clinical and resource-use data obtained in the CorMicA trial, from a UK NHS perspective. The intervention included an invasive diagnostic procedure (IDP) of coronary vascular function during coronary angiography to define clinical endotypes to target with linked medical therapy. Outcomes of interest were mean total cost and QALY gain between treatment groups, and the incremental cost-effectiveness ratio. We undertook probabilistic sensitivity and scenario analyses. RESULTS: The incremental cost per QALY gained at 12 months was £4500 (£2937, £33264). Compared with a willingness-to-pay (WTP) threshold of £20,000 per QALY, the use of the IDP test is cost-effective. At this WTP threshold there is a 96% probability of the IDP being cost-effective, based on the uncertainty described by bootstrap analysis. CONCLUSIONS: The burden of INOCA, particularly in women, is known to be significant. These findings provided new evidence to inform this unmet clinical need.

The longitudinal relationship between child emotional disorder and parental mental health in the British Child and Adolescent Mental Health surveys 1999 and 2004.

BACKGROUND: Research suggests parental psychopathology has an adverse effect on child mental health. However, due to the interactional nature of parent-child relationships and with a high rate of emotional disorders reported in school-age children, it is important to know whether the effect is reciprocal. METHODS: We explored the longitudinal relationship between child and parent mental health in the British Child and Adolescent Mental Health Surveys (N=7,100 child-parent dyads) and their three-year follow-ups. The Development and Well-Being Assessment with DSM-IV diagnostic criteria was used to measure child psychiatric diagnoses, while parental mental health was assessed using the General Health Questionnaire. Multivariable logistic regression was used to explore the longitudinal association between child emotional disorder and parent mental health. RESULTS: Parents of children who had an emotional disorder at baseline were more likely to have poor mental health three years later compared with parents whose children had no psychiatric diagnosis (33.3% versus 16.7%; crude odds ratio=2.52; adjusted odds ratio=2.19, 95% CI=1.58 to 3.05, p<0.001). Children of parents with poor mental health at baseline were more likely to develop an emotional disorder three years later compared with children whose parents had good mental health (5.2% versus 2.5%; crude odds ratio=2.08; adjusted odds ratio=1.63, 95% CI=1.18 to 2.25, p=0.003). LIMITATIONS: The findings of this research are limited by the survey data collected, the measures used and survey dropout. CONCLUSIONS: We detected a bi-directional relationship between child and parent mental health, suggesting that effective intervention for one individual may benefit other family members.

Estimating the impact of child and early adolescent depression on subsequent educational attainment: secondary analysis of an existing data linkage.

AIMS: Depression is thought to be associated with lower subsequent educational attainment during school. But, without longitudinal studies which take account of prior attainment and other potential confounders, estimates of the impact of clinically recognised depression in childhood and early adolescence are unknown. We investigated whether a clinical diagnosis of depression is associated with lower subsequent educational attainment, and whether the association is modified by gender, ethnicity and socioeconomic status. METHODS: We conducted a secondary analysis of an existing administrative data linkage between national educational data and a large mental healthcare provider in London, UK (2007-2013). Depression diagnosis before age 15 (exposure) was measured from electronic health records, and subsequent educational attainment at age 15-16 (outcome) was measured from educational records. We fitted logistic regression models and adjusted for gender, ethnicity, socioeconomic status, relative age in school year, neurodevelopmental disorder diagnosis and prior attainment. We investigated effect modifiers using interaction terms. RESULTS: In total, n = 63 623 were included in analysis, of whom n = 242 had record of a depression diagnosis before age 15. Depression was associated with lower odds of subsequently achieving expected attainment levels in national exams, after adjustment for all covariates (odds ratio = 0.60, 95% confidence interval = 0.43 to 0.84, p = 0.003). There was no evidence that gender, ethnicity or socioeconomic status modified this association. CONCLUSIONS: These findings support a relationship between depression and lower subsequent educational attainment. This highlights the need for tailored educational interventions to support children and adolescents with depression, particularly in the lead up to key educational milestones.

Barriers and predictors of medication use for childhood ADHD: findings from a UK population-representative cohort.

PURPOSE: Little is known about sociodemographic and clinical factors that predict and act as barriers to ADHD medication independently of symptom severity. We examined the proportion of children using medication for ADHD, age of initiation of medication, and predictors of medication use in a population-representative cohort. METHODS: Data from the Millennium Cohort Study on child ADHD, medication use for ADHD at age 14 (in 2014-2015) and child, parent and sociodemographic variables were collated. Logistic regression models were used to identify factors that predict medication use for ADHD (the main outcome measure), adjusting for symptom severity at age seven. RESULTS: The weighted prevalence of ADHD was 3.97% (N = 11,708). 45.57% of children with ADHD (N = 305) were taking medication. The median age at initiation was 9 years (range 3-14). Male gender (AOR 3.66, 95% CI 1.75, 7.66) and conduct problems at age seven (AOR 1.24 95% CI 1.04, 1.47) and 14 predicted medication use at age 14 after adjusting for symptom severity. CONCLUSIONS: Our study is the first to assess predictors of medication whist adjusting for ADHD symptom severity. Girls with ADHD were less likely to be prescribed medication, even when they displayed similar ADHD symptom levels to boys. Conduct problems also predicted medication independently of ADHD symptoms. ADHD may be more often medicated in boys because clinicians may think a prototypical ADHD child is male, and perhaps conduct problems make boys more disruptive in the classroom, leading to boys being more often treated.

Psychological distress among primary school teachers: a comparison with clinical and population samples.

OBJECTIVES: This analysis explored the level of psychological distress among primary school teachers in the South West of England as compared with clinical and general population samples. STUDY DESIGN: Secondary analysis of data from the Supporting Teachers and Children in Schools (STARS) trial completed by up to 90 teachers at baseline, 9, 18 and 30 months of follow-up. METHODS: We used the Everyday Feelings Questionnaire (EFQ) as a measure of psychological distress. Baseline data on teachers were compared with a population sample of professionals and a clinical sample of patients attending a depression clinic. RESULTS: Our teacher cohort experienced higher levels of psychological distress than comparable professionals from the general population, which were sustained over 30 months of follow-up. Levels of psychological distress were lower than those found in the clinical sample. Using a cut-point indicative of moderate depression, our data suggest that between 19% and 29% of teachers experienced clinically significant distress at each time-point. CONCLUSIONS: We detected high and sustained levels of psychological distress among primary school teachers, which suggests an urgent need for intervention. Effective support for teachers' mental health is particularly important given the potential impact of poor teacher mental health on pupil well-being, pupil attainment and teacher-pupil relationships.

Cardiac modulation of alpha motoneuron discharges.

Recordings of alpha motoneuron discharges from branches of the intercostal and abdominal nerves in anesthetized cats were analyzed for modulation during the cardiac cycle. Cardiac modulation was assessed by the construction of cross-correlation histograms between the R-wave of the ECG and the largest amplitude efferent spikes. In all but two recordings (which were believed to have either no or few alpha spikes), the histograms showed relatively short duration peaks and/or troughs (widths at half amplitude 4-50 ms) at lags of 10-150 ms. These observations were deduced to result from activity in oligosynaptic pathways, probably from muscle spindle afferents, whose discharges are known to be synchronized to the cardiac pulse. The results suggest that onward transmission of the cardiac signal from thoracic muscle afferents (and possibly from other dynamically sensitive afferents) to other parts of the central nervous system is highly likely and that therefore these afferents could contribute to cardiac interoception. NEW & NOTEWORTHY It has been recognized since 1933 that muscle spindles respond to the cardiac pulse, but it is unknown whether this cardiac signal is transmitted to other levels in the nervous system. Here we show that a cardiac signal, likely arising from muscle spindles, is present in the efferent activities of thoracic and abdominal muscle nerves, suggesting probable onward transmission of this signal to higher levels and therefore that muscle spindles could contribute to cardiac interoception.

Which children and young people are excluded from school? Findings from a large British birth cohort study, the Avon Longitudinal Study of Parents and Children (ALSPAC).

BACKGROUND: Exclusion from school is increasingly recognized as pertinent to child health. National educational data reveal that boys, children who are looked-after, living in poverty, have special educational needs, or from certain ethnic minorities, are disproportionately excluded from school. As population-based data on the wider characteristics of excluded children are scarce, we aimed to describe predictors of school exclusion in the Avon Longitudinal Study of Parents and Children. METHOD: Avon Longitudinal Study of Parents and Children, a prospective U.K. population-based birth cohort study, collected parent reports of permanent school exclusions by 8 years and parent and self-reports of permanent and fixed-term exclusions in the preceding 12 months at 16 years. Potential risk factors were examined for associations with exclusion using logistic regression, with a focus on child mental health and neurodevelopment. RESULTS: Analyses were based on all available data on 53/8,245 (0.6%) pupils excluded from school by 8 years and 390/4,482 (8.7%) at 16 years. Key factors associated with exclusion at both time points included male gender, lower socio-economic status, maternal psychopathology, mental health and behavioural difficulties, psychiatric disorder, social communication difficulties, language difficulties, antisocial activities, bullying/being bulled, lower parental engagement with education, low school engagement, poor relationship with teacher, low educational attainment, and special educational needs (all p < .05). CONCLUSION: Exclusion from school was associated with child, family and school-related factors identifiable at, or prior to, primary school age. Child health professionals have an important role in the holistic, multidisciplinary assessment of children who are at risk of exclusion from school. Mental health and neurodevelopmental difficulties should be recognized and supported, to improve the health and educational outcomes among this vulnerable group.

The relationship between exclusion from school and mental health: a secondary analysis of the British Child and Adolescent Mental Health Surveys 2004 and 2007.

BACKGROUND: Children with poor mental health often struggle at school. The relationship between childhood psychiatric disorder and exclusion from school has not been frequently studied, but both are associated with poor adult outcomes. We undertook a secondary analysis of the British Child and Adolescent Mental Health Surveys from 2004 and its follow-up in 2007 to explore the relationship between exclusion from school and psychopathology. We predicted poorer mental health among those excluded. METHOD: Psychopathology was measured using the Strengths and Difficulties Questionnaire, while psychiatric disorder was assessed using the Development and Well-Being Assessment and applying Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM IV) criteria. Exclusion from school and socio-demographic characteristics were reported by parents. Multi-variable regression models were used to examine the impact of individual factors on exclusion from school or psychological distress. RESULTS: Exclusion from school was commoner among boys, secondary school pupils and those living in socio-economically deprived circumstances. Poor general health and learning disability among children and poor parental mental health were also associated with exclusion. There were consistently high levels of psychological distress among those who had experienced exclusion at baseline and follow-up. CONCLUSIONS: We detected a bi-directional association between psychological distress and exclusion. Efforts to identify and support children who struggle with school may therefore prevent both future exclusion and future psychiatric disorder.

Examining the psychological and social impact of relative age in primary school children: a cross-sectional survey.

BACKGROUND: A number of studies demonstrate that children who are younger within their school year have poorer academic attainment and are more likely to have special educational needs. Few, however, have considered the impact relative age may have on child mental health, behaviour and happiness in school. METHODS: This paper utilized data from the Supporting Teachers and Children in Schools study (2075 pupils aged 5 to 9 years from 80 primary schools) to explore the relationship among relative age, behaviour and happiness in school. Behavioural and emotional development was assessed by using the teacher-reported and parent-reported Strengths and Difficulties Questionnaire and the Pupil Behaviour Questionnaire. Children's happiness within school was assessed by using the How I Feel About My School Questionnaire. RESULTS: Relatively younger children had higher Total Difficulties scores on the Strengths and Difficulties Questionnaire than their peers. There was a mean increase per 30-day decrease in relative age of 0.09 (95% CI: 0.03 to 0.16; p = 0.007) in teacher-reported and 0.08 (0.001 to 0.16; p = 0.05) in parent-reported scores. There was little evidence of a relationship between relative age and children's behaviour and happiness in school. CONCLUSIONS: For children with complex difficulties, being relatively young for their school year may be an additional stressor that may undermine mental health.