Case identification of non-traumatic brain injury in youth using linked population data.

BACKGROUND: Population-level administrative data provides a cost-effective means of monitoring health outcomes and service needs of clinical populations. This study aimed to present a method for case identification of non-traumatic brain injury in population-level data and to examine the association with sociodemographic factors. METHODS: An estimated resident population of youth aged 0-24 years was constructed using population-level datasets within the New Zealand Integrated Data Infrastructure. A clinical consensus committee reviewed the International Classification of Diseases Ninth and Tenth Editions codes and Read codes for inclusion in a case definition. Cases were those with at least one non-traumatic brain injury code present in the five years up until 30 June 2018 in one of four databases in the Integrated Data Infrastructure. Rates of non-traumatic brain injury were examined, both including and excluding birth injury codes and across age, sex, ethnicity, and socioeconomic deprivation groups. RESULTS: Of the 1 579 089 youth aged 0-24 years on 30 June 2018, 8154 (0.52%) were identified as having one of the brain injury codes in the five-years to 30 June 2018. Rates of non-traumatic brain injury were higher in males, children aged 0-4 years, Maori and Pacific young people, and youth living with high levels of social deprivation. CONCLUSION: This study presents a comprehensive method for case identification of non-traumatic brain injury using national population-level administrative data.

Protocol for the Gut Bugs in Autism Trial: a double-blind randomised placebo-controlled trial of faecal microbiome transfer for the treatment of gastrointestinal symptoms in autistic adolescents and adults.

INTRODUCTION: Autism (formally autism spectrum disorder) encompasses a group of complex neurodevelopmental conditions, characterised by differences in communication and social interactions. Co-occurring chronic gastrointestinal symptoms are common among autistic individuals and can adversely affect their quality of life. This study aims to evaluate the efficacy of oral encapsulated faecal microbiome transfer (FMT) in improving gastrointestinal symptoms and well-being among autistic adolescents and adults. METHODS AND ANALYSIS: This double-blind, randomised, placebo-controlled trial will recruit 100 autistic adolescents and adults aged 16-45 years, who have mild to severe gastrointestinal symptoms (Gastrointestinal Symptoms Rating Scale (GSRS) score ≥2.0). We will also recruit eight healthy donors aged 18-32 years, who will undergo extensive clinical screening. Recipients will be randomised 1:1 to receive FMT or placebo, stratified by biological sex. Capsules will be administered over two consecutive days following an overnight bowel cleanse with follow-up assessments at 6, 12 and 26 weeks post-treatment. The primary outcome is GSRS score at 6 weeks. Other assessments include anthropometry, body composition, hair cortisol concentration, gut microbiome profile, urine/plasma gut-derived metabolites, plasma markers of gut inflammation/permeability and questionnaires on general well-being, sleep quality, physical activity, food diversity and treatment tolerability. Adverse events will be recorded and reviewed by an independent data monitoring committee. ETHICS AND DISSEMINATION: Ethics approval for the study was granted by the Central Health and Disability Ethics Committee on 24 August 2021 (reference number: 21/CEN/211). Results will be published in peer-reviewed journals and presented to both scientific and consumer group audiences. TRIAL REGISTRATION NUMBER: ACTRN12622000015741.

Mortality risk among Autistic children and young people: A nationwide birth cohort study.

LAY ABSTRACT: Existing literature indicates that Autistic people have shorter life expectancy, but little is known about the mortality risk among Autistic children and young people (0-24 years). We used a 15-year nationwide birth cohort study to estimate the mortality risk among Autistic children and young people in Aotearoa/New Zealand. The study included 895,707 children and 11,919 (1.4%) were Autistic. We found that autism was associated with a significantly higher mortality risk compared to the non-Autistic population. In addition, we found that this risk was significantly higher among females compared to males and for those with a co-occurring intellectual disability. Increased efforts are required to better meet the health needs of this population.

Not heading in the right direction: Five hundred psychiatrists' views on resourcing, demand, and workforce across New Zealand mental health services.

OBJECTIVE: To explore the views of psychiatrists (including trainees) regarding the current state and future direction of specialist mental health and addictions services in Aotearoa New Zealand. METHODS: Psychiatrists and trainee psychiatrists (registrars) in Aotearoa New Zealand were surveyed in August 2021. Of 879 eligible doctors, 540 participated (83% qualified and 17% trainee psychiatrists), a response rate of over 60%. Data were analysed quantitatively and with content analysis. RESULTS: Psychiatrists thought specialist mental health and addictions services had been neglected during recent reforms, with 94% believing current resourcing was insufficient, and only 3% considering future planning was heading in the right direction. The demand and complexity of on-call work had markedly increased in the preceding 2 years. Ninety-eight percent reported that people needing specialist treatment were often (85%) or sometimes (13%) unable to access the right care due to resourcing constraints. The pressures were similar across sub-specialties. A key theme was the distress (sometimes termed 'moral injury') experienced by psychiatrists unable to provide adequate care due to resource limitations, 'knowing what would be a good thing to do and being unable to do it . . . is soul destroying'. Recommendations were made for addressing workforce, service design and wider issues. CONCLUSION: Most psychiatrists in Aotearoa New Zealand believe the mental health system is not currently fit for purpose and that it is not heading in the right direction. Remedies include urgently addressing identified staffing challenges and boosting designated funding to adequately care for the 5% of New Zealanders with severe mental health and addiction needs.

Proximity of alcohol outlets and presentation to hospital by young people after self-harm: A retrospective geospatial study using the integrated data infrastructure.

OBJECTIVES: There is a well-established association between alcohol use, misuse, intoxication and self-harm, the latter of which is associated with suicide. This study aimed to better understand the association between proximity to alcohol outlets and the likelihood of young people presenting to hospital following self-harm. METHODS: This was a nationwide retrospective geospatial study using data from the New Zealand Integrated Data Infrastructure using population-level data for 10-29-year-olds for the 2018 and 2017 calendar years. Presentations to hospital following self-harm were identified using the national minimum data set. Proximity to alcohol outlets was defined in road network distance (in kilometres) and ascertained using Integrated Data Infrastructure geospatial data. Alternative measures of proximity were employed in sensitivity analyses. Complete-case two-level random intercept logistic regression models were used to estimate the relationship between alcohol outlet proximity and hospital presentation for self-harm. Adjusted models included sex, age, ethnicity, area-level deprivation, urbanicity and distance to nearest medical facility. Analyses were also stratified by urbanicity. RESULTS: Of the 1,285,368 individuals (mean [standard deviation] age 20.0 [5.9] years), 7944 (0.6%) were admitted to hospital for self-harm. Overall, the odds of presenting to hospital for self-harm significantly decreased as the distance from the nearest alcohol outlet increased, including in adjusted models (adjusted odds ratio 0.980; 95% confidence interval = [0.969-0.992]); the association was robust to changes in the measure of alcohol proximity. The effect direction was consistent across all categorisations of urbanicity, but only statistically significant in large urban areas and rural areas. CONCLUSIONS: The findings of this study show a clear association between young people's access to alcohol outlets and presentation to hospital for self-harm and may provide a mandate for government policies and universal interventions to reduce young people's access to alcohol outlets. Further research regarding causative mechanisms is needed.

Exploring the Usability and Acceptability of a Well-Being App for Adolescents Living With Type 1 Diabetes: Qualitative Study.

Background: Adolescents living with either type 1 diabetes (T1D) or type 2 diabetes (T2D) have an increased risk of psychological disorders due to the demands of managing a chronic illness and the challenges of adolescence. Psychological disorders during adolescence increase the risk of suboptimal glycemic outcomes and may lead to serious diabetes-related complications. Research shows that digital health interventions may increase access to psychological support for adolescents and improve physical and mental health outcomes for youth with diabetes. To our knowledge, there are no evidence-based, publicly available mental health apps with a focus on improving the psychological well-being of adolescents with diabetes. Objective: This study aimed to explore the acceptability and usability of our evidence-based well-being app for New Zealand adolescents, Whitu: 7 Ways in 7 Days (Whitu), to allow us to further tailor it for youth with diabetes. We interviewed adolescents with T1D and T2D, their parents, and health care professionals to explore their views on the Whitu app and suggestions for tailoring the app for adolescent with diabetes. We also explored the cultural acceptability of the Whitu app for Maori and Pacific adolescents. Methods: A total of 34 participants, comprising 13 adolescents aged 12-16 years (11 with T1D and 2 with T2D), 10 parents, and 11 health care professionals, were recruited from a specialist diabetes outpatient clinic and Facebook diabetes groups. Each participant attended one 1-hour focus group on Zoom, in person, or via phone. Researchers gathered general feedback on what makes an effective and engaging app for adolescents with diabetes, as well as specific feedback about Whitu. Transcribed audio recordings of the focus groups were analyzed using directed content analysis. Results: Adolescents with T1D, their parents, and health care professionals found Whitu to be acceptable and usable. Adolescents with T1D and their parents signaled a preference for more diabetes-specific content. Health care professionals expressed less awareness and trust of digital health interventions and, as such, recommended that they be used with external support. Due to challenges in recruitment and retention, we were unable to include the views of adolescents with T2D in this qualitative study. Conclusions: There appears to be sufficient openness to the use of an app such as Whitu for supporting the well-being of adolescents with T1D, albeit with modifications to make its content more diabetes specific. Based on this qualitative study, we have recently developed a diabetes-specific version of Whitu (called LIFT: Thriving with Diabetes). We are also planning a qualitative study to explore the views of youth with T2D and their perspectives on the new LIFT app, where we are using alternative research approaches to recruit and engage adolescents with T2D and their families.

An open-label pilot trial of faecal microbiome transfer to restore the gut microbiome in anorexia nervosa: protocol.

INTRODUCTION: Individuals with anorexia nervosa (AN) harbour distinct gut microbiomes compared with healthy individuals, which are sufficient to induce weight loss and anxiety-like behaviours when transplanted into germ-free mice. We hypothesise that faecal microbiome transfer (FMT) from healthy donors would help restore the gut microbiome of individuals with AN, which in turn, may aid patient recovery. METHODS: We aim to conduct an open-label pilot study in 20 females aged 16-32 years in Auckland, New Zealand who meet the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for AN and have a body mass index 13-19 kg/m2. We will recruit four healthy, lean, female donors, aged 18-32 years, who will undergo extensive clinical screening prior to stool donation. Faecal microbiota will be harvested from donors and double encapsulated in delayed release, acid-resistant capsules. All participants will receive a single course of 20 FMT capsules (five from each donor) which they can choose to take over two or four consecutive days. Stool and blood samples will be collected from participants over a period of 3 months to assess their gut microbiome profile, metabolome, levels of intestinal inflammation and nutritional status. Our primary outcome is a shift in the gut microbiome composition at 3 weeks post-FMT (Bray-Curtis dissimilarity). We will also monitor participants' body composition (whole-body dual-energy X-ray absorptiometry scans), eating disorder psychopathology, mental health and assess their views on, and tolerability of, treatment. All adverse events will be recorded and reviewed by an independent data monitoring committee. ETHICS AND DISSEMINATION: Ethics approval was provided by the Central Health and Disability Ethics Committee (Ministry of Health, New Zealand, 21/CEN/212). Results will be published in peer-reviewed journals and presented to both scientific and consumer group audiences. TRIAL REGISTRATION NUMBER: ACTRN12621001504808.

Acceptability and Feasibility of "Village," a Digital Communication App for Young People Experiencing Low Mood, Thoughts of Self-harm, and Suicidal Ideation to Obtain Support From Family and Friends: Mixed Methods Pilot Open Trial.

BACKGROUND: Young people experiencing low mood, thoughts related to self-harm, and suicidal ideation often struggle to communicate their emotions and receive timely support from family and friends. Technologically delivered support interventions may be useful in addressing this need. OBJECTIVE: This paper aimed to evaluate the acceptability and feasibility of "Village," a communication app co-designed with young people and their family and friends from New Zealand. METHODS: A mixed methods pilot open trial design was adopted. Participants were primarily recruited via social media advertisements and clinicians in specialist mental health services over an 8-month period. The primary outcomes were acceptability of the app (via thematically analyzed qualitative feedback and retention rates) and feasibility of conducting a larger randomized controlled trial gauged via effectiveness of recruitment methods, completion of chosen outcome measures, and occurrence of unanticipated operational issues. Secondary outcomes were app usability, safety, and changes in symptoms of depression (via the Patient Health Questionnaire-9 modified for adolescents), suicidal ideation (on the Suicidal Ideation Questionnaire), and functioning (using the World Health Organization Disability Assessment Schedule 2.0 or Child and Youth version). RESULTS: A total of 26 young people ("users") were enrolled in the trial, of which 21 recruited friends and family members ("buddies") and completed quantitative outcome measures at baseline, 4 weeks, and 3 months. Furthermore, 13 users and 12 buddies also provided qualitative feedback about the app, identifying the key themes of appeal of app features and layout, usefulness of its content, and technological challenges (primarily with onboarding and notifications). Users gave Village a mean rating of 3.8 (range 2.7-4.6) out of 5 on a 5-point scale for app quality and an overall star rating of 3.4 out of 5 for subjective quality. Within this limited sample, users reported a clinically significant reduction in depressive symptoms (P=.007), but nonsignificant changes in suicidal ideation and functioning. The embedded risk detection software was activated on 3 occasions, and no additional support was required for users. CONCLUSIONS: During this open trial, Village was found to be acceptable, usable, and safe. The feasibility of a larger randomized controlled trial was also confirmed after some modifications to the recruitment strategy and app. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Network Registry ACTRN12620000241932p; https://tinyurl.com/ya6t4fx2.

Identifying neurodevelopmental disabilities from nationalised preschool health check.

OBJECTIVE: Models of psychometric screening to identify individuals with neurodevelopmental disabilities (NDDs) have had limited success. In Aotearoa/New Zealand, routine developmental surveillance of preschool children is undertaken using the Before School Check (B4SC), which includes psychometric and physical health screening instruments. This study aimed to determine whether combining multiple screening measures could improve the prediction of NDDs. METHODS: Linked administrative health data were used to identify NDDs, including attention deficit hyperactivity disorder, autism spectrum disorder and intellectual disability, within a multi-year national cohort of children who undertook the B4SC. Cox proportional hazards models, with different combinations of potential predictors, were used to predict onset of a NDD. Harrell's c-statistic for composite models were compared with a model representing recommended cutoff psychometric scores for referral in New Zealand. RESULTS: Data were examined for 287,754 children, and NDDs were identified in 10,953 (3.8%). The best-performing composite model combining the Strengths and Difficulties Questionnaire, the Parental Evaluation of Developmental Status, vision screening and biological sex had 'excellent' predictive power (C-statistic: 0.83) compared with existing referral pathways which had 'poor' predictive power (C-statistic: 0.68). In addition, the composite model was able to improve the sensitivity of NDD diagnosis detection by 13% without any reduction in specificity. CONCLUSIONS: Combination of B4SC screening measures using composite modelling could lead to significantly improved identification of preschool children with NDDs when compared with surveillance that rely on individual psychometric test results alone. This may optimise access to academic, personal and family support for children with NDDs.

Editorial: Control alt delete - technology and children's mental health.

With international contributions from Denmark, Peru, Italy, Turkey, Estonia, Russia, Canada, the USA, Australia and the UK, this special issue offers insights and evidence about the technology's ability to act as a force of good and a source of harm for young people's mental health. As we better understand the complex and bidirectional relationship between technology and mental health, we need to move beyond dichotomous narratives about it being good or bad; it is both, depending on how it is used. Collective responsibility across technology companies, researchers, public services and community organisations, parents and the young people themselves can make a difference in the way technology is used to protect and improve mental health.

Mental health inequities for Maori youth: a population-level study of mental health service data.

AIM: To examine specialist mental health service, hospital discharge, and pharmaceutical dispensing data for emotional conditions (anxiety, depression), substance use, and self-harm for Maori compared to non-Maori/non-Pasifika (NMNP) youth. METHODS: A novel population-level case identification method using New Zealand's Integrated Data Infrastructure for 232,845 Maori and 627,891 NMNP aged 10-24 years. Descriptive statistics on mental health conditions were generated and stratified by Maori/NMNP. Unadjusted and adjusted risk ratios (RRs) of mental health conditions were generated using generalised linear regression. RESULTS: Maori were less likely to be identified for anxiety (ARR=0.88; 95% CI 0.85-0.90) or depression (ARR=0.92; 95% CI 0.90-0.95) than NMNP. They were more likely to be identified for substance problems (ARR)=2.66; 95% CI 2.60-2.71) and self-harm (ARR=1.56; 95% CI 1.50-1.63). Maori living in high deprivation areas were significantly more likely to be identified for substance problems, but less likely for emotional conditions, than Maori in least deprived areas. CONCLUSION: Despite known high levels of mental health concerns for rangatahi Maori, administrative data suggests significant under-reporting, assessment, and treatment of emotional conditions relative to NMNP. These differences were exacerbated by deprivation. Maori were more likely to be referred to services for externalised symptoms of distress (substance use and self-harm).

Young people don't tend to ask for help more than once: Child and adolescent psychiatrists' views on ailing mental health services for young New Zealanders.

OBJECTIVES: To explore the views of New Zealand doctors working in child and adolescent psychiatry regarding the state of public mental health services. METHODS: All practicing child and adolescent psychiatrists/advanced trainees were electronically surveyed in August 2021. Quantitative and qualitative analysis of feedback was undertaken. RESULTS: Almost 100 specialists responded, an 80% response rate. High levels of dissatisfaction with current services and future service plans were identified. Content analysis identified an overarching theme that child and adolescent services were under great pressure, with subthemes of increased demand, a stretched workforce and social issues driving complex presentations. Recommendations were made for addressing workforce, service design and wider issues. CONCLUSIONS: Multiple measures are needed to improve currently ailing child mental health services, including urgently expanding the number of psychiatrists and other clinical staff.

'As Long as It's Used for Beneficial Things': An Investigation of non-Maori, Maori and Young People's Perceptions Regarding the Research use of the Aotearoa New Zealand Integrated Data Infrastructure (IDI).

The Aotearoa New Zealand Integrated Data Infrastructure (IDI) is a national database containing a wide range of data about people and households. There is limited information about public views regarding its use for research.A qualitative study was undertaken to examine the views of forty individuals attending a large hospital in Auckland, including those of Maori ethnicity and young people. Semi-structured interview data were analysed using Braun and Clarke's method of thematic analysis.Seven key themes emerged: 1) Limited knowledge about medical data held in national databases; 2) Conditional support for the use of the IDI, including for research; 3) Concerns regarding the misuse of IDI data; 4) The importance of privacy; 5) Different views regarding consent for use of data for research; 6) Desire for access to personal data and the results of research; and 7) Concerns regarding third party and commercial use. Young people and those of Maori ethnicity were more wary of data misuse than others.Although there is reasonable support for the secondary use of public administrative data in the IDI for research, there is more work to be done to ensure ethical and culturally appropriate use of this data via improved consent privacy management processes and researcher training.

Well-being app to support young people during the COVID-19 pandemic: randomised controlled trial.

OBJECTIVES: To evaluate the efficacy and acceptability of 'Whitu: seven ways in seven days', a well-being application (app) for young people. DESIGN: Prospective randomised controlled trial of Whitu against waitlist control, with 45 participants in each arm. PARTICIPANTS: 90 New Zealand young people aged 16-30 recruited via a social media advertising campaign. SETTING: Participants' homes. INTERVENTIONS: Developed during the COVID-19 pandemic, and refined from a prototype version that was evaluated during a smaller qualitative study, 'Whitu: seven ways in seven days' is a well-being app that, as its name suggests, contains seven modules to help young people (1) recognise and rate emotions, (2) learn relaxation and mindfulness, (3) practice self-compassion and (4) gratitude, (5) connect with others, (6) care for their physical health and (7) engage in goal-setting. It can be completed within a week or as desired. MAIN OUTCOME MEASURES: Primary outcomes were changes in well-being on the WHO 5-item Well-Being Index and Short Warwick-Edinburgh Mental Well-Being Scale. Secondary outcomes were changes in depression on the Centre for Epidemiological Studies Depression Scale, anxiety on the Generalised Anxiety Disorder 7-item Scale, self-compassion on the Self Compassion Scale-Short Form, stress on the 10-item Perceived Stress Scale, sleep on the single-item Sleep Quality Scale and user engagement on the end-user version of the Mobile Application Rating Scale and via qualitative feedback during an online survey. Outcomes were evaluated at baseline, 4 weeks (primary study endpoint) and 3 months, and analysed using linear mixed models with group, time and a group-time interaction. RESULTS: At 4 weeks, participants in the Whitu group experienced significantly higher emotional (Mean difference (md) 13.19 (3.96 to 22.42); p=0.005) and mental (md 2.44 (0.27 to 4.61); p=0.027) well-being, self-compassion (md 0.56 (0.28 to 0.83); p<0.001) and sleep (md 1.13 (0.24 to 2.02); p=0.018), and significantly lower stress (md -4.69 (-7.61 to -1.76); p=0.002) and depression (md -5.34 (-10.14 to -0.53); p=0.030), compared with the waitlist controls. Group differences remained statistically significant at 3 months for all outcomes. Symptoms of anxiety were also lower in the intervention group at 4 weeks (p=0.096), with statistically significant differences at 3 months (md -2.31 (-4.54 to -0.08); p=0.042). Usability of Whitu was high (subjective ratings of 4.45 (0.72) and 4.38 (0.79) out of 5 at 4 weeks and 3 months, respectively) and qualitative feedback indicated individual and cultural acceptability of the app. CONCLUSIONS: Given the evolving psychological burden of the COVID-19 pandemic, Whitu could provide a clinically effective and scalable means of improving the well-being, mental health and resilience of young people. Replication of current findings with younger individuals and in other settings is planned. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12620000516987).

Immersive Reality Experience Technology for Reducing Social Isolation and Improving Social Connectedness and Well-being of Children and Young People Who Are Hospitalized: Open Trial.

BACKGROUND: Children and young people who are hospitalized can feel disconnected from their peers and families, which can, in turn, predispose them to psychological problems, including anxiety and depression. Immersive reality experience technology, recently developed by the New Zealand Patience Project Charitable Trust, may help to overcome these issues. Immersive reality experience technology uses immersive 360° live streaming and a virtual reality headset to enable children and young people who are hospitalized to connect through cameras located in either their school or home environment and via SMS text messaging with a designated buddy. OBJECTIVE: This trial aims to expand qualitative findings from a previous smaller proof of concept trial to ascertain the views of New Zealand children and young people who are hospitalized, their caregivers, and teachers regarding immersive reality experience technology and quantitatively evaluate the effectiveness of immersive reality experience technology in reducing social isolation and improving social connectedness and well-being using validated outcome measures. METHODS: An open trial of immersive reality experience technology was conducted between December 2019 and December 2020 for which 19 New Zealand children and young people aged 13 to 18 years who had been hospitalized at Starship Hospital-a specialist pediatric hospital in Auckland-for at least 2 weeks were recruited. All young people completed the Short Warwick-Edinburgh Mental Well-Being Scale, an abbreviated version of the Social Connectedness Scale, and the Social Inclusion Scale at baseline. Of the 19 participants, 10 (53%) used immersive reality experience technology as often as they wished over a 6-week period and completed postintervention measures. Semistructured interviews with a subset of the 10 young people, 4 caregivers, and 6 teachers were conducted immediately after the intervention. RESULTS: Participants reported improvements in social inclusion (mean change 3.9, SD 2.8; P=.06), social connectedness (mean change 14.2, SD 10.0; P=.002), and well-being (mean change 5.7, SD 4.0; P=.001). Key themes from interviews with participants, caregivers, and teachers were the importance of support for using immersive reality experience technology, connecting versus connectedness, choice and connection, and the value of setting it up and getting it right. Recommendations for improving connectedness via immersive reality experience and related technologies were also provided. CONCLUSIONS: Immersive reality experience technology can improve the social inclusion, social connectedness, and well-being of New Zealand children and young people who are hospitalized. With some technological modifications and simplified implementation, immersive reality experience and related technology could become part of standard care and support children and young people who are hospitalized in New Zealand and elsewhere to sustain family and peer cohesion, experience fewer psychological problems, and more easily return to normal life following the completion of treatment. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Network Registry ACTRN12619000252112; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376837&isReview=true.

The relationship between diet and sleep in 2-y-old children: Results from Growing Up in New Zealand.

OBJECTIVES: This study aimed to examine the relationship between dietary practices and sleep in young children. METHODS: In this study, 2-y-old children (n = 6327) and their mothers were enrolled at birth and during pregnancy, respectively. The study obtained maternal demographic, health, and lifestyle data during late pregnancy. Parents reported the 2-y-old child's dietary practices on a food frequency questionnaire, as well as sleep duration and night-waking frequency. Measures of dietary intake quantified servings per day for each food group (grouped as low/moderate/high intake). Sleep measures were as inadequate sleep when <11 h sleep in a 24-h period and increased night waking when waking ≥2 times per night. Multivariable logistic regression analyses examined associations between toddler diet and sleep, which were described using adjusted odds ratios (ORs) and 95% confidence intervals. RESULTS: In this study, 2-y-old children (n = 6288) slept for a mean of 12.3 hours (standard deviation: ±1.5 hours) over a 24-h period, with 734 children (12%) getting <11 h of sleep in 24 h. Increased night waking occurred in 1063 children (17%). Compared with low intake, high soft drink/snack/fast food intake was associated with inadequate sleep (OR: 1.37) and increased night waking (OR: 1.34). High milk/cheese/yoghurt intake (OR: 1.55) was associated with increased odds of night waking, but moderate (OR: 0.81) or high (OR: 0.78) vegetable intake was associated with decreased odds of night waking. Exposure to screens (OR: 1.28) and heavy maternal cigarette smoking (OR: 2.20) were also associated with inadequate sleep and increased night waking, respectively. CONCLUSIONS: At age 2 y, higher consumption of soft drinks/snacks/fast foods is associated with shorter, more disrupted sleep. Conversely, higher vegetable consumption is associated with less disrupted sleep. Dietary modifications may improve toddlers' sleep.

A Survey of Autistic Adults from New Zealand on the Autism Diagnostic Process During Adolescence and Adulthood.

The diagnostic experiences of autistic adults in New Zealand have not been investigated and little is known globally about autistic adults' satisfaction with the autism diagnostic process. This study describes the diagnostic experiences of 70 autistic adults living in New Zealand and explores how these experiences are related to satisfaction during three stages of the diagnostic process. The results show that autistic adults were reasonably satisfied with the early query and diagnostic assessment stages, but were dissatisfied with the post-diagnostic support stage, with significant unmet needs. Dissatisfaction during the post-diagnostic support stage was also related to satisfaction during previous stages and poor coordination of supports. Suggestions are made on how to improve the autism diagnostic pathway for autistic adults in New Zealand.

Pilot study of a well-being app to support New Zealand young people during the COVID-19 pandemic.

BACKGROUND: Well-being apps represent a promising and scalable approach for improving mental health outcomes in youth, especially during a global pandemic when access to face-to-face interventions may be limited. Whitu (meaning 7 in the New Zealand Maori language Te Reo) is a newly developed well-being app with 7 modules that support young people to learn and practice evidence-based coping skills, including relaxation, mindfulness, self-compassion, and goal-setting. OBJECTIVE: During this pilot, we explored the acceptability, usability, and preliminary efficacy of Whitu before refining the app for a randomized controlled trial (RCT). METHODS: We recruited 20 New Zealand young people aged 16-25 years via social media to trial the first prototype of the Whitu app over 6 weeks. Within-group differences from baseline to 2- and 6-weeks post intervention in self-reported well-being, depression, anxiety, stress, self-compassion, optimism and sleep quality were evaluated using repeated-measures ANOVA. A further 21 participants aged 16-30 years were recruited to participate in 4 focus groups to give feedback on the app's usability and cultural acceptability. Feedback was analysed using directed content analysis. RESULTS: Statistically significant improvements in anxiety (p = 0.024) and stress (p = 0.017) were observed from baseline to 2-weeks post intervention. Improvements in well-being (p = 0.021), depression (p = 0.031), anxiety (p = 0.005), and stress (p = 0.004) were also observed from baseline to 6-weeks. No statistically significant changes were seen in self-compassion, optimism, or sleep quality. Effect sizes (partial η2s) ranged from 0.25 (depression) to 0.42 (stress). Qualitative feedback comprised of five key themes, namely: factors affecting engagement, issues with functionality, preferences regarding aesthetics, effectiveness and adverse effects, and cultural acceptability. CONCLUSIONS: Our preliminary results suggest that Whitu may be an effective app for improving multiple dimensions of young people's well-being. Modifications to the look and feel, cultural content, and onboarding have been undertaken based on the qualitative feedback, and an RCT is currently underway.

A Cognitive Behavioral Therapy-, Biofeedback-, and Game-Based eHealth Intervention to Treat Anxiety in Children and Young People With Long-Term Physical Conditions (Starship Rescue): Co-design and Open Trial.

BACKGROUND: Approximately 10%-12% of New Zealand children and young people have long-term physical conditions (chronic illnesses) and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse health care and poorer long-term outcomes. Recently, eHealth interventions, especially those based on principles of cognitive behavioral therapy and biofeedback, have been shown to be moderately effective in reducing anxiety. However, these modalities have rarely been combined. Young people have expressed a preference for well-designed and technology-based support to deal with psychological issues. OBJECTIVE: This study aims to co-design and evaluate the acceptability and usability of a cognitive behavioral therapy and biofeedback-based, 5-module eHealth game called Starship Rescue and to provide preliminary evidence regarding its effectiveness in addressing anxiety and quality of life in young people with long-term physical conditions. METHODS: Starship Rescue was co-designed with 15 children and young people from a tertiary hospital in New Zealand. Following this, 24 others aged 10-17 years participated in an open trial of the game, accessing it over an 8-week period. The acceptability of the game to all participants was assessed using a brief, open-ended questionnaire. More detailed feedback was obtained from a subset of 10 participants via semistructured interviews. Usability was evaluated via device-recorded frequency and duration of access on completion of the game and the System Usability Scale. Anxiety levels were measured at baseline, completion, and 3 months after completion of the game using the Generalized Anxiety Disorder 7-item scale and Spence Child Anxiety Scale, and at the start of each module and on completion using an embedded Likert visual analog scale. Quality of life was measured at baseline, completion, and 3 months after completion using the Pediatric Quality of Life Inventory scale. RESULTS: Users gave Starship Rescue an overall rating of 5.9 out of 10 (range 3-10) and a mean score of 71 out of 100 (SD 11.7; minimum 47.5; maximum 90) on the System Usability Scale. The mean period for the use of the game was just over 11 weeks (78.8 days, 13.5 hours, 40 minutes). Significant reductions in anxiety were noted between the start and end of the game on the Generalized Anxiety Disorder 7-item scale (-4.6; P<.001), Spence Child Anxiety Scale (-9.6; P=.005), and the Likert visual analog scales (-2.4; P=.001). Quality of life also improved on the Pediatric Quality of Life Inventory scale (+4.3; P=.04). All changes were sustained at the 3-month follow-up. CONCLUSIONS: This study provides preliminary evidence for Starship Rescue as an acceptable, usable, and effective eHealth intervention for treating anxiety in young people with long-term physical conditions. Further evaluation is planned via a randomized controlled trial. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Network Registry (ANZCTR) ACTRN12616001253493; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443.