Understanding cannabis use and mental health difficulties in context with women's experiences of stressful events and social health issues in pregnancy: The Aboriginal Families Study.

BACKGROUND: Few population-based data sources fully recognise the intersections between stressful events, social health issues, and cannabis use in pregnancy, and little is known about sequelae for women's mental health. METHODS: We draw on two waves of population-based data for 344 families participating in the Aboriginal Families Study longitudinal cohort. We examine women's mental health in the first year postpartum and when children were aged 5-9 years in context with life experiences and use of cannabis in pregnancy. OUTCOMES: One in five women (19·5%) used cannabis during pregnancy (with or without co-use of tobacco). Within this group of women, 88·3% experienced 3 or more (3+) stressful events or social health issues. Psychological distress (Kessler-5 scale, K-5) in the year postpartum was substantially higher amongst women who had used cannabis or experienced 3+ stressful events or social health issues. High proportions of women met criteria for support and referral for depression and/or anxiety (52·5% of women who had used cannabis compared to 20·9% amongst women who had neither used cannabis nor tobacco; 43·2% of women who had experienced 3+ stressful events or social health issues compared to 15·6% amongst women who had not indicated these experiences). Similar patterns of psychological distress, depressive (9-item adapted Personal Health Questionnaire, aPHQ-9) and anxiety symptoms (7-item Generalised Anxiety Disorder score, GAD-7) were evident when the study children were aged 5-9 years. INTERPRETATION: Amongst women who had used cannabis in pregnancy, a high burden of psychological distress, depression, and anxiety is evident in the postpartum period and as their children turn 5-9 years. The overlay of stressful events and social health issues and the high proportion of women meeting criteria for referral for mental health assessment and support indicate an urgent need to offer women opportunities for safe disclosure of cannabis use and opportunities to access sustained holistic services. Reducing the harms of cannabis use on Aboriginal and Torres Strait Islander families must be coupled with culturally safe ways of addressing the social, historical, and structural determinants of mental health distress and harmful use of substances.

Social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples in Aboriginal controlled social housing.

BACKGROUND: Little is known about the wellbeing and aspirations of Aboriginal and Torres Strait Islander peoples living in social housing. Aboriginal and Torres Strait Islander peoples living in social housing face common social housing challenges of low income, higher incidence of mental health issues and poorer health along with specific challenges due to the impacts of colonisation and its ongoing manifestations in racism and inequity. A greater understanding of social and emotional wellbeing needs and aspirations is essential in informing the provision of appropriate support. METHODS: Surveys of social and emotional wellbeing (SEWB) were completed by 95 Aboriginal people aged 16 years and older living in Aboriginal Housing Victoria social housing in 2021. The survey addressed a range of domains reflecting social and emotional wellbeing, as defined by Aboriginal and Torres Strait Islander peoples. RESULTS: Most respondents demonstrated a strong sense of identity and connection to family however 26% reported having 6 or more health conditions. Ill health and disability were reported to be employment barriers for almost a third of people (32%). Improving health and wellbeing (78%) was the most cited aspiration. Experiences of racism and ill health influenced engagement with organisations and correspondingly education and employment. CONCLUSION: Strong connections to identity, family and culture in Aboriginal peoples living in social housing coexist along with disrupted connections to mind, body and community. Culturally safe and appropriate pathways to community services and facilities can enhance these connections. Research aimed at evaluating the impact of strengths-based interventions that focus on existing strong connections will be important in understanding whether this approach is effective in improving SEWB in this population. TRIAL REGISTRATION: This trial was retrospectively registered with the ISRCTN Register on the 12/7/21 with the study ID:ISRCTN33665735.

Associations between responsive parental behaviours in infancy and toddlerhood, and language outcomes at age 7 years in a population-based sample.

BACKGROUND: A wealth of evidence supports the important role high-quality parent-child interactions play in children's early language acquisition. However, the impact on later language outcomes remains unclear. AIMS: To examine the associations between responsive parental behaviours across the early years and child language outcomes at age 7 years with families from an Australian longitudinal cohort study (N = 1148, 50% female). METHODS & PROCEDURES: At child ages 12, 24 and 36 months, parents completed a self-report measure of responsive parental behaviours. Child language was directly assessed at age 7 using the Clinical Evaluation of Language Fundamentals, 4th edition (CELF-4), Australian Standardisation. Linear regression was used to examine associations between responsive parental behaviours from 12 to 36 months (consistently high, inconsistent and consistently low responsive parental behaviours at the three time points) and language scores at age 7 years. Adjusted models were run, including the following potential confounders: child sex; birth weight; birth order; maternal education; socio-economic disadvantage; non-English-speaking background; family history of speech-language problems; mother's vocabulary score; maternal mental health score; and mother's age at birth of child. A final adjusted model was run, including the potential confounder variables as well as adjusting for children's earlier language skills. OUTCOMES & RESULTS: Linear regression results showed children with parents who rated high on responsive parental behaviours at all three time points had higher mean language scores at age 7 than children whose parents reported low responsive parental behaviours across early childhood. This association attenuated after adjusting for earlier child language skills. CONCLUSIONS & IMPLICATIONS: Findings support the consistent use of responsive parental behaviours across the very early years of childhood to support long-term language outcomes. Findings also suggest that models of surveillance and support which monitor and assist families at multiple time-points over the early years are likely to be most effective for preventing ongoing language difficulties. WHAT THIS PAPER ADDS: What is already known on this subject There is extensive evidence consistently demonstrating the important contribution of aspects of parent-child interaction, specifically responsive parental behaviours, to children's language development. What this paper adds to the existing knowledge Understanding the cumulative benefit of responsive parent-child interactions across the very early years may help to inform preventive interventions and service delivery models for supporting young children's language development. This study demonstrates in a large, population-based cohort the contribution of consistency of responsive parental behaviours during infancy and toddlerhood to school-age language outcomes, accounting for other child, family and environmental factors. Capturing regular parent behaviours via self-report during the early years may be a more efficient and less costly method than parent-child interaction observations to monitor the home language-learning environment during routine developmental checks. What are the potential or actual clinical implications of this work? Findings support the need for surveillance of children and families in the early years, ensuring that intervention occurs when families need it most, that is, support is responsive to changing needs and that nuanced advice and support strategies are provided to activate positive developmental cascades. Capturing both parent behaviours and child language may assist clinicians to identify those families who may benefit from parent-child interaction intervention.

Household income and maternal education in early childhood and risk of overweight and obesity in late childhood: Findings from seven birth cohort studies in six high-income countries.

BACKGROUND/OBJECTIVES: This study analysed the relationship between early childhood socioeconomic status (SES) measured by maternal education and household income and the subsequent development of childhood overweight and obesity. SUBJECTS/METHODS: Data from seven population-representative prospective child cohorts in six high-income countries: United Kingdom, Australia, the Netherlands, Canada (one national cohort and one from the province of Quebec), USA, Sweden. Children were included at birth or within the first 2 years of life. Pooled estimates relate to a total of N = 26,565 included children. Overweight and obesity were defined using International Obesity Task Force (IOTF) cut-offs and measured in late childhood (8-11 years). Risk ratios (RRs) and pooled risk estimates were adjusted for potential confounders (maternal age, ethnicity, child sex). Slope Indexes of Inequality (SII) were estimated to quantify absolute inequality for maternal education and household income. RESULTS: Prevalence ranged from 15.0% overweight and 2.4% obese in the Swedish cohort to 37.6% overweight and 15.8% obese in the US cohort. Overall, across cohorts, social gradients were observed for risk of obesity for both low maternal education (pooled RR: 2.99, 95% CI: 2.07, 4.31) and low household income (pooled RR: 2.69, 95% CI: 1.68, 4.30); between-cohort heterogeneity ranged from negligible to moderate (p: 0.300 to < 0.001). The association between RRs of obesity by income was lowest in Sweden than in other cohorts. CONCLUSIONS: There was a social gradient by maternal education on the risk of childhood obesity in all included cohorts. The SES associations measured by income were more heterogeneous and differed between Sweden versus the other national cohorts; these findings may be attributable to policy differences, including preschool policies, maternity leave, a ban on advertising to children, and universal free school meals.

Determinants of eating behaviour in Black, Asian and Minority Ethnic (BAME) university students when living at and away from home: With a focus on the influence of food enculturation and food acculturation.

For some students, university, can be a period of increased autonomy in food choice and for black, Asian and minority ethnic (BAME) and international students, the addition of culture may be a governing factor. This study aimed to examine the extent of dietary acculturation and dietary enculturation on the influence of student's food choices using a phenomenological approach. Sixty participants (forty-one home students and nineteen international students) recruited by purposive sampling, were included in the study. Data collection involved self-administered multiple choice and short answer questionnaires and semi structured interviews. The results were analysed using thematic analysis. When living away from home, six major themes influenced the eating behaviour of the studied population: social environment, individual factors, physical environment, university life, enculturation and acculturation. When at home, five major themes were influential: social environment, individual factors, physical environment, enculturation and acculturation. The main findings suggest dietary enculturation is a factor which influences the dietary behaviour of both international students and BAME home students.

Supporting Aboriginal and Torres Strait Islander Families to Stay Together from the Start (SAFeST Start): Urgent call to action to address crisis in infant removals.

Reducing the rate of over-representation of Aboriginal and Torres Strait Islander children in out-of-home care (OOHC) is a key Closing the Gap target committed to by all Australian governments. Current strategies are failing. The "gap" is widening, with the rate of Aboriginal and Torres Strait Islander children in OOHC at 30 June 2020 being 11 times that of non-Indigenous children. Approximately, one in five Aboriginal and Torres Strait Islander children entering OOHC each year are younger than one year. These figures represent compounding intergenerational trauma and institutional harm to Aboriginal and Torres Strait Islander families and communities. This article outlines systemic failures to address the needs of Aboriginal and Torres Strait Islander parents during pregnancy and following birth, causing cumulative harm and trauma to families, communities and cultures. Major reform to child and family notification and service systems, and significant investment to address this crisis, is urgently needed. The Family Matters Building Blocks and five elements of the Aboriginal and Torres Strait Islander Child Placement Principle (Prevention, Participation, Partnership, Placement and Connection) provide a transformative foundation to address historical, institutional, well-being and socioeconomic drivers of current catastrophic trajectories. The time for action is now.

Diet quality trajectories and cardiovascular phenotypes/metabolic syndrome risk by 11-12 years.

OBJECTIVE: To investigate associations between early-life diet trajectories and preclinical cardiovascular phenotypes and metabolic risk by age 12 years. METHODS: Participants were 1861 children (51% male) from the Longitudinal Study of Australian Children. At five biennial waves from 2-3 to 10-11 years: Every 2 years from 2006 to 2014, diet quality scores were collected from brief 24-h parent/self-reported dietary recalls and then classified using group-based trajectory modeling as 'never healthy' (7%), 'becoming less healthy' (17%), 'moderately healthy' (21%), and 'always healthy' (56%). At 11-12 years: During children's physical health Child Health CheckPoint (2015-2016), we measured cardiovascular functional (resting heart rate, blood pressure, pulse wave velocity, carotid elasticity/distensibility) and structural (carotid intima-media thickness, retinal microvasculature) phenotypes, and metabolic risk score (composite of body mass index z-score, systolic blood pressure, high-density lipoproteins cholesterol, triglycerides, and glucose). Associations were estimated using linear regression models (n = 1100-1800) adjusted for age, sex, and socioeconomic position. RESULTS: Compared to 'always healthy', the 'never healthy' trajectory had higher resting heart rate (2.6 bpm, 95% CI 0.4, 4.7) and metabolic risk score (0.23, 95% CI 0.01, 0.45), and lower arterial elasticity (-0.3% per 10 mmHg, 95% CI -0.6, -0.1) and distensibility (-1.2%, 95% CI -1.9, -0.5) (all effect sizes 0.3-0.4). Heart rate, distensibility, and diastolic blood pressure were progressively poorer for less healthy diet trajectories (linear trends p ≤ 0.02). Effects for systolic blood pressure, pulse wave velocity, and structural phenotypes were less evident. CONCLUSIONS: Children following the least healthy diet trajectory had poorer functional cardiovascular phenotypes and metabolic syndrome risk, including higher resting heart rate, one of the strongest precursors of all-cause mortality. Structural phenotypes were not associated with diet trajectories, suggesting the window to prevent permanent changes remains open to at least late childhood.

Infant Regulation: Associations with Child Language Development in a Longitudinal Cohort.

OBJECTIVE: To determine whether infants who have regulatory problems (eg, sleeping, crying, and feeding problems) at 1 year of age are at increased risk of experiencing language difficulties at ages 5 and 11 years, compared with settled infants. STUDY DESIGN: Parent survey and child assessment data (n = 1131) were drawn from a longitudinal community cohort study. Latent Class Analysis identified 5 profiles of infant regulation including those who were settled (37%), had tantrums (21%), had sleep problems (25%), were moderately unsettled (13%), and severely unsettled (3%) at 12 months of age. Adjusted regression analyses examined associations between infant regulatory profiles and language ability (Clinical Evaluation of Language Fundamentals-fourth edition) at ages 5 and 11 years. RESULTS: Infants who were moderately unsettled had lower language scores at age 5 (adjusted mean difference, -3.89; 95% CI, -6.92 to -0.86) and were more likely to have language difficulties (aOR, 2.71; 95% CI, 1.28-5.75), than infants who were settled. Infants who were severely unsettled at 12 months of age, had lower language scores at ages 5 (adjusted mean difference, -7.71; 95% CI, -13.07 to -2.36) and 11 (adjusted mean difference, -6.50; 95% CI, -11.60 to -1.39), than infants who were settled. Severely unsettled infants were 5 times more likely to have language difficulties at age 5 than their settled counterparts (aOR, 5.01; 95% CI, 1.72-14.63). CONCLUSIONS: Children at 1 year of age with multiple regulatory problems are at an increased risk for poorer language skills at ages 5 and 11 years.

Health-related quality of life of children with low language from early childhood to adolescence: results from an Australian longitudinal population-based study.

BACKGROUND: Low language abilities are known to be associated with significant adverse long-term outcomes. However, associations between low language and health-related quality of life (HRQoL) are unclear. We aimed to (a) examine the association between low language and HRQoL from 4 to 13 years and (b) classify the children's trajectories of HRQoL and language and examine the association between language and HRQoL trajectories. METHODS: Data were from an Australian community-based cohort of children. HRQoL was measured at ages 4-13 years using the parent-reported Pediatric Quality of Life Inventory 4.0. Language was assessed using the Clinical Evaluation of Language Fundamentals (CELF)-Preschool 2nd edition at 4 years and the CELF-4th edition at 5, 7 and 11 years. Multivariable linear regression and mixed effect modelling were used to estimate cross-sectional and longitudinal associations between low language and HRQoL from 4 to 13 years. A joint group-based trajectory model was used to characterize associations between HRQoL and language trajectories over childhood. RESULTS: Children with low language had substantially lower HRQoL than children with typical language from 4 to 13 years. Higher language scores were associated with better HRQoL, particularly in social and school functioning. Three HRQoL trajectories were identified: stable-high (51% of children), reduced with slow decline (40%) and low with rapid decline (9%). Children with low language were less likely to follow a stable-high HRQoL trajectory (40%) while 26% and 34% followed the reduced with slow decline and low with rapid decline trajectories, respectively. CONCLUSIONS: Children with low language experienced reduced HRQoL from 4 to 13 years. More than half had declining trajectories in HRQoL highlighting the need to monitor these children over time. Interventions should not only aim to improve children's language ability but also address the wider functional impacts of low language.

The maternal health study: Study design update for a prospective cohort of first-time mothers and their firstborn children from birth to age ten.

BACKGROUND: Maternal health is critical to the health and well-being of children and families, but is rarely the primary focus of pregnancy and birth cohort studies. Globally, poor maternal health and the exposure of women and children to family violence contribute to the perpetuation and persistence of intergenerational health inequalities. OBJECTIVES: The Maternal Health Study was designed to investigate the contribution of social and obstetric risk factors to common maternal physical and psychological morbidities. Over time, our focus has expanded to include mother-child pairs and investigation of intergenerational trauma and family violence. POPULATION: A total of 1507 first-time mothers were recruited in early pregnancy from six public hospitals in Melbourne, Australia, in 2003-2005. METHODS: Women completed questionnaires or telephone interviews in early pregnancy (≤24 weeks); at 32 weeks' gestation; at three, six, nine, 12 and 18 months postpartum; and at four and ten years. At ten years, women and children were invited to participate in face-to-face interviews, which included direct assessment of children's cognitive and language development. A wide range of obstetric, social and contextual factors have been measured, including exposure to intimate partner violence (IPV) (1-year, 4-year and 10-year follow-up). RESULTS: 1507 eligible women were recruited at a mean gestation of 15 weeks. At one year, four years and ten years postpartum, 90.0%, 73.1% and 63.2% of the original cohort took part in follow-up. One in three women in the study (34.5%) reported exposure to IPV in the first ten years of motherhood: 19% in the first 12 months postpartum, 20% in the year prior to four-year follow-up and 18.3% in the year prior to ten-year follow-up. CONCLUSION: The study affords a unique opportunity to examine patterns of maternal and child health and health service use associated with exposure to IPV.

Patterns of maternal depression, anxiety, and stress symptoms from pregnancy to 5 years postpartum in an Australian cohort experiencing adversity.

The objective of this study is to describe the longitudinal patterns of depression, anxiety, and stress symptoms from pregnancy to 5 years postpartum, in a cohort of Australian mothers experiencing adversity. Longitudinal data were drawn from the control group of a trial of nurse home visiting. Pregnant women experiencing adversity (≥ 2 of 10 adversity risk factors) were recruited from antenatal clinics across 2 Australian states (30 April 2013-29 August 2014). Women completed the Depression Anxiety and Stress Scales short-form (DASS-21) at 11 time-points from pregnancy to 5 years postpartum. DASS-21 scores were summarized at each time-point for all women and by level of adversity risk. Three hundred fifty-nine women (100%) completed the DASS-21 in pregnancy and 343 (96%) provided subsequent data. Mental health symptoms were highest in pregnancy and at 4 and 5 years postpartum. While this pattern was comparable across levels of antenatal adversity risk, women with greatest adversity risk had consistently higher mental health symptoms. In a cohort of mothers experiencing adversity, depression, anxiety, and stress symptoms were highest in pregnancy and at 4 to 5 years postpartum. The striking patterns of persistent, high, mental health symptoms, beyond the first year postpartum, can inform a more equitable and responsive health system.

Evaluation of an Aboriginal and Torres Strait Islander strengths based coaching program: a study protocol.

BACKGROUND: Increasingly, strength-based approaches to health and wellbeing interventions with Aboriginal and Torres Strait Islander Australians are being explored. This is a welcome counter to deficit-based initiatives which can represent a non-Indigenous view of outcomes of interest. However, the evidence base is not well developed. This paper presents the protocol for evaluating a strengths-based initiative which provides life coaching services to Aboriginal and Torres Strait Islander community housing tenants. The study aims to evaluate the effect of life coaching on social and emotional wellbeing (SEWB) of tenants in three Victorian regions. METHODS: The More Than a Landlord (MTAL) study is a prospective cohort study of Aboriginal Housing Victoria tenants aged 16 years and over that embeds the evaluation of a life coaching program. All tenant holders in one metropolitan and two regional areas of Victoria are invited to participate in a survey of SEWB, containing items consistent with key categories of SEWB as understood and defined by Aboriginal and Torres Strait Islander peoples, and key demographics, administered by Aboriginal and Torres Strait Islander peer researchers at baseline, 6 and 18 months. Survey participants are then invited to participate in strengths based life coaching, using the GROW model, for a duration of up to 18 months. Indigenous life coaches provide tenants with structured support in identifying and making progress towards their goals and aspirations, rather than needs. The study aims to recruit a minimum of 200 survey participants of which it is anticipated that approximately 73% will agree to life coaching. DISCUSSION: The MTAL study is a response to Aboriginal and Torres Strait Islander community and organisational requests to build the evidence base for an initiative originally developed and piloted within an Aboriginal controlled organisation. The study design aligns with key principles for research in Indigenous communities in promoting control, decision making and capacity building. The MTAL study will provide essential evidence to evaluate the effectiveness of strengths-based initiatives in promoting SEWB in these communities and provide new evidence about the relationship between strengths, resilience, self-determination and wellbeing outcomes. TRIAL REGISTRATION: This trial was retrospectively registered with the ISRCTN Register on the 12/7/21 with the study ID: ISRCTN33665735 .

Insights into adolescent well-being from computerised analysis of written language.

AIM: To examine associations between patterns of language use and early adolescent well-being. METHODS: Participants were 1763 Australian 11- to 12-year-olds in the Child Health CheckPoint. Six patterns of language use were identified from a writing activity using Linguistic Inquiry and Word Count and factor analysis: Acting in the present and future, Positive emotion, Gender and relationships, Self-aware, Inquisitive and time focused, and Confident. Well-being measures represented a spectrum from negatively to positively framed psychosocial health. Associations between language use and well-being were estimated using linear regression adjusted for age, sex and social disadvantage. RESULTS: Positive emotion (high emotional tone, positive emotion) was associated with better general well-being (standardised regression coefficient (SRC) 0.05; 95% confidence interval 0.00 to 0.11; p = 0.04), life satisfaction (0.06; 0.01 to 0.11; p = 0.03), psychosocial health (0.07; 0.02 to 0.12; p = 0.01) and quality of life (QoL) (0.06; 0.01 to 0.11; p = 0.02). Similarly, Self-aware (high first person singular pronouns, authentic, low clout) was associated with better general well-being, life satisfaction and psychosocial health (SRC 0.05, 0.09, 0.08), but Confident (high clout, first person plural pronouns, affiliation) was associated with worse life satisfaction, psychosocial health and QoL (SRC -0.06, -0.09, -0.06). CONCLUSION: If replicated in 'real-world' settings (e.g., social media), language patterns could provide naturalistic insights into early adolescents' well-being.

Maximizing Participant Engagement, Participation, and Retention in Cohort Studies Using Digital Methods: Rapid Review to Inform the Next Generation of Very Large Birth Cohorts.

BACKGROUND: Many current research needs can only be addressed using very large cohorts. In such studies, traditional one-on-one phone, face-to-face, or paper-based engagement may not be feasible. The only realistic mechanism for maintaining engagement and participation at this scale is via digital methods. Given the substantial investment being made into very large birth cohort studies, evidence for optimal methods of participant engagement, participation, and retention over sustained periods without in-person contact from researchers is paramount. OBJECTIVE: This study aims to provide an overview of systematic reviews and meta-analyses evaluating alternative strategies for maximizing participant engagement and retention rates in large-scale studies using digital methods. METHODS: We used a rapid review method by searching PubMed and Ovid MEDLINE databases from January 2012 to December 2019. Studies evaluating at least 1 e-engagement, participation, or retention strategy were eligible. Articles were screened for relevance based on preset inclusion and exclusion criteria. The methodological quality of the included reviews was assessed using the AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews 2) measurement tool, and a narrative synthesis of the data was conducted. RESULTS: The literature search yielded 19 eligible reviews. Overall, 63% (n=12) of these reviews reported on the effectiveness of e-engagement or participation promotion strategies. These evaluations were generally not conducted within very large observational digital cohorts. Most of the contributing reviews included multipurpose cohort studies (with both observational and interventional elements) conducted in clinical and research settings. Email or SMS text message reminders, SMS text messages or voice notifications, and incentives were the most commonly used design features to engage and retain participants. For parental outcomes, engagement-facilitation interventions influenced uptake and behavior change, including video feedback, goal setting, and intensive human facilitation and support. Participant-stated preferences for content included new knowledge, reminders, solutions, and suggestions about health issues presented in a clear, short, and personalized way. Perinatal and postpartum women valued self-monitoring and personalized feedback. Digital reminders and multiple SMS text messages were specific strategies that were found to increase adherence to medication and clinic attendance, respectively. CONCLUSIONS: This review adds to the growing literature evaluating methods to optimize engagement and participation that may apply to large-scale studies using digital methods; it is promising that most e-engagement and participation promotion strategies appear to be effective. However, these reviews canvassed relatively few strategies, suggesting that few alternative strategies have been experimentally evaluated. The reviews also revealed a dearth of experimental evidence generated within very large observational digital cohort studies, which may reflect the small number of such studies worldwide. Thus, very large studies may need to proactively build in experimental opportunities to test engagement and retention approaches to enhance the success of their own and other large digital contact studies.

Hair cortisol in mother-child dyads: examining the roles of maternal parenting and stress in the context of early childhood adversity.

Physiological stress is thought to be one way that early adversity may impact children's health. How this occurs may be related to parental factors such as mothers' own stress and parenting behaviour. Hair cortisol offers a novel method for examining long-term physiological stress in mother-child dyads. The current study used hair cortisol to examine the role that maternal physiological stress and parenting behaviours play in explaining any effects of adversity on young children's physiological stress. This cross-sectional study comprised 603 mother-child dyads at child age 2 years, recruited during pregnancy for their experience of adversity through an Australian nurse home visiting trial. Hair cortisol data were available for 438 participating mothers (73%) and 319 (53%) children. Confirmatory factor analysis was used to define composite exposures of economic (e.g. unemployment, financial hardship) and psychosocial (e.g. poor mental health, family violence) adversity, and positive maternal parenting behaviour (e.g. warm, responsive). Structural equation modelling examined maternal mediating pathways through which adversity was associated with children's physiological stress. Results of the structural model showed that higher maternal and child physiological stress (hair cortisol) were positively associated with one another. Parenting behaviour was not associated with children's physiological stress. There was no evidence of any mediating pathways by which economic or psychosocial adversity were associated with children's physiological stress. The independent association identified between maternal and child hair cortisol suggests that young children's physiological stress may not be determined by exogenous environmental exposures; endogenous genetic factors may play a greater role.

Prevalence of language and pre-literacy difficulties in an Australian cohort of 5-year-old children experiencing adversity.

BACKGROUND: Early reading success is predicated on language and pre-literacy skills. Children who are behind their peers in language and pre-literacy development before formal schooling are less likely to be proficient beginner readers, and difficulties may persist throughout primary school and beyond. We know children experiencing adversity are at greater risk of early language and pre-literacy difficulties; we do not know the prevalence of these difficulties in an Australian adversity context. AIMS: To investigate the prevalence and co-occurrence of language and pre-literacy difficulties in a cohort of Australian 5-year-old children experiencing social adversity. METHODS & PROCEDURES: Data were drawn from a large Australian community-based trial of nurse home visiting (right@home), which aimed to support women experiencing social adversity from pregnancy until their child turned 2 years of age. Social adversity was determined by two of more risk factors: young pregnancy, not living with another adult, no support, poorer health, current smoker, long-term illness, anxious mood, not finishing high school, no household income and no previous employment. Children whose mothers were enrolled in the control group (receiving usual maternal and child healthcare) were included in the current study (n = 359). Language and pre-literacy skills were measured at age 5 using the Clinical Evaluation of Language Fundamental Preschool-Second Edition (CELF-P2) and the School Entry Alphabetic and Phonological Awareness Readiness Test (SEAPART). Language difficulties were defined as ≥ 1.25 standard deviations (SD) below the Australian normative mean on CELF-P2 Core Language scores. Pre-literacy difficulties were defined as children scoring in the Beginner (versus Developing or Competent) criterion-referenced level on the SEAPART First Sound Identification and/or Alphabet Letter Identification subtests. Co-occurrence of language and pre-literacy difficulties was also determined. OUTCOMES & RESULTS: At the 5-year follow-up, 201/359 (56%) children were assessed (mean age = 5.1 years, SD = 0.1). Mean Core Language score for this cohort (91.8, SD = 15.9) was 0.54 SD below the normative mean (100, SD = 15). The proportion of children presenting with language difficulties was 24.9%. Regarding pre-literacy skills, 43.8% of children were 'Beginner' for identifying first sounds and 58.6% for identifying alphabet letters/sounds. There was also considerable overlap whereby 76.7% of children with language difficulties also exhibited pre-literacy difficulties. CONCLUSIONS & IMPLICATIONS: This is the first empirical Australian-based study highlighting the high prevalence and co-occurrence of language and pre-literacy difficulties in preschool children experiencing social adversity. Clinicians should be aware of co-morbid language and pre-literacy difficulties in disadvantaged populations and consider both areas during assessment and intervention planning. What this paper adds What is already known on the subject The prevalence of language and literacy difficulties is substantially higher in cohorts experiencing social adversity when compared with more advantaged families. There is some evidence that adversity also contributes to pre-literacy difficulties, but less is known here. What this paper adds to existing knowledge This study presents new prevalence data showing high rates of language and pre-literacy difficulties for 5-year-old children experiencing adversity within an Australian context. It is the first to explore these skills in a large cohort of pre-schoolers recruited from community settings in Australia. What are the potential or actual clinical implications of this work? In this cohort experiencing adversity, most children who presented with language difficulties likewise exhibited pre-literacy difficulties. This concordance reflects how early oral language and pre-literacy skills develop together. Clinicians should assess both skills in preschool populations-especially those working with children experiencing adversity-to ensure all children have strong foundations to become proficient beginner readers.

Evaluation of systems reform in public hospitals, Victoria, Australia, to improve access to antenatal care for women of refugee background: An interrupted time series design.

INTRODUCTION: Inequalities in maternal and newborn health persist in many high-income countries, including for women of refugee background. The Bridging the Gap partnership programme in Victoria, Australia, was designed to find new ways to improve the responsiveness of universal maternity and early child health services for women and families of refugee background with the codesign and implementation of iterative quality improvement and demonstration initiatives. One goal of this 'whole-of-system' approach was to improve access to antenatal care. The objective of this paper is to report refugee women's access to hospital-based antenatal care over the period of health system reforms. METHODS AND FINDINGS: The study was designed using an interrupted time series analysis using routinely collected data from two hospital networks (four maternity hospitals) at 6-month intervals during reform activity (January 2014 to December 2016). The sample included women of refugee background and a comparison group of Australian-born women giving birth over the 3 years. We describe the proportions of women of refugee background (1) attending seven or more antenatal visits and (2) attending their first hospital visit at less than 16 weeks' gestation compared over time and to Australian-born women using logistic regression analyses. In total, 10% of births at participating hospitals were to women of refugee background. Refugee women were born in over 35 countries, and at one participating hospital, 40% required an interpreter. Compared with Australian-born women, women of refugee background were of similar age at the time of birth and were more likely to be having their second or subsequent baby and have four or more children. At baseline, 60% of refugee-background women and Australian-born women attended seven or more antenatal visits. Similar trends of improvement over the 6-month time intervals were observed for both populations, increasing to 80% of women at one hospital network having seven or more visits at the final data collection period and 73% at the other network. In contrast, there was a steady decrease in the proportion of women having their first hospital visit at less than 16 weeks' gestation, which was most marked for women of refugee background. Using an interrupted time series of observational data over the period of improvement is limited compared with using a randomisation design, which was not feasible in this setting. CONCLUSIONS: Accurate ascertainment of 'harder-to-reach' populations and ongoing monitoring of quality improvement initiatives are essential to understand the impact of system reforms. Our findings suggest that improvement in total antenatal visits may have been at the expense of recommended access to public hospital antenatal care within 16 weeks of gestation.

Health-Related Quality of Life in Children With Low Language or Congenital Hearing Loss, as Measured by the PedsQL and Health Utility Index Mark 3.

OBJECTIVES: To examine health-related quality of life (HRQoL) in young children with low language or congenital hearing loss and to explore the value of assessing HRQoL by concurrently administering 2 HRQoL instruments in populations of children. METHODS: Data were from 2 Australian community-based studies: Language for Learning (children with typical and low language at age 4 years, n = 1012) and the Statewide Comparison of Outcomes study (children with hearing loss, n = 108). HRQoL was measured using the parent-reported Health Utilities Index Mark 3 (HUI3) and the Pediatrics Quality of Life Inventory 4.0 (PedsQL) generic core scale. Agreement between the HRQoL instruments was assessed using intraclass correlation and Bland-Altman plots. RESULTS: Children with low language and with hearing loss had lower HRQoL than children with normal language; the worst HRQoL was experienced by children with both. The lower HRQoL was mainly due to impaired school functioning (PedsQL) and speech and cognition (HUI3). Children with hearing loss also had impaired physical and social functioning (PedsQL), vision, hearing, dexterity, and ambulation (HUI3). Correlations between instruments were poor to moderate, with low agreement. CONCLUSIONS: Children with low language and congenital hearing loss might benefit from interventions targeting overall health and well-being, not just their impairments. The HUI3 and PedsQL each seemed to provide unique information and thus may supplement each other in assessing HRQoL of young children, including those with low language or congenital hearing loss.

Speech in children with cerebral palsy.

AIM: To examine the frequency, characteristics, and factors associated with speech delay and disorder in a community sample of children with cerebral palsy (CP). METHOD: Participants were 84 children (37 females, 47 males; aged between 4y 11mo-6y 6mo) with CP identified through a population-based registry. Speech and oromotor function were systematically evaluated to provide a differential diagnosis of articulation, phonological, and motor speech disorders. RESULTS: In total, 82% (69/84) of participants had delayed or disordered speech production, including minimally verbal presentations (n=20). Verbal participants (n=64) presented with dysarthria (78%), articulation delay or disorder (54%), phonological delay or disorder (43%), features of childhood apraxia of speech (CAS) (17%), or mixed presentations across these conditions. Speech intelligibility was poorest in those with dysarthria and features of CAS. Speech delay or disorder in verbal participants was associated with language impairment (p=0.002) and reduced health-related quality of life (p=0.04) (Fisher's exact test). Poorer speech accuracy (i.e. lower percentage consonants correct) correlated with greater impairments in both language (p<0.001) and oromotor function (p<0.001) (Spearman's test). INTERPRETATION: The speech profile of children with CP is characterized by impairment at multiple levels of speech production (phonetic, cognitive-linguistic, neuromuscular execution, and high-level planning/programming), highlighting the importance of a personalized differential diagnosis informing targeted treatment.

Correction to: Mapping PedsQL™ scores onto CHU9D utility scores: estimation, validation and a comparison of alternative instrument versions.

In the original publication of the article, the equation CHU9DPredicted = exp(BETAPrediction)∕(1 + exp(BETAPrediction)) was formatted incorrectly under Model 2.