Mental health problems among children and youths are common and have numerous negative consequences for young people and their social network. Therewith, these problems pose a social issue. GPs... Show moreMental health problems among children and youths are common and have numerous negative consequences for young people and their social network. Therewith, these problems pose a social issue. GPs play an important role in early detection and management of these problems. Insight into their clinical decision- making and, as a result, way of working would be helpful to develop methods for providing children and youths with the help they need. Previous literature suggest many doctors(-to-be), of whom some are or will become GPs, have (lived) experience related to mental health problems themselves. Previous studies also suggest having (lived) experience influences GPs’ clinical decision-making, and consequently their way of working. It would have clinical benefits for GPs and patients to explore this process. This thesis is constructed of four different articles, each contributing to answering the main question: ‘How do GPs decide on child and youth mental health problems and what is the influence of their(lived) experience regarding these problems on this decision?’ Article 1: How do GPs make decisions regarding mental health problems in children and youths? For answering this subquestion, a mixed methods design was used: interviews among 14 and an online survey among 15 GPs. GPs were asked about their clinical decision-making process on children and youths with mental health problems using three vignettes describing children and youths with mental health problems representative of clinical practice. The findings suggest GPs differ with regards to their decision- making regarding child and youth mental health problems, and that their decision-making is influenced by factors related to 1) the GP, for example if the GP approaches the problem somatically or psychosocially, if the GP considers themself competent enough to solve the problem with regards to their interest in and knowledge about youth mental health care, 2) the child and its social context, for example if the child or youth has psychiatric (co)morbidity, if the problem is likely to solve itself and if the problem could be assessed as being complex and 3) the GPs’ collaboration with other youth care providers, for example if GPs have existing collaboration agreements with these youth care providers and how they view their collaboration. Article 2: Can GPs’ decisions on child and youth mental health problems be supported by means of a decision-support method?For answering this subquestion, a literature search was conducted to retrieve studies that involved clinical decision support methods for GPs’ clinical decision-making related to mental health problems among children and youths. This systematic review yielded 25 studies on 18 clinical decision-support methods, divided into computer-based methods (such as MyGRaCE), telecommunication methods (such as CAP PC) and methods with a combination of components related to computer-based methods and telecommunication methods (such as Collaborative care for depression intervention). The article provides insight into (possible) beneficial clinical implications of clinical decision-support methods. These methods could give more insight into possible mental health problems, they could provide structured information which can be used by the GP and/or parents during their next consultation with the child or youth, and they could also decrease time and costs spent by the primary care practice and the GP. There are also less beneficial clinical implications, such as an inability for some computer-based methods to be used in emergency situations, when time is short, problems for children and youths when using computer-based methods because of their mental status, and impediment to discuss certain topics freely because the decision-support method gives too much direction to the consultation. The article describes certain considerations for GPs when choosing a decision-support method, which may indirectly have a positive impact on the implementation of such methods into general practice. For example, the GP can take into account their way of working, user flexibility of the method for the GP, the child/youth and their parent(s) with regards to understandability and ease of use, if the GP already uses a clinical decision-support method, if the GP already has collaboration agreements with youth care providers, as well as their own attitude and knowledge regarding mental health problems among children and youths.Article 3: Do doctors-to-be, among whom future GPs, have (lived) experience regarding mental health problems? Study focused on preclinical medical students.For answering this subquestion, self-report questionnaires were sent to 1311 preclinical medical students of Leiden University Medical Center to measure burnout-, depression- and anxiety-related symptoms. The article concludes that symptoms related to mental health problems are common among preclinical medical students. Burnout-related symptoms were found in 46%, depression-related symptoms in 27% and anxiety- related symptoms in 29% of preclinical medical students. Burnout-related symptoms among preclinical medical students were correlated with a sleep duration of less than 6 hours per night, low happiness and a high need for recovery after a day of study. Depression- and anxiety-related symptoms were mainly correlated with low optimism, low happiness, and a high need for recovery after a day of study. These findings suggest preclinical medical students are at risk to develop mental health problems, which can inspire universities to come up with preventive interventions.Article 4: Do doctors-to-be, among whom future GPs, have (lived) experience regarding mental health problems? Study focused on medical interns.For answering this subquestion, self-report questionnaires were sent to 709 medical interns of the same institution mentioned in article 3 to measure burnout-related symptoms. Burnout-related symptoms were found in 30% of medical interns. Burnout-related symptoms among medical interns were related to low dedication with regards to work, a high work pace and quantity, a high need for recovery after a day of work and low optimism. These correlates could be used to prevent mental health problems among medical interns by making adjustments to the medical curriculum. The articles of this thesis suggest GPs’ decision-making on mental health problems in children and youths is multifactorial and consists of objective and subjective components. Furthermore, decision-making seems to differ between GPs, which may be an explanation why there are a variety of clinical decision support methods. Some clinical decision support methods have been implemented in the context of research into general practice, like MyGRaCE, CHICA, Mobiletype, Youth StepCare, consultation-liason method(between GPs and psychiatrists), telepsychiatry consultation practice and the MC3 Program. A clinical implication is GPs can choose a decision-support method which match their personal style of clinical decision-making. However, the validity, trustworthiness and usability of available methods need to be further explored. A clinical implication with regards to medical students’ mental health comprises universities provide accessible proactive mental support to preclinical medical interns and medical interns, because many do not seek help themselves. Furthermore, universities could stimulate a stigma-reducing educational environment, for example in collaboration with the department of (Child- and Adolescent) Psychiatry. Therefore, medical students could be equipped with effective strategies to cope with mental health problems. Also, they might be made aware of their vulnerability, so that they may know their subjectivity and use their personal experiences in practice. The results of this thesis invite more (longitudinal) research on the diagnostic precision, predictive value and cost-efficiency of clinical decision-support methods. Furthermore, more research is needed on the prevalence of mental health problems among graduated doctors, like GPs, and possible effects of these problems on their way of working, their decision-making and their contacts with patients. Strengths of this thesis include exploration of a relatively unknown research area, namely GPs’ clinical decision-making regarding mental health problems among children and youths. Therefore, this thesis used multiple research methodologies and it used a practical scope. This thesis also contains several limitations, such as inclusion of a small GP population, as well as self-selection bias in the studies on preclinical medical students, medical interns and GPs. Finally, interpretation of the results of this thesis was impeded because the research has been conducted in one university, because cause and effect of results could not always be disentangled and because of low statistical power. Because having mental health problems may influence GPs’ clinical decision-making, one could explore how (future) doctors work, study and relax. Therefore, it is recommended to strive for educating balanced doctors: persons who, in collaboration with their colleagues, are – through reflection – aware of their needs and wants between professional boundaries. Show less
After standard surgery for neck hernias, about 25% of patients report low satisfaction. This thesis applied inferential statistics to clinical data and Machine Learning to medical imaging, with the... Show moreAfter standard surgery for neck hernias, about 25% of patients report low satisfaction. This thesis applied inferential statistics to clinical data and Machine Learning to medical imaging, with the goal of finding out where differences in functional outcomes after surgery come from and how artificial intelligence can improve the diagnostic and prognostic process. The initial idea that differences in functional recovery were due to surgical technique was refuted by an RCT from this dissertation. The differences in functional recovery between three different surgical groups (removal of the intervertebral disc without artificial material, placement of intervertebral disc prosthesis, and fusion of vertebrae with a cage) were found to be minimal. It was striking that not surgical technique, but patients' mental health and preoperative, radiological imaging were found to be predictive of clinical recovery after surgery. Although the intervertebral disc prosthesis did not deliver on the promise of preserving mobility and thus could not prevent degeneration at adjacent levels, using Deep Learning based solely on the preoperative MRI of the neck, researchers were able to predict, among other things, which patients would require reoperation after surgery for that adjacent degeneration. The Deep Learning model did that significantly better than an experienced neuroradiologist and neurosurgeon. Such Deep Learning models eliminate the need for time-consuming questionnaires and are thus more cost-effective and less stressful for the patient, while they can be used to identify radiological features important for predicting the postoperative course. After validation with larger radiological datasets, these models can support clinical decision-making and help physicians develop personalized treatment strategies. Challenges within image analysis research for the spine lies in integrating different models into one automated process, preferably built into the electronic health record. Show less
Background: Care leavers transitioning into adulthood represent a highly vulnerable population, confronted with usual developmental tasks under difficult predisposing conditions. Early-risk and... Show moreBackground: Care leavers transitioning into adulthood represent a highly vulnerable population, confronted with usual developmental tasks under difficult predisposing conditions. Early-risk and persistent substance use may be an obstacle for care leavers transitioning from youth residential care settings into an independent adult life.Objectives: This study aims to address the following questions: (1) How stable is high-risk substance use from within care to after youth residential care? (2) Are there differences between longitudinal substance use risk pathways and sociodemographic characteristics, placement history, and adverse exposures? (3) Is the persistency of high-risk substance use associated with impaired young adult psychosocial functioning?Method: In a prospective longitudinal design, with a baseline in youth residential care (t1) and a follow-up ten years later (t2), we investigated the courses of substance use in 182 young adult care leavers in Switzerland (32.4 % women; Mean age = 26.7 years). Psychosocial functioning was assessed across health, legal, educational, and financial domains.Results: We found large prevalence rates of high-risk substance use in and after residential youth care (41.2 % in residential care; 46.2 % after leaving care). Of those care leavers who reported earlier high-risk substance use, 61.3 % persisted, while 38.7 % remitted. Four substance risk pathways were identified longitudinally: low (N = 69, 37.9 %), remitted (N = 29, 15.9 %), newly-developed (N = 38, 20.9 %), and persistent risk (N = 46, 25.3 %). Persistent high-risk substance use was associated with higher rates of adverse functional outcomes in young adulthood.Conclusions: Findings of this study shed light on the high prevalence of earlier and persistent high-risk substance use in youth residential care leavers. High-risk substance use appears to have the potential to coincide with impaired psychosocial functioning during and after the transition to young adulthood. Implications for educational and vocational paths as well as harm-reducing interventions are discussed. More research disentangling risk pathways and intervention research in at-risk populations is warranted. Show less
Background: It is unclear to what extent mental health and negative life events (NLEs) contribute to weight change in patients with overweight. This study aimed to evaluate the association of... Show moreBackground: It is unclear to what extent mental health and negative life events (NLEs) contribute to weight change in patients with overweight. This study aimed to evaluate the association of anxiety, depression, NLEs and quality of life (QoL) with weight change over ten years in middle-aged individuals with overweight.Methods: Population-based cohort study of 2889 middle-aged men and women with a body mass index ≥27 kg/m2. Relative weight change over ten years was defined as weight loss (≤- 5 %), stable weight (between >- 5 % and <5 %) or weight gain (≥5 %). At baseline, participants reported anxiety symptoms, depressive symptoms, recent (last year) and distant (lifetime) NLEs, and a mental component summary of QoL. With multinomial logistic regression adjusting for potential confounding, we examined the association of mental health and NLEs with weight change after a median (25th, 75th percentiles) follow-up of 9.7 (9.0-10.5) years.Results: In 51 % participants weight was stable, 33 % participants lost weight and 17 % gained weight. Mild (odds ratio 1.36; 95 % confidence interval 1.05-1.75), and moderate to very severe depressive symptoms (1.43; 0.97-2.12) and four or more distant NLEs (1.35; 1.10-1.67) were associated with weight gain. Anxiety symptoms, the mental component summary of QoL were not associated with either weight gain or weight loss.Limitations: Due to the observational design residual confounding cannot be excluded.Conclusion: Our study suggests that depressive symptoms or having experienced distant NLEs are associated with weight gain over time in middle-aged individuals with overweight. These subgroups might benefit from proactive attention from their health care providers.Keywords: Body weight changes; Life change events; Longitudinal study; Mental health; Overweight. Show less
BackgroundIt is unclear to what extent mental health and negative life events (NLEs) contribute to weight changein patients with overweight. This study aimed to evaluate the association of anxiety... Show moreBackgroundIt is unclear to what extent mental health and negative life events (NLEs) contribute to weight changein patients with overweight. This study aimed to evaluate the association of anxiety, depression, NLEs and quality of life (QoL) with weight change over ten years in middle-aged individuals with overweight.MethodsPopulation-based cohort study of 2889 middle-aged men and women with a body mass index ≥27 kg/m2. Relative weight change over ten years was defined as weight loss (≤− 5 %), stable weight (between >− 5 % and <5 %) or weight gain (≥5 %). At baseline, participants reported anxiety symptoms, depressive symptoms, recent (last year) and distant (lifetime) NLEs, and a mental component summary of QoL. With multinomial logistic regression adjusting for potential confounding, we examined the association of mental health and NLEs with weight change after a median (25th, 75th percentiles) follow-up of 9.7 (9.0–10.5) years.ResultsIn 51 % participants weight was stable, 33 % participants lost weight and 17 % gained weight. Mild (odds ratio 1.36; 95 % confidence interval 1.05–1.75), and moderate to very severe depressive symptoms (1.43; 0.97–2.12) and four or more distant NLEs (1.35; 1.10–1.67) were associated with weight gain. Anxiety symptoms, the mental component summary of QoL were not associated with either weight gain or weight loss.LimitationsDue to the observational design residual confounding cannot be excluded.ConclusionOur study suggests that depressive symptoms or having experienced distant NLEs are associated with weight gain over time in middle-aged individuals with overweight. These subgroups might benefit from proactive attention from their health care providers. Show less
Background: The initial period of COVID-19-related restrictions affected substance use in some population groups. We explored how changes in alcohol use at the beginning of the pandemic impacted... Show moreBackground: The initial period of COVID-19-related restrictions affected substance use in some population groups. We explored how changes in alcohol use at the beginning of the pandemic impacted the health and wellbeing of people with and without mental health and neurodevelopmental conditions (MHDCs). Methods: Data came from the Global Drug Survey Special Edition on COVID-19 conducted in May-June 2020. Measured were; changes in drinking compared to February 2020 (pre-COVID-19 restrictions), reasons for changes, and impact on physical health, mental health, relationships, finances, work/study, and enjoyment. This study included 38,141 respondents (median age = 32 IQR 25-45; 51.9% cis man; 47.8% cis woman; 1.2% trans/nonbinary; 30.2% with MHDCs e.g. depression 20.0%, anxiety 16.3%, ADHD 3.8%, PTSD 3.3%). Results: A third (35.3%) of respondents with MHDCs and 17.8% without MHDCs indicated that increased drinking affected their mental health negatively (p < .001); 44.2% of respondents with MHDCS compared to 32.6% without MHDCs said it affected their physical health negatively (p < .001). Reduced drinking was associated with better mental health among a fifth (21.1%) of respondents with MHDCS and 14.4% without MHDCs (p < .001). Age, relationship status, living arrangements, employment, coping and distress were significant predictors of increases in drinking. Conclusion: Among people with MHDCS, reduced alcohol consumption was associated with better mental health, while the negative effects of increased drinking were more pronounced when compared to people without MHDCS. When supporting people in reducing alcohol consumption during uncertain times, people with MHDCS may need additional support, alongside those experiencing greater levels of distress. Show less
Voorend, C.G.N.; Oevelen, M. van; Nieberg, M.; Meuleman, Y.; Franssen, C.F.M.; Joosten, H.; ... ; POLDER Investigators 2021
Background: Older patients with advanced chronic kidney disease are at increased risk for a severe course of the coronavirus disease-2019 (COVID-19) and vulnerable to mental health problems. We... Show moreBackground: Older patients with advanced chronic kidney disease are at increased risk for a severe course of the coronavirus disease-2019 (COVID-19) and vulnerable to mental health problems. We aimed to investigate prevalence and associated patient (demographic and clinical) characteristics of mental wellbeing (health-related quality of life [HRQoL] and symptoms of depression and anxiety) before and during the COVID-19 pandemic in older patients with advanced chronic kidney disease.Methods: An ongoing Dutch multicentre prospective cohort study enrols patients of >= 70 years with an eGFR < 20 mL/min/1.73m(2) from October 2018 onward. With additional questionnaires during the pandemic (May-June 2020), disease-related concerns about COVID-19 and general anxiety symptoms were assessed cross-sectionally, and depressive symptoms, HRQoL, and emotional symptoms longitudinally.Results: The 82 included patients had a median age of 77.5 years (interquartile range 73.9-82.1), 77% were male and none had tested positive for COVID-19. Cross-sectionally, 67% of the patients reported to be more anxious about COVID-19 because of their kidney disease, and 43% of the patients stated that their quality of life was reduced due to the COVID-19 pandemic. Compared to pre-COVID-19, the presence of depressive symptoms had increased (11 to 22%; p = .022) and physical HRQoL declined (M = 40.4, SD = 10.1 to M = 36.1, SD = 10.4; p < .001), particularly in males. Mental HRQoL (M = 50.3, SD = 9.6 to M = 50.4, SD = 9.9; p = .913) and emotional symptoms remained similar.Conclusions: Older patients with advanced chronic kidney disease suffered from disease-related anxiety about COVID-19, increased depressive symptoms and reduced physical HRQoL during the COVID-19 pandemic. The impact of the pandemic on this vulnerable patient group extends beyond increased mortality risk, and awareness of mental wellbeing is important. Show less
Purpose This study aims to explore the perspectives of mental health professionals who are in a process of integrating their own experiential knowledge in their professional role. This study... Show morePurpose This study aims to explore the perspectives of mental health professionals who are in a process of integrating their own experiential knowledge in their professional role. This study considers implications for identity, dilemmas and challenges within the broader organization, when bringing experiential knowledge to practice. Design/methodology/approach As part of a participatory action research approach, qualitative methods have been used, such as in-depth interviews, discussions and observations during training and project team. Findings The actual use of experiential knowledge by mental health care professionals in their work affected four levels: their personal-professional development; the relation with service users; the relation with colleagues; and their position in the organization. Research limitations/implications Because of its limited context, this study may lack generalisability and further research with regard to psychologists and psychiatrists, as well as perceptions from users, is desirable. Social implications According to this study, social change starts from a bottom-up movement and synchronously should be facilitated by top-down policy. A dialogue with academic mental health professionals seems crucial to integrate this source of knowledge. Active collaboration with peer workers and supervisors is desired as well. Originality/value Professionals with lived experiences play an important role in working recovery-oriented, demonstrating bravery and resilience. Having dealt with mental health distress, they risked stigma and rejections when introducing this as a type of knowledge in current mental health service culture. Next to trainings to facilitate the personal-professional process, investments in the entire organization are needed to transform governance, policy and ethics. Show less
Background: Isolation precautions are applied to control the risk of transmission of multi drug resistant organisms (MDROs). These precautions have been associated with adverse effects, such as... Show moreBackground: Isolation precautions are applied to control the risk of transmission of multi drug resistant organisms (MDROs). These precautions have been associated with adverse effects, such as anxiety and depression. This study aimed to quantify stigma among MDRO carriers and its association with perceived mental health and experienced quality of care.Methods: A quantitative questionnaire study was performed in MDRO carriers exposed to >= 3 days of isolation precautions during hospitalization. Items derived from the Consumer Quality Index questionnaire (CQI) were used to assess perception of care. Stigma scores were calculated using the recently modified Berger Stigma Scale for meticillin-resistant Staphylococcus aureus (MRSA). Mental health was measured with the RAND Mental Health Inventory. The Spearman rank correlation test was used to assess the association between stigma score and RAND mental health score.Findings: Of the 41 included carriers, 31 (75.6%) completed both questionnaires. The experienced quality of care was 'good' according to CQI score. Twenty-four percent reported not to have received proper explanation about MDRO carriership from healthcare workers (HCWs). MDRO-associated stigma was reported in 1/31 (3.2%). Poor mental health was self-reported in 3/31 (9.7%). There was no correlation between stigma score and RAND mental health score (Spearman correlation coefficient: 0.347).Conclusions: In this study, MDRO carriers exposed to >= 3 days of isolation precautions did not report stigma. This contrasts with a recent study that investigated MRSA-associated stigma and may be explained by contact plus airborne isolation protocols in MRSA compared with contact isolation alone in most other MDROs. Also, the psychological impact may be of a different magnitude due to as yet unknown reasons. (C) 2020 The Author(s). Published by Elsevier Ltd on behalf of The Healthcare Infection Society. Show less
Objective: Contagious disease outbreaks and related restrictions can lead to negative psychological outcomes, particularly in vulnerable populations at risk due to pre-existing medical conditions.... Show moreObjective: Contagious disease outbreaks and related restrictions can lead to negative psychological outcomes, particularly in vulnerable populations at risk due to pre-existing medical conditions. No randomised controlled trials (RCTs) have tested interventions to reduce mental health consequences of contagious disease outbreaks. The primary objective of the Scleroderma Patient-centered Intervention Network COVID-19 Home-isolation Activities Together (SPIN-CHAT) Trial is to evaluate the effect of a videoconference-based program on symptoms of anxiety. Secondary objectives include evaluating effects on symptoms of depression, stress, loneliness, boredom, physical activity, and social interaction.Methods: The SPIN-CHAT Trial is a pragmatic RCT that will be conducted using the SPIN-COVID-19 Cohort, a sub-cohort of the SPIN Cohort. Eligible participants will be SPIN-COVID-19 Cohort participants without a positive COVID-19 test, with at least mild anxiety (PROMIS Anxiety 4a v1.0 T-score >= 55), not working from home, and not receiving current counselling or psychotherapy. We will randomly assign 162 participants to intervention groups of 7 to 10 participants each or waitlist control. We will use a partially nested RCT design to reflect dependence between individuals in training groups but not in the waitlist control. The SPIN-CHAT Program includes activity engagement, education on strategies to support mental health, and mutual participant support. Intervention participants will receive the 4-week (3 sessions per week) SPIN-CHAT Program via video-conference. The primary outcome is PROMIS Anxiety 4a score immediately post-intervention.Ethics and dissemination: The SPIN-CHAT Trial will test whether a brief videoconference-based intervention will improve mental health outcomes among at-risk individuals during contagious disease outbreak. Show less
Vinkers, C.H.; Amelsvoort, T. van; Bisson, J.I.; Branchi, I.; Cryan, J.F.; Domschke, K.; ... ; Wee, N.J.A. van der 2020
The epidemic of the 2019 novel coronavirus SARS-CoV-2, causing the coronavirus disease 2019 (COVID-19) is a global public health emergency with multifaceted severe consequences for people's lives... Show moreThe epidemic of the 2019 novel coronavirus SARS-CoV-2, causing the coronavirus disease 2019 (COVID-19) is a global public health emergency with multifaceted severe consequences for people's lives and their mental health. In this article, as members of the European College of Neuropsychopharmacology (ECNP) Resilience, we will discuss the urgent need for a focus on resilience during the current coronavirus pandemic. Resilience is pivotal to cope with stress and vital to stay in balance. We will discuss the importance of resilience at the individual and societal level, but also the implication for patients with a psychiatric condition and health care workers. We not only advocate for an increased focus on mental health during the coronavirus pandemic but also highlight the urgent need of augmenting our focus on resilience and on strategies to enhance it. (C) 2020 The Authors. Published by Elsevier B.V. Show less
Benthem, P. van; Spijkerman, R.; Blanken, P.; Kleinjan, M.; Vermeiren, R.R.J.M.; Hendriks, V.M. 2020
We investigated the potential role of first-session therapeutic alliance ratings to serve as an early marker of treatment outcome in youth mental health and addiction treatment. The present study... Show moreWe investigated the potential role of first-session therapeutic alliance ratings to serve as an early marker of treatment outcome in youth mental health and addiction treatment. The present study is among the first to incorporate both a youths' and a therapists' perspective of the therapeutic alliance in order to maximize predictive value of the alliance for treatment outcome. One hundred and twenty-seven adolescents participated in a multi-site prospective naturalistic clinical cohort study, with assessments at baseline and at 4 months post-baseline. Main outcome measure was favorable or unfavorable treatment outcome status at 4-month follow-up. Early therapeutic alliance had a medium and robust association with treatment outcome for youth' (b = 1.29) and therapist' (b = 1.12) perspectives and treatment setting. Based on the two alliance perspectives four subgroups were distinguished. Incorporating the alliance-ratings from both perspectives provided a stronger predictor of treatment outcome than using one perspective. Youth with a strong alliance according to both perspectives had an eightfold odds of favorable treatment outcome compared with youth with a weak alliance according to both perspectives. The association between therapeutic alliance and treatment outcome in youth mental health and addiction treatment may be substantially stronger than earlier assumed when both a youths' and therapists' perspective on alliance is considered. Show less
Child labour can stand in the way of linguistic development and mental health of Indian youth. "We looked at the linguistic development and mental health of children from different social classes... Show moreChild labour can stand in the way of linguistic development and mental health of Indian youth. "We looked at the linguistic development and mental health of children from different social classes in the context of child labour, sleep and academic activities. We saw that children with lower socioeconomic status devote more time to work and sleep and less time to academic tasks than their peers with a higher status," "What we found is that child labor provides a strong explanation for both poorer language development and mental health in lower SES-children. We discovered that the relationship between the linguistic results and academic time is stronger in children with lower socioeconomic status, suggesting that especially these children would benefit if they could invest more time in school and less in other work." This research is the only time-use study conducted in the Indian state of Maharashtra. It is also the only Indian study that uses the time spending methodology with youth represented from a very diverse range of socio-economic classes, including minimally literate school-going youth. Until now we knew little about this, because this group is difficult to reach. Show less
