Introduction Schools worldwide balance whole-class teaching with additional provision for children with special educational needs or disability (SEND). Robust evidence on equity and effectiveness of SEND provision is essential to address growing demand and rising costs globally. Objectives To synthesise findings from the Health Outcomes for young People throughout Education (HOPE) evaluation of variation in SEND provision and its impact on health and education outcomes in English primary schools. We integrated findings from 14 sub-studies using administrative data in the Education and Child Health Insights from Linked Data (ECHILD) database and 10 mixed methods sub-studies. Methods Analyses of ECHILD data followed children from birth to age 11 years. We examined how variation in SEND provision was associated with health conditions, and school, social and organisational factors. Using target trial emulation, we estimated the impact of SEND provision on hospital admissions, school absences and attainment. We surveyed and interviewed young people, parents, and professionals and reviewed information about services to understand SEND processes and contexts. Results Of 3.8 million children born 2004 to 2013, 30% had SEND provision recorded by age 11. Health conditions were only partially associated with SEND provision, which was also related to male gender, social disadvantage, low attainment and type of school. SEND provision modestly reduced rates of unauthorised absences in subgroups of children but showed no measurable benefit on hospital admissions or school attainment. Mixed methods studies highlighted benefits of early, responsive support, challenges posed by limited capacity, harms caused by delayed or inadequate provision, and need for parent advocacy to access SEND provision. Discussion Weak evidence of benefits of SEND provision in causal analyses likely reflects unmeasured confounding, lack of measures of provision received and insensitive outcomes in ECHILD data. SEND policies need robust evidence from analyses across jurisdictions using administrative data, enhanced with better measures, experimental methods and contextual evaluation.

Introduction:Linkage of National Pupil Database (NPD) to national hospital data has the potential to provide almost universal population coverage of children and young people in England. However, quantifying who is missed is a key requirement for producing unbiased population estimates. Methods:Deterministic linkage was conducted between longitudinal data from the NPD and secondary healthcare services via the NHS Personal Demographic Service. National Data OptOuts were applied to the linked data. We assessed the proportion of individuals who linked and used modified Poisson regression with robust standard errors to evaluate the risk of non-linkage when accounting for a variety of social determinants. Results:Of 25,286,870 individuals born between 1984-2020 included in NPD, 84% (21,287,176/25,286,870) linked to a secondary care dataset. Linkage rates improved from 66% (507,820/765,642) for those born in 1985/86 to 98% (306,165/311,121) in 2019/20 and ranged from 89% (908,998/1,026,575) for those with Black ethnicity to 95% (13,644,182/14,401,835) in White groups. Females (IRR: 1.08, 95%CI: 1.08- 1.09) and those living in more deprived areas or in London were more likely to be unlinked. Individuals with recorded Special Educational Needs provision (IRR: 0.81, 95%CI: 0.81-0.82) or Free School Meals (IRR: 0.67, 95%CI: 0.67-0.68) were less likely to be unlinked. Conclusions:Whilst linkage rates have improved over time, there remain important differences in sex, ethnicity, deprivation and geography, between those who are and are not included in the linked dataset. Given high overall linkage rates reported by data providers, these differences are primarily driven by the application of Opt-Outs.

Introduction Many jurisdictions have linked education and health data throughout childhood to address policy questions relating to equity and effectiveness of services. We use the example of special educational needs and disability (SEND) policy to show that causal evidence of effectiveness, based on administrative data, can be limited and potentially misleading. We discuss what needs to change. Methods We derived health phenotypes to group children likely to benefit from SEND provision and used the target trial emulation framework to define causal contrasts, reduce design biases and guide analytic methods. We estimated the effectiveness of SEND provision at age 5/6 on outcomes recorded in health and education data for two phenotypes (cerebral palsy and cleft lip/palate). Results SEND provision did not improve rates of unplanned hospital admissions or educational attainment but did reduce rates of unauthorised school absences for both phenotypes. These results are likely biased due to unmeasured confounding and imprecise measures of SEND provision and relevant outcomes. We failed to find instrumental variables to account for unmeasured confounding. Despite the detailed information on health and school characteristics in ECHILD, there is insufficient information on which children are selected for which SEND interventions or comparators. Conclusions Causal evaluations of SEND provision using observational analyses of ECHILD need linkage to additional measures of need, interventions and outcomes. Adding similar measures to linked health-education data across jurisdictions, and wider use of experimental designs, would help to quantify effective and generalisable SEND practices. These lessons are likely relevant to other practitioner-based interventions.

Background Adolescents with neurodisability (neurological conditions causing functional limitations) have more complex needs than their peers, yet population-level evidence on secondary school outcomes remains limited. Methods Using linked health and education records from the ECHILD database, we developed a national cohort of Year 6 pupils (final year of primary school, ages 10-11) in state schools between 2007/08-2016/17. Neurodisability was identified from hospital and school records before Year 6. We described the proportion of pupils with Special Educational Needs and Disabilities (SEND) provision in Year 6, and examined planned and unplanned hospital admission rates and school absence rates (% of school sessions missed) from Year 6 through secondary school (Years 6-11, ages 10-16). Results Of 5,291,458 adolescents in Year 6, 226,689 (4.3%) had recorded neurodisability, 78% of whom had any SEND provision (versus 20% without neurodisability). One-quarter had intensive local government-funded provision. Between Years 6-11, adolescents with neurodisability had 5 times higher planned admission rates (19.8 vs 3.7 per 100 person-years), 3 times higher unplanned rates (9.7 vs 3.8 per 100 person-years), and 2 times higher stress-related rates (2.5 vs 1.3 per 100 person-years) compared with peers. Overall absence rates were 7.2% versus 5.4% for peers, increasing over time and driven by authorised absences (5.8%, mostly health-related). Unauthorised rates were comparable (1.2-1.4%). Girls had consistently higher admission and absence rates than boys. Conclusion Adolescents with neurodisability experience substantially greater health and educational challenges. Linked administrative datasets can inform targeted and integrated support from secondary school transition onward.

BACKGROUND:Mortality risk rises from childhood into early adulthood. Young people with neurodisability (neurological conditions causing functional limitations) may be particularly vulnerable during the transition from paediatric to adult services. OBJECTIVES:To estimate all-cause and cause-specific mortality risk between the ages of 11-22 years in young people with and without neurodisability in England. METHODS:In this national cohort study, we used linked health and education records from ECHILD to follow pupils from age 11 between 2008-09 and 2014-15 to age 22. Neurodisability was identified from hospital admission records before age 11, likely capturing more severe conditions, and supplemented with education data for intellectual disability and autism. Gender-specific crude cumulative mortality risk and relative differences were estimated using Kaplan-Meier curves and Cox models, with cause-specific risk estimated using competing-risks methods. RESULTS:Among 3,601,180 young people, 143,864 (4.0%) had neurodisability. Between the ages of 11-22, 5565 (0.15%) died; 24% had neurodisability. By age 22, cumulative mortality risk was 1.6% (95% confidence interval [CI] 1.4, 1.8) among females with neurodisability versus 0.14% (95% CI 0.13, 0.15) among peers without neurodisability (hazard ratio [HR] 13.88, 95% CI 12.55, 15.35), an absolute risk difference of 1.5% (95% CI 1.3, 1.6). Among males with neurodisability, cumulative risk was 1.3% (95% CI 1.2, 1.4) versus 0.28% (95% CI 0.27, 0.29; HR 5.34, 95% CI 4.94, 5.78) among peers, an absolute risk difference of 1.0% (95% CI 0.9, 1.1). Most deaths among those with neurodisability were from medical causes, with cumulative risks of 1.5% (95% CI 1.3, 1.6; HR 25.87, 95% CI 23.03, 29.07) in females and 1.1% (95% CI 0.96, 1.2; HR 14.70, 95% CI 13.29, 16.26) in males by age 22. CONCLUSIONS:Young people with neurodisability had a higher mortality risk than peers between ages 11-22, largely from medical causes, with variation by gender and neurodisability subgroup.

Evidence of disparities in special educational needs and disability (SEND) provision at local authority (LA) level in England is needed to guide policies for equitable provision. We described LA-level variation in recorded SEND provision using linked health-education records. We used linked hospital-primary school records (ECHILD - Education and Child Health Insights from Linked Data) to create a cohort of 3 729 265 children born in England between 2003/04-2012/13. LA of pupil's residential address and SEND provision [SEND support or Educational Health and Care Plan (EHCP)] were defined at Year 1 (5/6 years old). We compared single-level and multilevel logistic models, adjusting for individual-level sociodemographic, health indicators, and school governance, and stratifying by gestational age. In further multilevel models, we added LA characteristics. After accounting for individual-level characteristics, there was between 2.0% (SEND support compared with no SEND provision) and 5.8% (EHCPs compared with SEND support) residual unexplained variation between LAs across gestational age groups. Adding LA-level income deprivation reduced the between-LA variance for EHCPs by 14%-24% across gestational age groups; less so for other LA characteristics. Under 6% of the differences in school-recorded SEND provision in Year 1 between 2009/10 and 2018/19 was associated with the LA context. We need to carefully disentangle structural factors at the school and individual level to understand inequities in recorded SEND provision.

OBJECTIVE:To compare educational attainment between children with and without hospital-recorded neurodisability in England at ages 5, 7 and 11 using linked administrative hospital and education data in the Education and Child Health Insights from Linked Data (ECHILD) database. DESIGN:Population-based cohort study. METHODS:We derived a national birth cohort of 2 351 589 children born in England between 1 September 2003 and 31 August 2008 enrolled in state-funded primary schools in Reception (age 4-5) using linked health and education records. Neurodisability, defined here as chronic conditions affecting the nervous system which result in functional limitations, is identified using hospital admission records. We described differences in primary school educational attainment for children with and without neurodisability. RESULTS:About 2.2% of children had a recorded neurodisability before starting Reception. These children consistently underperformed in national assessments, with fewer than half meeting nationally expected levels in Maths and English at every time point (vs ~70% of peers). By the end of primary school (age 10/11), 31% of children with neurodisability (vs 6% of peers) did not participate in national assessments despite being enrolled in school. Among children with neurodisability, educational attainment was lowest for children with Down syndrome and highest for children with perinatal conditions. IMPLICATIONS:Substantial attainment gaps exist between children with and without neurodisability and persist across primary school. By age 11, many children with neurodisability do not undertake national assessments, highlighting the need for personalised, functional outcome measures to capture their educational development.

BACKGROUND:Family court care proceedings are instigated to remove children at risk of harm from parental care. Limited information is available on the health of mothers involved in care proceedings. We assessed maternal mortality and causes of death within 10 years of first birth, comparing first-time mothers with and without care proceedings. METHODS:Using linked, administrative hospital and family court data, we followed a whole-population cohort of first-time mothers delivering between 2007 and 2017 up to 10 years. We calculated mortality rates comparing mothers with and without care proceedings. We examined proportions of deaths potentially preventable (suicide, homicide, drugs/alcohol or injury) and identified factors associated with death after care proceedings. RESULTS:Of 2 775 835 first-time mothers contributing 21 856 503 person-years of observation, 28 405 (1.0%) had proceedings. Following proceedings, 314 (1.1%) died, compared with 5103 (0.2%) among mothers without care proceedings (age-standardised mortality ratio 21.0, 95% CI 14.3 to 27.7). Mortality ratios were lowest among first-time mothers aged <20 years (4.5, 95% CI 3.5 to 5.9) and highest for those aged 30-34 years (28.3, 95% CI 21.3 to 37.5). Among mothers who died after proceedings, 73% of deaths were potentially preventable compared with 28% among mothers without proceedings. Factors associated with death were older maternal age at proceedings, health conditions and court orders related to child removal. CONCLUSION:First-time mothers with care proceedings had 21 times the risk of dying within 10 years than similar-aged mothers. Healthcare, social care and family courts must address the extreme health vulnerability of mothers before, during and after proceedings.

Introduction Children and young people in state care or with special educational needs (SEN) experience disproportionately higher rates of long-term physical and mental illness compared with their peers. However, few large-scale studies have explored the intersection of social care, education systems and healthcare services during adolescence. We aimed to quantify planned and unplanned hospital admissions during adolescence for pupils with SEN and/or experience of state care in England.Methods We analysed linked administrative records from hospital, education and social care systems for adolescents in England using the Education and Child Health Insights from Linked Data (ECHILD) database. The cohort comprised pupils starting secondary school between 2007–2008 and 2011–2012 (aged 11 years), with follow-up until March 2020 (aged 18–23 years). Hospital admission rates were examined by gender and age across six mutually exclusive groups reflecting statutory support during school: (1) no support, (2) school-based SEN support only, (3) formalised SEN support only (education, health and care plan; EHCP), (4) care-experienced only, (5) SEN support and care-experienced and (6) EHCP and care-experienced. Rate ratios were estimated for each group relative to no support using negative binomial regression models.Results The cohort included 2 807 230 pupils: 64% (1 791 190) received no support, 31% (876 400) received SEN support only, 3% (84 410) received EHCP only and 1% (29 330) received SEN support and care experience, with the remaining groups accounting for <1%. Unplanned admissions were higher in all groups receiving support than peers with no support and were highest in care-experienced girls with an EHCP (21.9 (95% CI 21.4 to 22.4)/100 person-years (100PY)). Mental health-related admissions accounted for 48% of all unplanned admissions in girls and 33% in boys. Pregnancy-related admission rates were highest in care-experienced girls (14/100PY).Conclusions We found evidence of high levels of unplanned admissions coupled with low levels of planned care for pupils with multiple needs, indicating a need for preventative care.

Introduction:UK policymakers have proposed supporting more children with neurodisability in Mainstream rather than Specialist secondary schools, despite little evidence on which schools provide better support. Methods:We aim to apply a target trial emulation (TTE) approach to linked health and education data from ECHILD to understand the causal impact of Mainstream versus Specialist secondary school (Year 7 [Y7], age 12) on health (hospitalisations) and education (absences) outcomes for pupils with neurodisability in England. We followed cohorts attending Mainstream Year 6 (baseline) between 2008 and 2017 with four categories of neurodisability: Down syndrome (DS), cerebral palsy (CP), autism, and learning disability (LD). We evaluated requisite assumptions for conducting causal analyses using a TTE approach by estimating propensity scores (PS) based on baseline health, education, and sociodemographic characteristics. Results:Cohorts included 43,535 pupils (DS: n = 1,984; CP: n = 3,694; autism: n = 27,451; LD: n = 10,406). The proportions in Mainstream Y7 were respectively 43%, 80%, 74%, and 60%. For all cohorts, those in Specialist Y7 had higher levels of health complexity, absences, and deprivation. We found common support for each cohort, with highest support between pupils with DS in Mainstream (mean PS: 0.62, standard deviation [SD]: 0.14) and Specialist Y7 (mean PS: 0.52, SD: 0.15). Conclusions:The estimated PS distributions suggest that causal inference will be a viable approach. We will apply PS-based methods to adjust for non-randomised school placement (inverse probability weighting [IPW], augmented IPW, and g-computation) and estimate the causal effect of Mainstream versus Specialist secondary school placement on outcomes for pupils with neurodisability.

Why we did this research Parents and young people are concerned that help for special educational needs or disability (SEND) is unfair and inadequate. We looked at whether the help children receive is based on their actual needs or on other factors, like where they live. We tried to find out if help for SEND improves health and education outcomes during primary school. What we did We conducted 14 studies using a large database of school and health records called ECHILD (Education and Child Health Insights from Linked Data) to follow millions of children in England from birth to age 11 through their anonymised records. We investigated how much children’s health conditions, social circumstances, school test scores, schools and neighbourhoods, influenced who received help for SEND. We used statistical methods to estimate the benefit of help for SEND provided in Year 1 among subgroups of children with health conditions, such as cerebral palsy. We also conducted 10 mixed methods studies where we used both data and personal stories. We interviewed and surveyed hundreds of parents, children and practitioners about their experiences of help for SEND. We analysed documents and consulted parents, young people and practitioners to help understand what the results meant. What we found SEND provision was recorded in 30% of children by age 11. Health conditions increased the likelihood of help for SEND. Social disadvantage, being a boy, having low school test scores, attending a community school and starting school in a state nursery also increased the likelihood of receiving help for SEND. When all these factors were taken into account, voluntary schools and sponsor-led academies provided less intensive help for SEND than community schools. We found only weak evidence that help for SEND reduced the rate of unauthorised school absences. Help for SEND did not reduce the rate of hospital admissions or improve school test scores. Yet parents, young people and practitioners told us in interviews and surveys that SEND provision improved their children’s lives when given early and in a responsive way. They also reported harms due to delayed or inadequate help for SEND and said that parents needed to be able to argue strongly to get the more intensive type of help for SEND. What we learned Who needs help for SEND is not measured well enough in education data or in children’s health records. What types of help children receive, when and for how long, is also not well measured. Parents, young people and practitioners see benefits of good quality, timely and responsive help for SEND. However, the changes they see, such as feeling happier, able to participate in class, and progress in skills, are not measured by standard school tests collected by the government. Two changes are needed in future research: Better measures of the need for help, type of help, and what changes, should be linked to ECHILD data. Different types of help for SEND need to be compared in randomised trials (fair tests that compare two or more groups) so that the government can improve services for children with SEND.

BACKGROUND:Major congenital anomalies (CA) affect 2.3% of livebirths and are associated with lower educational attainment. Understanding attainment trajectories throughout primary school would inform parents, schools and organisations and help plan support. OBJECTIVES:We compared school enrolment and attainment at ages 5, 7 and 11 in children with different CA and their peers in England using the Education and Child Health Insights using Linked Data database. METHODS:We included all singleton children born in NHS-funded hospitals from September 2003 to August 2008 who enrolled in state-funded schools at ages 4-5. CA were identified from hospital diagnoses, procedures or death records. We described school enrolment, school-readiness, the percentage who sat curriculum assessments and who achieved expected English and Maths attainment at three ages. We estimated risk ratios of children with CA achieving expected attainment compared with peers, adjusting for sociodemographic factors. RESULTS:Of 2,351,589 children enrolled at age 5, 78,847 (3.5%) had CA. At age 11, 88.7% of enrolled children with CA sat assessments versus 97.2% of peers. Proportionally fewer children with CA (45.7%) were school-ready at age 5 versus peers (57.0%). For English, 56.9%, 55.4% and 65.3% of children with CA achieved expected levels at ages 5, 7 and 11 respectively, consistently 11%-12% fewer than peers; similar gaps persisted for Maths. Children with CA were less likely than peers to achieve expected attainment (adjusted risk ratio [aRR], 0.86, 95% confidence interval [CI] 0.85, 0.86), but this varied substantially (aRR 0.01, 95% CI 0.01, 0.02 for Down syndrome; aRR 1.04, 95% CI 0.96, 1.12 for unilateral renal agenesis). CONCLUSIONS:Attainment gaps between children with CA and peers remained unchanged across subjects and ages, with proportionally fewer sitting assessments at age 11. Better monitoring and support for these children from school entry could help optimise learning experiences and fulfil their academic potential.

IntroductionSchool absences rates in England have remained high since the COVID-19 pandemic and reducing absence is a policy priority. Evidence shows that young people with chronic health conditions have higher school absence and worse educational outcomes. We examined the perspectives of young people, caregivers and school staff on school absence and return for English secondary school pupils with chronic health conditions.MethodsWe recruited participants through professional networks and health/education organizations, emailing a link to an online qualitative survey. Data analysis was thematic.ResultsWe received survey responses from 12 young people, 33 caregivers, and 18 school staff. Across the young people and caregiver sample (n = 45), two-thirds reported that they or their child had 2 + conditions; 49 different conditions were reported. The nature of absence and its predictability varied. While absent, participants reported that young people fell behind with schoolwork and were isolated from their peers; school support was described as patchy or non-existent. On return to school, young people’s health affected their performance in class and exams and inclusion with peers. Attending school, and its associated stresses, could also negatively impact on young people’s conditions. Young people and caregivers reported that pupils needed caring, reassuring behavior from staff and support to catch-up and succeed academically. Gaps were identified in staff knowledge.DiscussionPolicy and practice should focus on mitigating the impact of unavoidable health-related absence.

Background Policies to reduce school absence can place a burden on children with chronic health conditions (CHCs). Although estimates suggest > 25% of children in England have a CHC before age 16, there is limited evidence on extent of absence, exclusion, and non-enrolment from school among children with CHCs. Methods We used all-of-England inpatient data (Hospital Episode Statistics) to identify groups of adolescents with CHCs from age 5 to 15. Cohorts were born in 2000/01 to 2002/03. Data were linked to England’s National Pupil Database for secondary school (age 11 to 16) persistent absence (>1 month missed/year), exclusion, and non-enrolment to examine rates of each outcome by CHC groups. Results Of 1 456 361 children, 12.5% had a CHC from age 5 to 11, and 18.9% to age 16. Rates of persistent absence were higher among children with CHCs than unexposed peers (e.g. 25.9% compared to 14.7% aged 15/16), especially among those with mental health presentations (32.1%). Increased rates were found for exclusion and non-enrolment for children with CHCs. The percentage of absence recorded as health-related was lowest among children with externalizing presentations. Conclusions Approaches to improve school attendance should consider needs of children with CHCs, ensuring adequate support.

Objectives Children with major congenital anomalies (CA) face greater risks of lower educational attainment than their peers due to ill-health, disability and lack of support. We aimed to evaluate attainment gaps by comparing educational outcomes of children with CA (cases) and without CA (controls) throughout primary school in England. Methods Using linked administrative data from the ECHILD database, we followed singleton children born in NHS-funded hospitals from 01/09/2003 to 31/08/2008 that were linked to the National Pupil Database up to age 10/11 (end of primary school). CA subgroups were indicated by hospital diagnosis and procedure codes, and/or causes of death. We compared the proportions of children enrolled, assessed, and who reached National Curriculum expected levels of attainment, by CA subgroup, key stage (Reception, KS1, KS2) and subject (Good Level of Development (GLD), English and Maths). We estimated relative risks of attainment comparing cases and controls, adjusting for sociodemographic factors. Results Of 2,351,589 children enrolled in Reception (age 4/5), 82,112 (3.5%) were cases. By end of KS2 (age 10/11), enrolment rates were similar for cases and controls (96%), but 11% of enrolled cases were not assessed, versus 3% of controls. At Reception, 46% of cases achieved GLD compared with 57% for controls. Attainment rates for cases peaked at KS2 (65%) for English and remained 67% throughout for Maths, but were consistently 11% lower than for controls. Females performed considerably better in English than males, although cases exhibited smaller sex-differences. Adjusting for sex, cases were about 15% and 6% less likely to achieve expected levels at Reception/KS1 and KS2 respectively versus controls, partly attributable to a subset of generally better performing children progressing to KS2 assessments. Conclusion Many children with CA performed relatively well throughout, with two-thirds reaching expected attainment at KS2. One in nine, however, fall behind significantly and were no longer assessed beyond KS1. Better monitoring and support for these children, ideally from Reception, are needed to support their learning and fulfil their potential.

AIM:To systematically examine evidence on the impact of attending mainstream compared with special secondary school for adolescents with Down syndrome, in terms of health, education, and well-being outcomes. METHOD:We searched four bibliographic databases for studies comparing education and health (including social and self-care) outcomes in adolescents with Down syndrome who attended mainstream secondary school to those attending special secondary school. RESULTS:Of 4458 publications, we identified three studies from the UK and the Netherlands, which involved 246 adolescents with Down syndrome: 49 attended mainstream and 197 attended special secondary school. Of three studies examining education outcomes, two reported improved attainment among adolescents attending mainstream school, but both were at risk of bias from participant selection, missing data, and deviations to the intended intervention. One study reported social and self-care outcomes, with no significant differences. No studies reported health outcomes. Studies provided only cursory information about teaching support. INTERPRETATION:Parents, policy-makers, and others who make choices about education for adolescents with Down syndrome lack evidence on whether outcomes differ, on average, between mainstream and special secondary schools. Well-designed studies are needed to quantify the impact of secondary school type on outcomes among adolescents with Down syndrome.

Background Public health research and prevention policies often use the small area Index of Multiple Deprivation (IMD) at neighbourhood level to proxy individual socio-economic status because it is readily available. We investigated what household income adds to IMD in early childhood for predicting adverse health in adolescence.Methods Using data from the Millennium Cohort Study, we analysed IMD and self-reported equivalised household income (ages 0-5) to predict outcomes at age 17: poor academic achievement, psychological distress, poor health, smoking, and obesity. Predictions were compared using IMD quintile groups alone, household income quintile groups alone, and both together.Results Household income was a stronger and more consistent predictor of age 17 outcomes than IMD and revealed inequalities within neighbourhoods. Decreasing household income showed steep gradients in educational attainment and smoking across all IMD quintiles, and moderate gradients in obesity, psychological distress and poor health in most quintiles. IMD did not predict smoking or psychological distress within any income group, or educational attainment within the poorest income group.Conclusions Household income is associated with inequality gradients within all quintiles of neighbourhood IMD. Early childhood public health strategies should consider household income in combination with neighbourhood deprivation.

Background Children with major congenital anomalies (MCAs) disproportionately experience complex health problems requiring additional health and educational support. Objectives To describe survival to the start of school and recorded special educational needs (SEN) provision among children with and without administrative record-identified MCAs in England. We present results for 12 system-specific MCA subgroups and 25 conditions. We also describe the change of prevalence in recorded SEN provision before and after SEN reforms in 2014, which were implemented to improve and streamline SEN provision. Methods We created a birth cohort of 6,180,400 singleton children born in England between 1 September 2003 and 31 August 2013 using linked administrative records from the ECHILD database. MCAs were identified using hospital admission and mortality records during infancy. SEN provision in primary school was defined by one or more recording of SEN provision in state-school records during years 1 to 6 (ages 5/6 years to 10/11 years). Results Children with any MCA had a 5-year survival rate of 95.1% (95% confidence interval (CI) 95.0, 95.2) compared with 99.7% (95% CI 99.7, 99.7) among children without an MCA. 41.6% (75,381/181,324) of children with an MCA had any recorded SEN provision in primary school compared with 25.7% (1,285,572/5,008,598) of unaffected children. Of the 12 system-specific MCA subgroups, children with chromosomal, nervous system and eye anomalies had the highest prevalence of recorded SEN provision. The prevalence of recorded SEN provision decreased by 4.8% (99% CI -5.4, -4.3) for children with any MCA compared with a reduction of 4.2% (99% CI -4.3, -4.2) for unaffected children, when comparing pupils in year 1 before and after 2014. Conclusion We observed that approximately two fifths of children with MCAs have some type of SEN provision recorded during primary school, but this proportion varied according to condition and declined following the 2014 SEN reforms, similar to children unaffected by MCAs.

BACKGROUND:Child maltreatment (CM) and parental domestic violence and abuse (pDVA) impose considerable lifelong adverse outcomes on those affected. Despite sharing multiple family and environmental risk factors, the economic burden of child exposure where they co-occur has not previously been estimated in detail. OBJECTIVE:To estimate average lifetime societal costs resulting from CM or childhood exposure to pDVA, and incremental costs for scenarios where they co-occur. PARTICIPANTS AND SETTING:Avon Longitudinal Study of Parents and Children, G1 (child) cohort. METHODS:We developed a model to estimate lifetime societal costs (2019 GBP) for fatal and non-fatal exposure to CM and/or pDVA for the study sample. Total lifetime costs per child exposed, total UK economic burden, and UK government-specific costs were then estimated for the cohort of children born in the UK in 2013. RESULTS:Lifetime costs for childhood exposure to CM and/or pDVA, were £71,309 per child (non-fatal exposure), and £1,292,377 per CM fatality, with £27.8 billion projected costs (2013 UK birth cohort). Total costs for exposure to pDVA alone was £1.0 billion (£16,639 per child exposed), rising to £2.0 billion (£71,037 per exposed child) for children reporting awareness of pDVA. Co-occurring CM and pDVA imposed greater costs than either alone, including costs from child perpetration of intimate partner violence. CONCLUSIONS:CM and/or pDVA exposure incurs large personal and societal economic burdens, and costs from both pDVA exposure and intergenerational transmission of IPV perpetration, highlight the importance for policies to address both CM and domestic violence and abuse in affected households.