Editorial Perspective: How Sir Michael Rutter revolutionised our understanding of human development: An introduction to a systematic Digest of his life's work.

Professor Sir Michael Rutter died on 23 October 2021. He had made an unparalleled and profound contribution to the science underpinning our understanding of the origins and development of psychopathology in children and young people. The unique combination of reforming motivations, intellectual curiosity and commitment to hypothesis-driven science that made this possible are discussed in the editorial for this issue (Sonuga-Barke, Fearon & Scott, 2022). I have recently compiled a systematic and comprehensive Digest of his life's work - 546 journal papers and 52 books published [https://doi.org/10.13056/acamh.13072]. This Editorial Perspective will summarise some highlights of the main areas of his many scientific achievements.

Language and reading comprehension in middle childhood predicts emotional and behaviour difficulties in adolescence for those with permanent childhood hearing loss.

BACKGROUND: Permanent childhood hearing loss (PCHL) is associated with an elevated level of emotional and behaviour difficulties (EBD). In children and adolescents with PCHL, EBD has been found to be linked to language ability in children with PCHL. The present study was designed to test whether childhood language and/or reading comprehension abilities of children with PCHL predict subsequent EBD in adolescence. METHODS: Language comprehension (LC) and reading comprehension (RC) were measured at ages 6-10 years (Time 1) and 13-20 years (Time 2) in participants with PCHL who preferred to communicate using spoken language (n = 57) and a hearing comparison group (n = 38). EBD was measured at both time points by parent and by teacher ratings on the Strengths and Difficulties Questionnaire. RESULTS: Within the PCHL group there were negative correlations between EBD scores and concurrent LC and RC scores at Time 1 and at Time 2. Cross-lagged latent variable models fitted to the longitudinal data indicated that the associations between LC, RC and teacher-rated EBD were more likely to arise from the impact of LC and RC on behaviour rather than the other way around. CONCLUSIONS: In those with PCHL, poor language and reading comprehension in middle childhood increased the risk of emotional and behaviour difficulties at school in the teenage years. The results suggest that effective language and literacy interventions for children with hearing loss may also bring benefits to their mental health.

Language Outcomes in Deaf or Hard of Hearing Teenagers Who Are Spoken Language Users: Effects of Universal Newborn Hearing Screening and Early Confirmation.

OBJECTIVES: This study aimed to examine whether (a) exposure to universal newborn hearing screening (UNHS) and b) early confirmation of hearing loss were associated with benefits to expressive and receptive language outcomes in the teenage years for a cohort of spoken language users. It also aimed to determine whether either of these two variables was associated with benefits to relative language gain from middle childhood to adolescence within this cohort. DESIGN: The participants were drawn from a prospective cohort study of a population sample of children with bilateral permanent childhood hearing loss, who varied in their exposure to UNHS and who had previously had their language skills assessed at 6-10 years. Sixty deaf or hard of hearing teenagers who were spoken language users and a comparison group of 38 teenagers with normal hearing completed standardized measures of their receptive and expressive language ability at 13-19 years. RESULTS: Teenagers exposed to UNHS did not show significantly better expressive (adjusted mean difference, 0.40; 95% confidence interval [CI], -0.26 to 1.05; d = 0.32) or receptive (adjusted mean difference, 0.68; 95% CI, -0.56 to 1.93; d = 0.28) language skills than those who were not. Those who had their hearing loss confirmed by 9 months of age did not show significantly better expressive (adjusted mean difference, 0.43; 95% CI, -0.20 to 1.05; d = 0.35) or receptive (adjusted mean difference, 0.95; 95% CI, -0.22 to 2.11; d = 0.42) language skills than those who had it confirmed later. In all cases, effect sizes were of small size and in favor of those exposed to UNHS or confirmed by 9 months. Subgroup analysis indicated larger beneficial effects of early confirmation for those deaf or hard of hearing teenagers without cochlear implants (N = 48; 80% of the sample), and these benefits were significant in the case of receptive language outcomes (adjusted mean difference, 1.55; 95% CI, 0.38 to 2.71; d = 0.78). Exposure to UNHS did not account for significant unique variance in any of the three language scores at 13-19 years beyond that accounted for by existing language scores at 6-10 years. Early confirmation accounted for significant unique variance in the expressive language information score at 13-19 years after adjusting for the corresponding score at 6-10 years (R change = 0.08, p = 0.03). CONCLUSIONS: This study found that while adolescent language scores were higher for deaf or hard of hearing teenagers exposed to UNHS and those who had their hearing loss confirmed by 9 months, these group differences were not significant within the whole sample. There was some evidence of a beneficial effect of early confirmation of hearing loss on relative expressive language gain from childhood to adolescence. Further examination of the effect of these variables on adolescent language outcomes in other cohorts would be valuable.

Emotional and behavioural difficulties in children and adolescents with hearing impairment: a systematic review and meta-analysis.

The aim of this study is to estimate the extent to which children and adolescents with hearing impairment (HI) show higher rates of emotional and behavioural difficulties compared to normally hearing children. Studies of emotional and behavioural difficulties in children and adolescents were traced from computerized systematic searches supplemented, where appropriate, by studies referenced in previous narrative reviews. Effect sizes (Hedges' g) were calculated for all studies. Meta-analyses were conducted on the weighted effect sizes obtained for studies adopting the Strength and Difficulties Questionnaire (SDQ) and on the unweighted effect sizes for non-SDQ studies. 33 non-SDQ studies were identified in which emotional and behavioural difficulties in children with HI could be compared to normally hearing children. The unweighted average g for these studies was 0.36. The meta-analysis of the 12 SDQ studies gave estimated effect sizes of 0.23 (95% CI 0.07, 0.40), 0.34 (95% CI 0.19, 0.49) and -0.01 (95% CI -0.32, 0.13) for Parent, Teacher and Self-ratings of Total Difficulties, respectively. The SDQ sub-scale showing consistent differences across raters between groups with HI and those with normal hearing was Peer Problems. Children and adolescents with HI have scores on emotional and behavioural difficulties measures about a quarter to a third of a standard deviation higher than hearing children. Children and adolescents with HI are in need of support to help their social relationships particularly with their peers.

Research review: the role of diet in the treatment of attention-deficit/hyperactivity disorder--an appraisal of the evidence on efficacy and recommendations on the design of future studies.

BACKGROUND: The efficacy of three dietary treatments for ADHD has been repeatedly tested in randomized controlled trials (RCTs). These interventions are restricted elimination diets (RED), artificial food colour elimination (AFCE) and supplementation with free fatty acids (SFFA). There have been three systematic reviews and associated meta-analyses of the RCTs for each of these treatments. SCOPE: The aim of this review is to critically appraise the studies on the dietary treatments of ADHD, to compare the various meta-analyses of their efficacy that have been published and to identify where the design of such RCTs could be improved and where further investigations are needed. FINDINGS: The meta-analyses differ in the inclusion and exclusion criteria applied to potentially eligible studies. The range of average effect sizes in standard deviation units is RED (0.29-1.2), AFCE (0.18-0.42) and SFFA (0.17-0.31). The methodology of many of the trials on which the meta-analyses are based is weak. CONCLUSIONS: Nevertheless, there is evidence from well-conducted studies for a small effect of SFFA. Restricted elimination diets may be beneficial, but large-scale studies are needed on unselected children, using blind assessment and including assessment of long-term outcome. Artificial food colour elimination is a potentially valuable treatment but its effect size remains uncertain, as does the type of child for whom it is likely to be efficacious. There are additional dietary supplements that have been used with children with ADHD. A systematic search identified 11 RCTs that investigated the effects of these food supplements. Despite positive results for some individual trials, more studies are required before conclusions can be reached on the value in reducing ADHD symptoms of any of these additional supplements.

Editorial: Accumulating Evidence for the Benefit of Micronutrients for Children With Attention-Deficit/Hyperactivity Disorder.

The first paper indicating that a central nervous system stimulant (amphetamine) could be beneficial for children with attention-deficit/hyperactivity disorder (ADHD)-like behavioral symptoms appeared in 1937.1 Over the subsequent 80 years, a range of additional stimulant (methylphenidate) and nonstimulant (atomoxetine, clonidine, guanfacine, and, most recently, viloxazine) drugs have been approved to treat children and adolescents with ADHD. These drug treatments have been the subject of a large number of randomized controlled trails (RCTs). A network meta-analysis found that using clinician ratings, amphetamine, methylphenidate, and atomoxetine were all significantly superior to a placebo.2 These findings suggest that in the short-term at least, these treatments are effective-data are sparse on the efficacy of longer-term drug treatment. However, there are longstanding worries about the use of such drug treatments with children. In particular there are concerns over possible adverse impact on growth. There are also less tangible, but important, concerns of parents as the whether it is appropriate to subject their children to the modification of behavior by drugs.3 For these reasons, there is an urgent need to develop nonpharmacological treatments for children and adolescents with ADHD. One such nonpharmacological treatment is dietary supplementation with micronutrients. In this issue of the Journal, Johnstone et al.4 present a study of micronutrients showing that, under the stringent conditions of an RCT, micronutrients substantially benefit the well-being of young people with ADHD and irritability (risk ratio [RR] = 2.97; 97.5% CI = 1.50-5.90).

The effect of early confirmation of hearing loss on the behaviour in middle childhood of children with bilateral hearing impairment.

AIM: To determine if the benefit of early confirmation of permanent childhood hearing impairment (PCHI) on children's receptive language development is associated with fewer behavioural problems. METHOD: Follow-up of a total population cohort of 120 children with PCHI of moderate or greater severity (≥ 40 decibels relative to hearing threshold level) (67 males, 53 females; mean age 7 y 11 mo, range 5 y 5 mo-11 y 8 mo) and 63 hearing children (37 males, 26 females; mean age 8 y 1 mo, range 6 y 4 mo-9 y 10 mo). The main outcome measures were the Strengths and Difficulties Questionnaire (SDQ) completed by teachers and parents and the Vineland Adaptive Behaviour Scales (VABS) which are completed on the basis of a parental interview. RESULTS: Children with PCHI had lower standard scores than hearing children on the Daily Living Skills (p=0.001) and the Socialisation (p=0.001) scales of the VABS. They had significantly higher Total Behaviour Problem scores on the parent-rated (p=0.002) and teacher-rated SDQ (p=0.03). Children for whom PCHI was confirmed by 9 months did not have significantly fewer problems on the behavioural measures than those confirmed after that age (p=0.635 and p=0.196). INTERPRETATION: Early confirmation has a beneficial effect on receptive language development but no significant impact in reducing behavioural problems in children with PCHI.

The relationship between language development and behaviour problems in children with hearing loss.

BACKGROUND: There are well-replicated findings that link poor development on a range of communication skills with increased behavioural problems. This paper examines this relationship in children with hearing loss. METHOD: One hundred and twenty children with hearing loss (67 boys, 53 girls) and 63 hearing children (37 boys, 26 girls) with a mean age of 8 years from eight districts in Southern England were assessed for receptive and expressive language skills. The relationships between these measures and an aggregate of parent- and teacher-reported behaviour problems in the children were investigated. RESULTS: Children with hearing loss had higher levels of behaviour problems compared to hearing children. Once the language abilities of children with hearing loss are taken into account, the negative effects of hearing loss on behaviour disappear. CONCLUSIONS: Behaviour problems are found more commonly in children with hearing loss and the level of behaviour problems is highest amongst those children with hearing loss with the least developed language capabilities.

A comparison of actigraphy and parental report of sleep habits in typically developing children aged 6 to 11 years.

There are limited published data comparing the information provided by parental reports of sleep habits with actigraphic information. This study compares parental report of sleep habits using the Children's Sleep Habits Questionnaire with actigraphic data in 91 typically developing children aged 6 to 11 years. The study found that sleep duration (as measured using actigraphy [ACT]) was longer in children whose parents rated their child as having enough sleep. Parental reports of night wakings did not correspond with ACT measures of night wakings. The findings show that ACT and parental reports provide differing, but complimentary, information about a child's sleep habits.

Recent Research on Food Additives: Implications for CAMH.

The question of the possible role of food additives, and specifically food colours, in elevating hyperactive behaviour in children has been long debated. There is now replicated evidence that the removal of food colours from the diet can make a small improvement in the behaviour of some children with ADHD. However, as yet the characteristics of those who benefit from this dietary change are unknown. Two studies from a research group at Southampton have extended this work to show that some children from the general population without ADHD show a similar benefit. The implications of these findings for those in CAMH services are discussed. They are considered alongside other forms of dietary treatment for ADHD such as the use of 'few foods' diet and omega-3 fatty acids.

Sex Differences in the Meaning of Parent and Teacher Ratings of ADHD Behaviors: An Observational Study.

Objective: To test explanations for the underrecognition of female ADHD by examining differences in adult ratings of boys and girls matched for levels of directly observed ADHD behaviors. Method: In a secondary analysis of a population-based sample, 3- to 4-year-olds (n = 153, 79 male) and 8- to 9-year-olds (n = 144, 75 male) were grouped according to levels of directly observed ADHD behaviors (low/moderate/high). Groups were then compared with parent/teacher ADHD ratings. Results: There were no sex differences in levels of directly observed ADHD behaviors within groups. For preschoolers, parents' ratings of males, but not females, significantly increased across groups-mirroring levels of observed behaviors. For older children, both parent and teacher mean ratings were significantly higher for males than females across groups. Conclusion: Identified differences in adult ratings of males and females matched for directly observed behaviors may contribute to understanding the substantial ADHD underrecognition in females.

Language ability after early detection of permanent childhood hearing impairment.

BACKGROUND: Children with bilateral permanent hearing impairment often have impaired language and speech abilities. However, the effects of universal newborn screening for permanent bilateral childhood hearing impairment and the effects of confirmation of hearing impairment by nine months of age on subsequent verbal abilities are uncertain. METHODS: We studied 120 children with bilateral permanent hearing impairment identified from a large birth cohort in southern England, at a mean of 7.9 years of age. Of the 120 children, 61 were born during periods with universal newborn screening and 57 had hearing impairment that was confirmed by nine months of age. The primary outcomes were language as compared with nonverbal ability and speech expressed as z scores (the number of standard deviations by which the score differed from the mean score among 63 age-matched children with normal hearing), adjusted for the severity of the hearing impairment and for maternal education. RESULTS: Confirmation of hearing impairment by nine months of age was associated with higher adjusted mean z scores for language as compared with nonverbal ability (adjusted mean difference for receptive language, 0.82; 95 percent confidence interval, 0.31 to 1.33; and adjusted mean difference for expressive language, 0.70; 95 percent confidence interval, 0.13 to 1.26). Birth during periods with universal newborn screening was also associated with higher adjusted z scores for receptive language as compared with nonverbal ability (adjusted mean difference, 0.60; 95 percent confidence interval, 0.07 to 1.13), although the z scores for expressive language as compared with nonverbal ability were not significantly higher. Speech scores did not differ significantly between those who were exposed to newborn screening or early confirmation and those who were not. CONCLUSIONS: Early detection of childhood hearing impairment was associated with higher scores for language but not for speech in midchildhood.

Self-esteem, negative emotionality, and depression as a common temperamental core: a study of mid-adolescent twin girls.

We tested the structure and magnitude of genetic and environmental influences on the overlap among self-esteem, negative emotionality, and major depression symptoms in adolescent girls (N=706) from the Minnesota Twin Family Study. Genetic and environmental influences on all three operated via a general, heritable factor. Genetic influences explained the majority of overlap among the three constructs, as well as most of the variance in self-esteem and negative emotionality. Genetic influences on depression were more modest and largely due to genetic factors specific to depression. These findings support the theory that self-esteem, depression, and neuroticism represent aspects of a common temperamental core. The interrelations among the three constructs in mid-adolescence is consistent with their interrelations in adulthood.

Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial.

BACKGROUND: We undertook a randomised, double-blinded, placebo-controlled, crossover trial to test whether intake of artificial food colour and additives (AFCA) affected childhood behaviour. METHODS: 153 3-year-old and 144 8/9-year-old children were included in the study. The challenge drink contained sodium benzoate and one of two AFCA mixes (A or B) or a placebo mix. The main outcome measure was a global hyperactivity aggregate (GHA), based on aggregated z-scores of observed behaviours and ratings by teachers and parents, plus, for 8/9-year-old children, a computerised test of attention. This clinical trial is registered with Current Controlled Trials (registration number ISRCTN74481308). Analysis was per protocol. FINDINGS: 16 3-year-old children and 14 8/9-year-old children did not complete the study, for reasons unrelated to childhood behaviour. Mix A had a significantly adverse effect compared with placebo in GHA for all 3-year-old children (effect size 0.20 [95% CI 0.01-0.39], p=0.044) but not mix B versus placebo. This result persisted when analysis was restricted to 3-year-old children who consumed more than 85% of juice and had no missing data (0.32 [0.05-0.60], p=0.02). 8/9-year-old children showed a significantly adverse effect when given mix A (0.12 [0.02-0.23], p=0.023) or mix B (0.17 [0.07-0.28], p=0.001) when analysis was restricted to those children consuming at least 85% of drinks with no missing data. INTERPRETATION: Artificial colours or a sodium benzoate preservative (or both) in the diet result in increased hyperactivity in 3-year-old and 8/9-year-old children in the general population.

Predicting reading ability in teenagers who are deaf or hard of hearing: A longitudinal analysis of language and reading.

BACKGROUND: Deaf and hard of hearing (D/HH) children and young people are known to show group-level deficits in spoken language and reading abilities relative to their hearing peers. However, there is little evidence on the longitudinal predictive relationships between language and reading in this population. AIMS: To determine the extent to which differences in spoken language ability in childhood predict reading ability in D/HH adolescents. METHODS: and procedures: Participants were drawn from a population-based cohort study and comprised 53 D/HH teenagers, who used spoken language, and a comparison group of 38 normally hearing teenagers. All had completed standardised measures of spoken language (expression and comprehension) and reading (accuracy and comprehension) at 6-10 and 13-19 years of age. OUTCOMES: and results: Forced entry stepwise regression showed that, after taking reading ability at age 8 years into account, language scores at age 8 years did not add significantly to the prediction of Reading Accuracy z-scores at age 17 years (change in R2 = 0.01, p = .459) but did make a significant contribution to the prediction of Reading Comprehension z-scores at age 17 years (change in R2  = 0.17, p < .001). CONCLUSIONS: and implications: In D/HH individuals who are spoken language users, expressive and receptive language skills in middle childhood predict reading comprehension ability in adolescence. Continued intervention to support language development beyond primary school has the potential to benefit reading comprehension and hence educational access for D/HH adolescents.

Executive functions in school-age children born very prematurely.

BACKGROUND: School-age preterm children are at risk for cognitive difficulties including Executive Dysfunction and low average IQ. AIM: The aim of this study was to determine the performance of very preterm, school-age children on three components of Executive Function (EF), two components of Executive Attention and a measure of IQ. STUDY DESIGN: Cross-sectional, independent samples comparison. METHODS: A UK sample of 40 very preterm (<32 weeks gestational age, Mean 28.43, SD 2.41) children and 41 term born control children aged between 6 and 12 years (mean ages 8 years 5 months in both groups) was assessed on IQ, EF (inhibition, working memory and set shifting) and attention (sustained and selective). Between group comparisons were made using multivariate analysis of variance and covariance. RESULTS: Multivariate analyses indicated that preterm children scored significantly lower than their term born peers across Executive Function and executive attention tasks. As expected, the preterm group achieved IQ scores at the low end of the average range. Univariate analyses indicated some difficulties with shifting and inhibition components of EF, although covariate analysis revealed that only shifting was independent of IQ. CONCLUSIONS: Preterm children showed mild executive function and executive attention difficulties in the context of average IQ scores. The findings highlight the benefit of using multivariate assessments of executive skills rather than general intellectual outcome alone, to obtain a better distinction of the specific cognitive weaknesses associated with preterm birth.

Emotional and behaviour difficulties in teenagers with permanent childhood hearing loss.

OBJECTIVES: It is known that during the middle childhood years those with permanent childhood hearing loss (PCHL) are at increased risk of showing emotional and behaviour difficulties (EBD). It has yet to be established whether this risk continues into the late teenage years. There is a paucity of longitudinal studies on the association between PCHL and EBD. METHODS: The Strengths and Difficulties Questionnaire (SDQ) was used to measure EBD based on parent, teacher and self-ratings in 76 teenagers with PCHL and 38 in a hearing comparison group (HCG) from a population sample of children that was followed up from birth to adolescence. RESULTS: On parent-rated SDQ, the PCHL group had significantly higher Total Difficulties score than the HCG (Standardised mean difference (SMD) = +0.39, 95%CI 0.00 to 0.79). Amongst the PCHL group the presence of disabilities other than hearing loss had a substantial impact on the level of parent-rated EBD (SMD = +1.68, 1.04 to 2.33). There was a relationship between receptive language ability and EBD in both the HCG (r = -0.33, 95%CI -0.59 to -0.01) and the PCHI group (r = -0.33, 95%CI -0.53 to -0.02). The effect of PCHL on EBD became non-significant when receptive language was included as a covariate (F = 0.12, df = 1,95, p = 0.729). Early confirmation of hearing loss (i.e. before 9 months of age) did not have a significant effect on EBD scores (SMD = +0.31, 95%CI -0.15 to 0.77). CONCLUSIONS: PCHL continues to be associated with elevated EBD scores as measured by parent rated SDQ into the late teenage years but the degree of this elevation is less than in childhood and is not apparent on teacher or self-ratings. Poor receptive language ability appeared to account for these elevated EBD scores in the group with PCHL. Particular attention needs to be paid to the mental health of children and adolescents with PCHL that is accompanied by other disabilities and to those with poor receptive language ability. However, the majority of teenagers with PCHL do not show clinically significant elevated levels of EBD.