Alan Emond

Background: Antidepressants are commonly prescribed during pregnancy, despite a lack of evidence from randomised trials on the benefits or risks. Some studies have reported associations of antidepressants during pregnancy with adverse offspring neurodevelopment, but whether or not such associations are causal is unclear.Objectives: To study the associations of antidepressants for depression in pregnancy with outcomes using multiple methods to strengthen causal inference.Design: This was an observational cohort design using multiple methods to strengthen causal inference, including multivariable regression, propensity score matching, instrumental variable analysis, negative control exposures, comparison across indications and exposure discordant pregnancies analysis.Setting: This took place in UK general practice.Participants: Participants were pregnant women with depression.Interventions: The interventions were initiation of antidepressants in pregnancy compared with no initiation, and continuation of antidepressants in pregnancy compared with discontinuation.Main outcome measures: The maternal outcome measures were the use of primary care and secondary mental health services during pregnancy, and during four 6-month follow-up periods up to 24 months after pregnancy, and antidepressant prescription status 24 months following pregnancy. The child outcome measures were diagnosis of autism, diagnosis of attention deficit hyperactivity disorder and intellectual disability.Data sources: UK Clinical Practice Research Datalink.Results: Data on 80,103 pregnancies were used to study maternal primary care outcomes and were linked to 34,274 children with at least 4-year follow-up for neurodevelopmental outcomes. Women who initiated or continued antidepressants during pregnancy were more likely to have contact with primary and secondary health-care services during and after pregnancy and more likely to be prescribed an antidepressant 2 years following the end of pregnancy than women who did not initiate or continue antidepressants during pregnancy (odds ratio_initiation2.16, 95% confidence interval 1.95 to 2.39; odds ratio_continuation2.40, 95% confidence interval 2.27 to 2.53). There was little evidence for any substantial association with autism (odds ratio_{multivariableregression}1.10, 95% confidence interval 0.90 to 1.35; odds ratio_{propensityscore}1.06, 95% confidence interval 0.84 to 1.32), attention deficit hyperactivity disorder (odds ratio_{multivariableregression}1.02, 95% confidence interval 0.80 to 1.29; odds ratio_{propensityscore}0.97, 95% confidence interval 0.75 to 1.25) or intellectual disability (odds ratio_{multivariableregression}0.81, 95% confidence interval 0.55 to 1.19; odds ratio_{propensityscore}0.89, 95% confidence interval 0.61 to 1.31) in children of women who continued antidepressants compared with those who discontinued antidepressants. There was inconsistent evidence of an association between initiation of antidepressants in pregnancy and diagnosis of autism in offspring (odds ratio_{multivariableregression}1.23, 95% confidence interval 0.85 to 1.78; odds ratio_{propensityscore}1.64, 95% confidence interval 1.01 to 2.66) but not attention deficit hyperactivity disorder or intellectual disability; however, but results were imprecise owing to smaller numbers.Limitations: Several causal-inference analyses lacked precision owing to limited numbers. In addition, adherence to the prescribed treatment was not measured.Conclusions: Women prescribed antidepressants during pregnancy had greater service use during and after pregnancy than those not prescribed antidepressants. The evidence against any substantial association with autism, attention deficit hyperactivity disorder or intellectual disability in the children of women who continued compared with those who discontinued antidepressants in pregnancy is reassuring. Potential association of initiation of antidepressants during pregnancy with offspring autism needs further investigation.Future work: Further research on larger samples could increase the robustness and precision of these findings. These methods applied could be a template for future pharmaco-epidemiological investigation of other pregnancy-related prescribing safety concerns.Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (15/80/19) and will be published in full inHealth Technology Assessment; Vol. 27, No. 15. See the NIHR Journals Library website for further project information.

Purpose: Social, emotional and behavioural difficulties (SEBD) in childhood are associated with negative consequences across the life course. Children with developmental language disorder have been identified as being at risk of developing SEBD but it is unclear whether a similar risk exists for children with speech sound disorder, a condition which impacts on children's ability to make themselves understood and has been shown to be associated with poor educational outcomes.Methods: Participants were children who attended the 8‐year‐old clinic in the Avon Longitudinal Study of Parents and Children (N = 7390). Children with speech sound disorder that had persisted beyond the period of typical speech acquisition (persistent speech disorder [PSD]) at age 8 were identified from recordings and transcriptions of speech samples (N = 263). Parent‐, teacher‐ and child‐reported questionnaires and interviews including the Strengths and Difficulties Questionnaire, Short Moods and Feelings Questionnaire and measures for antisocial and risk‐taking behaviour were used to provide outcome scores for SEBD at 10–14 years in a series of regression analyses.Results: Following adjustment for biological sex, socio‐economic status and Intelligence Quotient, children with PSD at age 8 were more likely to show peer problems at age 10–11 years compared with their peers, as reported by teachers and parents. Teachers were more likely to report problems with emotionality. Children with PSD were no more likely to report symptoms of depression than their peers. No associations were observed between PSD, risk of antisocial behaviour, trying alcohol at age 10 or smoking cigarettes at age 14.Conclusions: Children with PSD may be at risk in terms of their peer relationships. This could impact on their wellbeing and, while not observed at this age, may lead to depressive symptoms in older childhood and adolescence. There is also the potential that these symptoms may impact on educational outcomes.

From 5 July 2021, the BLC threshold (referred to as the ‘public health intervention concentration’) at which public health action is recommended in England has reduced to ≥5 µg/dL (0.24 μmol/L), for children under 16 years and for pregnant women. The higher threshold of ≥10 µg/dL (≥0.48 μmol/L) will still apply to adults. There are two main …

Gambling is a common activity amongst young adults in the UK, and was a behavior of interest during the early mitigation against COVID-19 (first lockdown). The Avon Longitudinal Study of Parents and Children (ALSPAC) was used to investigate attitudes, moods and behavior during lockdown in England. ALSPAC participants were invited to complete online questionnaires in May 2020, including a set of questions about frequency of gambling and gambling activities which had been asked three years previously. Mental health and wellbeing data and alcohol use were also collected as part of lockdown questionnaires. Gambling questions were completed by 2632 young adults, 71% female, with a mean age of 27.8 years. Overall, gambling frequency reduced during lockdown for both males and females, but more males engaged in regular (weekly) gambling. Gambling activities became more restricted compared to previous reports, but online gambling (e.g. online poker, bingo, casino games) was more frequent. Previous gambling behaviour predicted gambling frequency during lockdown. No associations were apparent between gambling frequency and measures of mental health and well-being. Heavy alcohol use was strongly linked with regular gambling during lockdown. Gamblers were more than twice as likely as non-gamblers to have experienced financial difficulties pre-COVID, but gambling frequency was not related to employment status during lockdown. Online gambling increased during lockdown, whilst offline gambling activities decreased in frequency. A small minority of regular weekly gamblers, who tended to be male and heavy users of alcohol, participated in a wide range of online and offline gambling activities.

Background: Children with persistent speech disorder (PSD) are at higher risk of difficulties with literacy, with some evidence suggesting an association with poorer educational attainment. However, studies to date have either used small clinical samples, which exclude children who have not been referred to clinical services, or relied on parent–teacher report of children's speech development. There is a need for an inclusive study to investigate the impact of PSD on educational outcomes using a population‐based sample and robust measures of speech development.Aim: Using a large prospective UK population‐based study—the Avon Longitudinal Study of Parents and Children (ALSPAC)—this study investigated: (1) how children identified with PSD at age 8 years perform on educational attainment tests at ages 10–11 and 13–14 years in comparison with children without PSD; and (2) whether children identified with PSD at age 8 years are more likely to receive a label of special educational needs (SEN) in secondary school.Methods & Procedures: We examined the data for 263 children with PSD and 6399 controls who had speech assessed at age 8 years in a research clinic. Educational attainment was measured using data from English school standard attainment tests. Data on SEN categorization were obtained between 11 and 13 years of age. Children with PSD and controls were compared using regression analyses adjusted for biological sex, maternal age, verbal, performance and full‐scale IQ.Outcomes & Results: Children with PSD at age 8 years were more likely to achieve lower attainment scores at ages 10–11 years in English and mathematics and across all three subjects of English, mathematics and science at ages 13–14 years after controlling for biological sex and maternal education; score below target levels for English at both time points after controlling for verbal IQ, and at ages 13–14 years after controlling for performance IQ; and receive a label of SEN (typically for the category of cognition and learning needs or communication and interaction needs) in secondary school.Conclusions & Implications: PSD identified at age 8 years is associated with poor educational attainment at ages 10–11 and 13–14 years in the core subjects of English, mathematics and science. Children with PSD at age 8 years are more likely to be identified with SEN at ages 11–13 years, particularly cognition and learning needs, and communication and interaction needs. We need to be aware of the potential for the long‐term impact of PSD on educational attainment in providing appropriate and effective support throughout school. What this paper adds: What is already known on the subject: Speech‐sound disorder is associated with reading and spelling difficulties, with some evidence to suggest that PSD is associated with a higher risk of literacy difficulties. Limited evidence also suggests that speech‐sound disorder may be associated with poorer educational attainment. However, studies to date have used small clinical samples or parent–teacher report of speech development and there is a need to determine whether the association is observed in larger and more inclusive population‐based samples. What this paper adds to existing knowledge: This prospective, longitudinal study of a large community‐based sample of English children has shown that PSD is associated with poorer educational attainment at the end of primary school and at ages 13–14 years. Children with PSD are also more likely to be identified as having SEN in secondary school, especially communication and interaction needs but also including cognition and learning needs. What are the potential or actual clinical implications of this work?: Understanding the long‐term implications of PSD on educational attainment highlights the importance of ongoing monitoring and support to enable children to reach their potential throughout primary and secondary school. The identification of children with a history of PSD during transition to secondary school will enable effective support to be put in place. The intervention for children with PSD should involve close collaboration between speech and language therapists and education professionals.

The aims of this study were to investigate stability of problem gambling between 20 and 24 years of age, and the antecedents and consequences of problem gambling at age 20 years. Young adult participants in the Avon Longitudinal Study of Parents and Children (ALSPAC) completed computer-administered gambling surveys on paper, or online. Responses to the Problem Gambling Severity Index (PGSI) were complete for 2624 participants at 20 years, and 1921 participants at 24 years. Responses were categorized into ‘non-problem’ (71–78%), ‘low-risk gambling’ (16–21%), ‘moderate-risk gambling’ (4–5.5%), and ‘problem gambling’ (1–1.5%). The overall frequency of moderate-risk/problem gambling varied little between age 20 and 24 years, and scratch cards, online betting and gambling were the most frequent activities. Problem gamblers at age 20 years had a history of hyperactivity and conduct problems in adolescence, high sensation seeking, and an external locus of control. They were more likely to have mothers who had problems with gambling, reported less parental supervision, and higher social media usage. Moderate-risk/problem gambling at age 20 years was associated with regular cigarette smoking, high levels of illicit drug use, and problematic use of alcohol at age 24 years. A significant minority of young adults (mainly males) showed problem gambling behaviours which appeared to be established by the age of 20 years and were associated with other potentially addictive behaviours.

Introduction: Children are susceptible to problems with gambling because of developmental and cognitive immaturities, as well as a sensitivity to peer pressure and marketing. Sources of data: This review uses recent UK data from the Gambling Commission and from the Avon Longitudinal Study of Parents and Children, and evidence from recent reviews of gambling in children and adolescents. Areas of agreement: The prevalence of gambling in children worldwide and in the UK is stable, having generally decreased since 2013. Online gambling is increasing in children and young people. A small minority of adolescents who gamble develop a gambling disorder. Adolescents who have problems with gambling tend to have lower self-esteem and a history of hyperactivity and impulsivity, are more likely to have parents who gamble, report less parental supervision and to use more alcohol than their peers. Areas of controversy: Children’s access to slot machines, the relationship between gaming and gambling, and social media advertizing of gambling targeting children. Growing points: An increase in online gambling and in-play sports betting by adolescents and the use of skins betting in video gaming. Areas timely for developing research: impact on young people of betting on e-gaming. How best to protect children from early exposure to gambling in the current internet age. Implications for clinicians: Need to be aware of the growing and complex phenomenon of gaming and gambling, and implications for the mental health of children and adolescents. The effective management of gambling disorders in children and adolescents requires close working with families.

A large contemporary UK cohort study, the Avon Longitudinal Study of Parents and Children, was used to investigate gambling behavior and to explore the antecedents of regular gambling in the 17–24-year age group. Participants completed computer-administered gambling surveys in research clinics, on paper, and online. The sample sizes were 3566 at age 17 years, 3940 at 20 years, and 3841 at 24 years; only 1672 completed all three surveys. Participation in gambling in the last year was reported by 54% of 17-year-olds, rising to 68% at 20 years, and 66% at 24 years, with little overall variance. Regular (weekly) gambling showed a strong gender effect, increasing among young men from 13% at 17 years to 18% at 20 years, and 17% at 24 years. Although gambling frequency increased between the ages of 17 and 20 years, gambling behaviors showed little variance between 20 and 24 years, except online gambling and betting on horseraces. The commonest forms of gambling were playing scratchcards, playing the lottery, and private betting with friends. Gambling on activities via the internet increased markedly between 17 and 24 years, especially among males. In the fully adjusted model, individual antecedents of regular gambling were being male, and having a low IQ, an external locus of control, and high sensation seeking scores. Parental gambling behavior and maternal educational background were associated with regular gambling in both sexes. Regular gambling was associated with smoking cigarettes and frequent and harmful use of alcohol, but no associations with depression were found.

The presence of a tongue-tie (ankyloglossia) in an infant may lead to breastfeeding difficulties, but debate continues about which babies should be treated with frenotomy. The Bristol Tongue Assessment Tool (BTAT), a clear and simple evaluation of the severity of tongue-tie, is being used worldwide and translated into different languages. We aimed to produce a simple picture version of the BTAT to aid and enhance consistent assessment of infants with tongue-tie. The Tongue-tie and Breastfed Babies (TABBY) assessment tool was developed from the BTAT by a graphic designer, with iterative discussion with four practicing NHS midwives. The TABBY tool consists of 12 images demonstrating appearance of the infant tongue, its attachment to the gum and the limits of tongue mobility. The TABBY tool is scored from 0 to a maximum of 8. Two initial audits of the TABBY were undertaken at a large maternity unit in a secondary care NHS Trust, in Bristol UK from 2017 to 2019. TABBY was evaluated by five midwives on 262 babies with tongue-ties and experiencing breastfeeding difficulties who were referred for assessment to a tongue-tie assessment clinic using both BTAT and TABBY. Each pair of scores was recorded by one midwife at a time. A further training audit with 37 babies involved different assessors using BTAT and TABBY on each baby. All midwives found the TABBY easy to use, and both audits showed 97.7% agreement between the scores. We suggest that a score of 8 indicates normal tongue function; 6 or 7 is considered as borderline and 5 or below suggests an impairment of tongue function. Selection of infants for frenotomy required an additional breastfeeding assessment, but all infants with a score of 4 or less in the audits had a frenotomy, following parental consent. The TABBY Assessment Tool is a simple addition to the assessment of tongue-tie in infants and can provide an objective score of tongue-tie severity. Together with a structured breastfeeding assessment it can inform selection of infants for frenotomy. It can be used by clinical staff following a short training and will facilitate translation into other languages.

The objective of this study is to explore the association between maternal somatic anxiety in pregnancy and hyperactivity symptoms and ADHD diagnosis in children. Data from the Avon Longitudinal Study of Parents and Children cohort were used to examine the association between somatic anxiety symptoms in pregnancy measured with five items of the Crown-Crisp Experiential Index, ADHD diagnosis in children at 7.5 and 15 years (obtained with the Development and Well-Being Assessment-DAWBA) and hyperactivity at 4 and 16 years (measured with the Strengths and Difficulties Questionnaire hyperactivity subscale-SDQ). Maternal somatic anxiety was associated with ADHD diagnosis at age 7.5 [crude OR = 1.87 (95% CI = 1.21–2.91)], adjusted model [OR = 1.57 (95% CI = 0.99–2.48)]. There was no evidence of association with ADHD at 15: crude OR = 2.27 (95% CI = 0.90–5.71), adjusted OR = 1.65 (95% CI = 0.63–4.35). An association was found at 4 and 16 with the SDQ hyperactivity subscale: crude OR at 4: 1.70 (95% CI =1.37–2.11), adjusted OR = 1.34 (95% CI = 1.07–1.69); crude OR at 16: 1.95 (95% CI = 1.47–2.58), adjusted OR = 1.62 (95% CI = 1.21–2.17).Thus, there was evidence for an association between maternal somatic anxiety in pregnancy and increased hyperactivity symptoms (SDQ) at 4 and 16. There was no association with ADHD diagnosis.