Background. Among children aged 6-16, there is a clear association between attention-deficit/hyperactivity disorder (ADHD) symptoms and academic attainment. We wanted to know whether this association was replicated in younger children. Aims. To explore the relationship between children aged 4-8 with probable ADHD and their academic attainment and school attendance. Secondly, the study aimed to explore their behaviour within school and their reported attitudes towards school. Sample. A total of 1,152 children who were taking part in the Supporting Teachers and Children in Schools (STARS) cluster randomized controlled trial. Methods. ADHD status was established by using the Strengths and Difficulties Questionnaire predictive algorithm to identify children with probable ADHD. Using baseline data, random-effects regression models on ADHD status were fitted to attainment, attendance, special educational needs (SEN) provision, and attitudes towards school and classroom behaviour; models that were also fitted to attainment were evaluated again at 9, 18, and 30 months after baseline. Results. Children with probable ADHD (n = 47) were more likely than controls (n = 1,105) to have below-expected attainment in literacy (odds ratio (OR) 16.7, 95% CI 6.93-to-40.1), numeracy (OR 11.3, 95% CI 5.34-to-24.1) and to be identified as having SEN (OR-55.2, 95%-CI 22.1-to-137). Their attendance was poorer with more unauthorized absences (rate ratio (RR)-1.91, 95%-CI-1.57-to-2.31). They had more teacherreported behavioural problems (mean difference (MD) 5.0, 95%-CI 4.6-to-5.4) and less This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Purpose – The purpose of this paper is to explore the association between children who are at risk of being or who have been excluded from school between the ages of 4 and 12 years and the role of psychopathology, development and attainment. Design/methodology/approach – A case-control approach was conducted. Cases were children who had been excluded from school compared to those who had no reported exclusions and normative data where possible. A range of measures were used to collect information from the parent, child and teacher on areas covering the child’s mental health and well-being. Findings – The findings showed the number of difficulties faced by children who are at risk of being or who have been excluded from school compared to gender- and age-matched controls and normative data increased. Behavioural difficulties were apparent in the majority of the cases and an alarming number of children reported self-harm. Interestingly nearly all the cases had recognised needs, but not all of them were accessing appropriate services. Practical implications – There have been a number of changes regarding the identification and support of children’s mental health and well-being. This study highlights gaps in resources and provision, particularly around behavioural difficulties for children who are presenting as not coping in school. Originality/value – The findings from the SKIP study indicate the complexities and compounded difficulties faced by children who are experiencing exclusion from school. By implementing a systematic group of assessments the study was able to identify these complexities of need across a vulnerable group of children.

Interspecialty referrals are an essential part of most inpatient stays. With over 130 referrals occurring per week at the Royal Devon and Exeter Hospital, the process must be efficient and safe. The current paper-based ’white card' system was felt to be inefficient, and a Trust incident highlighted patient safety concerns. Questionnaires reinforced the need for improvement, with concerns such as a lack of referral traceability and delays in the referral delivery due to workload. The aims of the project were to improve patient safety and junior doctor efficiency in the referral process. Through appreciative enquiry and the PDSA (Plan-Do-Study-Act) model, an electronic referral system was developed, piloted within two specialties and later expanded to others with improvements made along the way based on user feedback. The system includes novel features including specialties ’acknowledging' a referral to allow referral progress to be tracked. The system stores all referrals, creating a fully auditable inpatient referral pathway. Qualitative data indicated improvement to patient safety and user experience (n=31). Timings for referrals were measured over a 6-month period; referrals became faster with the electronic system, with average time from decision to refer to referral submission improving from 2.1 hours to 1.9 hours, with a noted statistically significant improvement in timings on a statistical process control chart. An unexpected benefit was that patients were also reviewed faster by specialties. Measuring these changes presented a significant challenge due to the complexity of the referral process, and this was a big limitation. Overall, the re-design of a paper-based referral system into an electronic system has been proven to be more efficient and felt to be safer for patients. This is a sustainable change which is being rolled out Trust-wide. We hope that the reporting of this project will help others considering reviewing their inpatient referral pathways.

Sleep is a pillar of health, alongside adequate nutrition and exercise. Problems with sleep are common and often treatable. Twenty years ago, UK medical school education on sleep disorders had a median teaching time of 15 min; we investigate whether education on sleep disorders has improved. This is a cross-sectional survey, including time spent on teaching sleep medicine, subtopics covered and forms of assessment. Thirty-four medical degree courses in the UK were investigated via a questionnaire. We excluded responses not concerned with general undergraduate education (i.e. optional modules). Twenty-five (74%) medical schools responded. Time spent teaching undergraduates sleep medicine was: median, 1.5 hr; mode, <1 hr; mean, 3.2 hr (SD = 2.6). Only two schools had a syllabus or core module (8%) and five (22%) were involved in sleep disorders research. Despite the above, half of the respondents thought provision was sufficient. Free-text comments had recurring themes: sleep medicine is subsumed into other specialties, obstructive sleep apnea dominates teaching, knowledge of sleep disorders is optional, and there is inertia regarding change. A substantial minority of respondents were enthusiastic about improving provision. In conclusion, little has changed over 20 years: sleep medicine is neglected despite agreement on its importance for general health. Sleep research is the exception rather than the rule. Obstacles to change include views that "sleep is not a core topic" or "the curriculum is too crowded". However, there is enthusiasm for improvement. We recommend establishment of a sleep medicine curriculum. Without better teaching, doctors will remain ill-equipped to recognize and treat these common conditions.

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