Teachers reported that children with special health care needs displayed more attention problems.

AIM: Children with special health care needs (SHCN) perform more poorly at school compared to their classmates. Specific causal pathways have not yet been extensively studied. Therefore, we investigated teacher-rated global attention, an important prerequisite for educational attainment, in children with SHCN. METHODS: Data of a population-based prospective cohort study, which recruited preschool children from the Mainz-Bingen area, Germany, were analysed. Children with SHCN were identified by the Children with Special Health Care Needs screening tool. In 2016, global attention was reported by teachers at the end of first grade (mean age: 7.3 years) on a 5-point rating scale ranging from -2 through +2. Associations between SHCN consequences and teacher-rated attention were estimated by linear mixed models, adjusted for confounding variables. RESULTS: We included 1921 children (51% males); of these, 14% had SHCN. Compared to their classmates, children with SHCN had poorer teacher-rated attention scores (adjusted mean difference: -0.35, 95% CI: -0.52 to -0.17). The effect was strongest among children with treatment or counselling for mental health problems or functional limitations. The effect remained after excluding children with attention deficit hyperactivity disorder from the analysis. CONCLUSION: Children with SHCN showed more teacher-rated attention problems, which could explain their lower educational attainment.

School absenteeism in children with special health care needs. Results from the prospective cohort study ikidS.

OBJECTIVE: Children with special health care needs (SHCN) due to a chronic health condition perform more poorly at school compared to their classmates. There is still little knowledge on the causal pathways and which factors could be targeted by interventions. We, therefore, investigated school absenteeism in children with SHCN compared to their peers. METHODS: This study was based on data from the German population-based prospective cohort study ikidS (German for: I will start school). Children with SHCN were identified by the Children with Special Health Care Needs screener that captures five consequences of physical or mental chronic health conditions: (1) use or need of prescription medication, (2) above average use or need of medical, mental health, or educational services, (3) functional limitations compared with others of the same age, (4) use or need of specialized therapies, and (5) treatment or counseling for emotional, behavioral, or developmental problems. School absenteeism was defined as days absent from school due to illness during first grade and was reported by classroom teachers. Associations between SHCN consequences and school absenteeism were investigated by negative binomial regression models. Effect estimates were adjusted for confounding variables identified by a causal framework and directed acyclic graphs. RESULTS: 1,921 children (mean age at follow-up 7.3 years, standard deviation 0.3; 49% females) were included; of these, 14% had SHCN. Compared to their classmates, children with SHCN had more days absent (adjusted rate ratio: 1.37; 95% confidence interval 1.16, 1.62). The effect was strongest among children with i) functional limitations, ii) treatment or counseling for emotional, behavioral, or developmental problems, and iii) those who experienced two or more SHCN consequences. CONCLUSIONS: Children with SHCN have higher school absenteeism, which could-at least partly-explain their poorer school performance and lower educational attainment. SHCN-specific targeted interventions may reduce the adverse effects of SHCN on educational outcomes in children.

[Chronically ill at School - School Performance in Children with Special Health Care Needs. Results of the Child Health Study ikidS]. / Chronisch krank in der Schule ­ schulische Fähigkeiten von Kindern mit speziellem Versorgungsbedarf. Ergebnisse der Kindergesundheitsstudie ikidS.

BACKGROUND: The association between health status in childhood and later educational achievement is unknown. We describe the association between a chronic health condition (CHC) and school performance at the end of first grade. PATIENTS: As part of the child health survey ikidS, 2,003 preschoolers from the Mainz-Bingen area (Rhineland-Palatinate; Germany) were recruited. METHOD: In a prospective cohort study, children with CHC were identified by the children with special health care needs screener. At the end of first grade, classroom teachers evaluated the child's school performance on a rating scale ranging from - 2 through+2 in 5 domains: numeracy, science, reading, writing, and social competencies. Associations between special health care needs (SHCN) and each domain were assessed by linear mixed regression models adjusted for potential confounders. RESULTS: 1,463 children (51% males) were analyzed. Of these, 15% had SHCN. Compared to their classmates, children with SHCN performed poorer in numeracy (adjusted mean difference: - 0.40; 95% CI[- 0.57; - 0.23]) and writing (- 0.22; 95% CI[- 0.39; - 0.05]). DISCUSSION: For the first time in a German sample, we found an indication which educational competencies might be negatively impacted by SHCN early in school. This could have long-lasting effects on educational attainment and later socio-economic status. CONCLUSION: Our results question the uptake and/or effectiveness of existing medical care as well as educational support concepts for children with a CHC.

Efficacy of a Toothpaste Based on Microcrystalline Hydroxyapatite on Children with Hypersensitivity Caused by MIH: A Randomised Controlled Trial.

PURPOSE: Hypersensitivity is a frequent complaint in children with molar incisor hypomineralisation (MIH). This double-blind randomised controlled trial aimed to evaluate non-inferiority in hypersensitivity relief of a toothpaste containing microcrystalline hydroxyapatite compared to amine fluoride in children with MIH. MATERIALS AND METHODS: Children were randomised into 2 groups: either hydroxyapatite (intervention) or amine fluoride toothpaste (control). The primary endpoint was pain sensation in response to tactile stimulus (Wong-Baker FACES Pain Rating Scale) 56 days after randomisation and analysed by mixed effects linear regression analysis. Non-inferiority was inferred if the upper limit of the one-sided 95% confidence interval (CI) of the difference between intervention and control group was below the non-inferiority margin of 1 in the ITT (intention-to-treat) and PP (per protocol) population. RESULTS: Twenty-one children were randomised and 14 children finished the study per protocol. In the ITT population, hydroxyapatite was non-inferior to amine fluoride (mean difference: -0.75 95%CI [-∞;0.49]). In the PP population, non-inferiority could not be shown (-0.62 [-∞;1.08]). CONCLUSIONS: Overall non-inferiority in hypersensitivity relief of a toothpaste containing hydroxyapatite compared to amine fluoride could not be shown. However, the hydroxyapatite group tended to be less hypersensitive in both populations. Attrition of the PP population due to the COVID-19 pandemic led to loss of statistical power.

Mental health and health-related quality of life in preschool-aged childhood cancer survivors. Results of the prospective cohort study ikidS-OEVA.

OBJECTIVES: Long-term survivors of childhood cancer are at increased risk for sequelae such as poor mental health (MH) or impaired health-related quality of life (HrQoL). We aimed to evaluate early adverse effects on MH and HrQoL in young childhood cancer survivors (YCCS) before school entry. METHODS: In a nationwide prospective cohort study, children with cancer other than brain tumors diagnosed at preschool age and completed cancer treatments were identified from the German Childhood Cancer Registry. The comparison group was children of the same age without a cancer diagnosis who participated in the prospective population-based health survey ikidS. MH problems and HrQoL were assessed by parental versions of the Strengths and Difficulties Questionnaire (SDQ) and the questionnaire for health-related quality of life in children (KINDL), respectively. Associations between cancer and MH as well as HrQoL were analyzed by multivariable linear regression. RESULTS: Of 382 YCCS contacted, 145 were enrolled (mean age 6.6 years) and 124 analyzed. Compared to children without a cancer diagnosis (3683 contacted, 2003 enrolled, 1422 analyzed), YCCS had more MH problems (13% vs. 3%) and slightly worse HrQoL (median 78.7 vs. 80.2 points). In the adjusted analysis, YCCS had higher SDQ scores (2.2 points, 95% confidence interval [CI] 1.3, 3.0) and lower KINDL scores (-2.4 points, 95% CI -3.7, -1.1) compared to children without cancer diagnosis. CONCLUSION: Already at preschool age, YCCS may be at increased risk of MH problems and impaired HrQoL. This could have impacts on subsequent school performance and educational attainment. Follow-up health care for YCCS may include early screening for MH problems and reasons for HrQoL deficits.

[Evaluation of the Language-related Domain of the Pediatric Developmental Screening Instrument for Preschool Health Examinations (SOPESS): Results from the Prospective Child Health Survey ikidS]. / Evaluation der Sprachaufgaben des sozialpädiatrischen Entwicklungsscreenings für Schuleingangsuntersuchungen (SOPESS): Ergebnisse der prospektiven Kindergesundheitsstudie ikidS.

PURPOSE OF THE STUDY: Developmental delays at school enrollment can affect early educational achievement. Thus, diagnosis and treatment prior to school entry are important. In Germany, SOPESS - a pediatric developmental screening instrument for preschool health examinations (PHE) - was introduced in several federal states. We investigated the relationships between the results of the language-related domain of the SOPESS and later academic language competencies at the end of first grade. PROCEDURES: Data of the population-based cohort study ikidS (Rhineland Palatinate; Germany) and the PHE provided by public health authorities were linked at individual level. The relationship between the SOPESS-language risk score (range: 0 to 6, higher values indicate more developmental delay) and class teacher-based ratings of academic language competencies (range: -4 to+4, higher values indicate better competencies) was investigated with linear regression models and adjusted for several socio-economic and medical language predictors (e. g. age at school entry, gender, parental education, migration background, hearing disorder). The additional benefits of the SOPESS-language risk score was analyzed using analysis of variance. RESULTS: In total, 1357 children (48% girls, age at PHE 4.9-7.2 years) were included. A clear negative relationship between the SOPESS-language risk score and competencies in spoken and written language was found. Mean academic language competencies decreased with increasing SOPESS-language risk level from 0.8 (SD=1.7) at a risk score of 0 to-3.2 (SD=0.9) at a risk score of 6. The relationship persisted after adjusting for other language predictors. Analysis of variance showed significant benefits of the SOPESS-language risk score, even when further language predictors were considered. CONCLUSIONS: There was a clear relationship between results of the SOPESS-language screening and later academic language competencies. Hence, the language-related domain of the SOPESS may be useful for further recommendations of tailored special educational and medical support services, especially if additional socio-economic and medical factors are considered.

Pharmacological neuroenhancement and the ability to recover from stress - a representative cross-sectional survey among the German population.

BACKGROUND: Pharmacological neuroenhancement (PNE) refers to the use of psychoactive substances without doctor's prescription to enhance cognitive performance or to improve mood. Although some studies have reported that drugs for PNE are also being used to cope with stressful life situations, nothing is known about the relationship of PNE and resilience, i.e. the ability to recover from stress. This study aimed at investigating the relationship of PNE and resilience in the first representative population sample. METHODS: A cross-sectional survey in a representative sample of 1128 adults (age ≥ 18 yrs.) living in Germany was conducted. The use of PNE and related attitudes, perceptions and behaviours were assessed by structured interviews and self-report questionnaires. Stepwise logistic regression with backward elimination was conducted to identify potential risk factors for PNE use. RESULTS: Lifetime prevalence for the use of stimulating prescription drugs without medical indication was 4.3%, 10.2% for stimulating illicit drugs, 20.3% for mood modulating prescription drugs, and 23.4% for cannabis. Coping with stressful situations was more frequently reported as underlying motive for using stimulant or mood modulating prescription drugs than stimulating illicit drugs or cannabis. The individual perceived stress increased the risk of using stimulating prescription drugs (OR: 2.86; 95% Cl: 1.49-5.46) and the individual ability to recover from stress decreased the risk of using any substance for PNE and especially mood modulating prescription drugs (OR: .62; 95% Cl: .47-.81). CONCLUSIONS: The non-medical use of prescription drugs for PNE appears to be more prevalent in subjects who are less resilient to stress. Tailored resilience interventions that improve the ability to adapt to and recover from stressors may prevent the use of prescription medication for PNE. Further research should disentangle the association between psychological resilience and PNE as well as examine the efficacy of resilience interventions in the prevention of PNE.

Young lives disrupted: gender and well-being among adolescent Syrian refugees in Lebanon.

BACKGROUND: The conflict in Syria that began in 2011 has resulted in the exodus of over 5 million Syrian refugees to neighbouring countries, with more than one million refugees currently registered by UNHCR in Lebanon. While some are living in tented settlements, the majority are living in strained conditions in rented accommodation or collective shelters in the Bekaa Valley next to Syria. Adolescents are particularly vulnerable in any crisis. In 2013-4, the American University in Beirut in collaboration with the Women's Refugee Commission, Johns Hopkins and Save the Children, sought to understand the specific experiences of very young adolescents, those 10-14 years of age, in this protracted crisis context. METHODS: The study was conducted in 2014 in Barelias and Qabelias - two urban areas located close to each other in the Beka'a valley that has a large concentration of Syrian refugees. Focus group discussions (FGDs), including community mapping and photo elicitation, were conducted with 10-12 and 13-14 year old Syrian refugee adolescents, in order to obtain information about their experiences and perspectives. FGDs were also implemented with 15-16 year old Syrian refugees and separately also with adult refugees, to consider their perspectives on the needs and risks of these adolescents. RESULTS: A total of 16 FGD (8 for each sex, with 6-9 participants in each) were conducted in Arabic across the two sites, with 59 female participants and 59 male participants. The experiences and risks faced by these adolescents were significantly impacted by economic strain and loss of educational opportunities during displacement, and only a minority of adolescents in the study reported attending school. Additionally, on-going protection risks for girls were felt to be higher due to the crisis and displacement. In Lebanon this has resulted in increased risks of child marriage and limitations in mobility for adolescent girls. Adolescents, themselves expressed tensions with their Lebanese counterparts and feared verbal attacks and beatings from school-aged Lebanese male youth. CONCLUSIONS: Families and adolescents have been dramatically affected by the conflict in Syria, and the resulting forced displacement. The loss of educational opportunities is perhaps the most significant effect, with long-term devastating outcomes. Additionally, the futures of Syrian girls are deeply affected by new protection concerns, particularly as they are exposed to an unfamiliar and more liberal society in Lebanon. Child marriage and limitations in their mobility - particularly for girls - are presented by families as coping strategies to these risks. Programming is needed to ensure sustained education access for all adolescents, and to educate very young adolescents and their parents on managing their own health and well-being, given the multiple strains. More effort is needed to encourage positive interaction between adolescent Lebanese and adolescent Syrian refugees.

Transitions into puberty and access to sexual and reproductive health information in two humanitarian settings: a cross-sectional survey of very young adolescents from Somalia and Myanmar.

BACKGROUND: Very young adolescents (VYA) in humanitarian settings are largely neglected in terms of sexual and reproductive health (SRH). This study describes the characteristics of VYA aged 10-14 years in two humanitarian settings, focusing on transitions into puberty and access to SRH information. METHODS: Data were collected through a cross-sectional survey with Somali VYA residing in the Kobe refugee camp in Ethiopia (N = 406) and VYA from Myanmar residing in the Mae Sot and Phop Phra migrant communities in Thailand (N = 399). The average age was 12 years (about half were girls) in both communities. Participants were recruited using multi-stage cluster-based sampling with probability proportional to size in each site. Descriptive statistics were used to describe the sociodemographic, family, peer, and schooling characteristics and to explore transitions into puberty and access to SRH information. RESULTS: Most VYA in both sites reported living with both parents; nine in ten reported feeling that their parents/guardians care about them, and over half said that their parents/guardians monitor how and with whom they spend their free time. High proportions in both sites were currently enrolled in school (91.4% Somali, 87.0% from Myanmar). Few VYA, particularly those aged 10-12, reported starting puberty, although one in four Somali indicated not knowing whether they did so. Most girls from Myanmar who had started menstruating reported access to menstrual hygiene supplies (water, sanitation, cloths/pads). No Somali girls reported access to all these supplies. While over half of respondents in both sites reported learning about body changes, less than 20% had learnt about pregnancy and the majority (87.4% Somali, 78.6% from Myanmar) indicated a need for more information about body changes. Parents/guardians were the most common source of SRH information in both sites, however VYA indicated that they would like more information from friends, siblings, teachers and health workers. CONCLUSIONS: This study highlights gaps in SRH information necessary for healthy transitions through puberty and supplies for menstrual hygiene in two humanitarian settings. VYA in these settings expressed closeness to their parents/guardians and the majority were in school. Introducing early SRH interventions that involve parents and educational centers may thus yield promising results, providing VYA with the necessary skills for understanding and dealing with their pubertal and sexual development.

A qualitative study exploring child marriage practices among Syrian conflict-affected populations in Lebanon.

BACKGROUND: Recent reports have suggested that child marriage among Syrians may be increasing as a result of displacement and conflict. This study sought to gather qualitative data about the factors that promote child marriage practices among Syrian refugees in Al Marj area in the Bekaa valley, Lebanon, where the majority of Syrian refugees have settled in Lebanon. The second aim of this study was to generate recommendations on how to mitigate the drivers and consequences of child marriage practices based on the findings. METHODS: Eight focus group discussions were conducted separately with married and unmarried young women and mothers and fathers of married and unmarried women. Furthermore, researchers conducted 11 key informant interviews with service providers and stakeholders to understand how conflict and displacement influenced marriage practices of Syrian refugees in Al Marj community. RESULTS: Although child marriage was a common practice in pre-conflict Syria, new factors seem to contribute to a higher risk of child marriage among Syrian refugees in Lebanon. Respondents cited conflict- and displacement-related safety issues and feeling of insecurity, the worsening of economic conditions, and disrupted education for adolescent women as driving factors. Service providers, young women, and parents also reported changes in some marriage practices, including a shorter engagement period, lower bride price, change in cousin marriage practices, and a reduced age at marriage. CONCLUSIONS: Recommendations for interventions to mitigate the drivers of child marriage and its negative consequences should be built on a clear understanding of the local refugee context and the drivers of child marriage in refugee settings. Interventions should involve multiple stakeholders, they should be adjusted to target each specific context, age group and marital status. For these interventions to be effective, they should be addressed concurrently, and they should be delivered in a culturally sensitive and practical manner.

Understanding the unique experiences, perspectives and sexual and reproductive health needs of very young adolescents: Somali refugees in Ethiopia.

BACKGROUND: Kobe Refugee camp hosts roughly 39,000 refugees displaced from Somalia during the 2011-2012 Horn of Africa Crisis. Sexual and reproductive health, as with the greater issues of health and well-being for adolescents displaced from this crisis remain largely unknown and neglected. In 2013, the Women's Refugee Commission, Johns Hopkins University, and International Medical Corps in Ethiopia, implemented qualitative and quantitative research to explore the factors and risks that impact the health of very young adolescents (VYAs), those 10-14 years of age, in this setting. This paper presents findings from the qualitative effort. METHODS: Focus group discussions (FGD), incorporating community mapping and photo elicitation activities, were conducted with 10-12 and 13-14 year-olds to obtain information about their own perspectives, experiences and values. FGDs were also implemented with 15-16 year-olds and adults, to consider their perspectives on the sexual and reproductive health needs and risks of VYAs. RESULTS: This research identified several factors that were found to influence the health and well-being of VYAs in Kobe refugee camp, including newfound access to education and security, combined with gender divisions and parental communication around early SRH and puberty that remained intact from traditional Somali culture. Girls were found to face an additional risk of child marriage and early pregnancy exacerbated since displacement, which significantly limited their ability to access education and achieve future aspirations. CONCLUSION: Findings from this study could help to inform future programs in Kobe and similar contexts involving long-term displacement from conflict, focusing on the health and development needs of VYAs. Future programs should consider the determinants of positive VYA health and development, including access to education, gender equity, and safety.By better understanding the unique experiences, perspectives and needs of VYAs, practitioners, policy makers and donors can invest in the individual and community assets that reinforce positive behaviors established in early adolescence, in order to achieve long-term SRH impacts.

Early relationships and marriage in conflict and post-conflict settings: vulnerability of youth in Uganda.

While there is increased attention to child marriage, defined as marriage before 18 years of age, in countries where the practice is especially prevalent, less attention has been directed at understanding the factors affecting relationships, marriage and cohabitation among adolescents affected by conflict and displacement. This article presents factors which contribute to early relationships and informal marriages in conflict and post-conflict settings, based on qualitative research undertaken among two distinct populations in Uganda: internally displaced persons in Mucwini transit camp in northern Uganda and Congolese refugees in the Nakivale refugee settlement in southwestern Uganda. Themes were examined through a social-ecological framework. Findings indicate that fundamental shifts in economies, family relationships, and communication combined with structural changes encountered in settlements resulted in changed relationships and marriage patterns. Participants reported that poverty, splintering of family, and lack of education - which they believed to be exacerbated by conflict in both settings - had profoundly affected the views, perceptions and behaviours of youth around relationships and marriage. We identify interventions applicable to humanitarian settings that would offer refugee and internally displaced adolescents greater and more meaningful opportunities for development.

Pregnancies in perinatally HIV-infected young women and implications for care and service programs.

A cohort of individuals with perinatally acquired HIV is maturing into reproductive age. This study describes pregnancy incidence and outcomes among females ages 15-25 with perinatally acquired HIV infection receiving comprehensive family-centered services in New York City. Chart reviews from 1998-2006 indicated 33 pregnancies among 96 young women. Twenty-six percent of the cohort experienced a pregnancy during the study period, with a rate of 125 per 1,000 person years in 2006. The age of first pregnancy ranged from 15-25; 24% were younger than 18. Fourteen pregnancies (42%) were terminated. Nineteen pregnancies resulted in live births, and all infants tested negative for HIV. The success of preventing vertical HIV transmission is attributed to interdisciplinary family-centered services, including reproductive health education, family planning, obstetric-gynecologic services and psychosocial support. Such approach is most likely to be effective at promoting healthy reproductive decisions and reducing morbidity in perinatally infected mothers and their children.

Family planning in conflict: results of cross-sectional baseline surveys in three African countries.

BACKGROUND: Despite the serious consequences of conflict for reproductive health, populations affected by conflict and its aftermath face tremendous barriers to accessing reproductive health services, due to insecurity, inadequate numbers of trained personnel and lack of supplies. Family planning is often particularly neglected. METHODS: In six conflict-affected areas in Sudan, northern Uganda and the Democratic Republic of Congo, household surveys of married or in-union women of reproductive age were conducted to determine baseline measures of family planning knowledge, attitudes and behaviors regarding contraception. Health facility assessments were carried out to assess baseline measures of family planning services availability. Data were double-entered into CSPro 3.2 and exported to SAS 9.2, which was used to calculate descriptive statistics. The studies' purposes were to guide program activities and to serve as a baseline against which program accomplishments could be measured. RESULTS: Knowledge of modern contraceptive methods was low relative to other sub-Saharan African countries, and use of modern methods was under 4% in four sites; in two sites with prior family planning services it was 12% and 16.2%. From 30% to 40% of women reported they did not want a child within two years, however, and an additional 12% to 35% wanted no additional children, suggesting a clear need for family planning services. The health facilities assessment showed that at most only one-third of the facilities mandated to provide family planning had the necessary staff, equipment and supplies to do so adequately; in some areas, none of the facilities were prepared to offer such services. CONCLUSIONS: Family planning services are desired by women living in crisis situations when offered in a manner appropriate to their needs, yet services are rarely adequate to meet these needs. Refugee and internally displaced women must be included in national and donors' plans to improve family planning in Africa.

Reproductive health: a right for refugees and internally displaced persons.

Continued political and civil unrest in low-resource countries underscores the ongoing need for specialised reproductive health services for displaced people. Displaced women particularly face high maternal mortality, unmet need for family planning, complications following unsafe abortion, and gender-based violence, as well as sexually transmitted diseases, including HIV. Relief and development agencies and UN bodies have developed technical materials, made positive policy changes specific to crisis settings and are working to provide better reproductive health care. Substantial gaps remain, however. The collaboration within the field of reproductive health in crises is notable, with many agencies working in one or more networks. The five-year RAISE Initiative brings together major UN and NGO agencies from the fields of relief and development, and builds on their experience to support reproductive health service delivery, advocacy, clinical training and research. The readiness to use common guidance documents, develop priorities jointly and share resources has led to smoother operations and less overlap than if each agency worked independently. Trends in the field, including greater focus on internally displaced persons and those living in non-camp settings, as well as refugees in camps, the protracted nature of emergencies, and an increasing need for empirical evidence, will influence future progress.