Child mental health and maternal depression history in Pakistan

Anxiety-focused cognitive behavioral therapy delivered by non-specialists to prevent postnatal depression: a randomized, phase 3 trial

Anxiety experienced by women during pregnancy is highly prevalent, especially in resource-poor settings and strongly predicts postnatal common mental disorders (CMDs), anxiety and depression. We evaluated the effectiveness of an anxiety-focused early prenatal intervention on preventing postnatal CMDs. This study was a phase 3, two-arm, single-blind, randomized controlled trial conducted in Pakistan with women who were ≤22 weeks pregnant and had at least mild anxiety without clinical depression. Participants were randomized to the Happy Mother-Healthy Baby program, based on cognitive behavioral therapy, consisting of six one-on-one intervention sessions in pregnancy delivered by non-specialist providers, or to enhanced care alone. The primary outcome was major depression, generalized anxiety disorder or both at 6 weeks after delivery. Overall, 755 women completed postnatal assessments (380 (50.3%), intervention arm; 375 (49.7%) enhanced-care arm). The primary outcomes were met. Examined jointly, we found 81% reduced odds of having either a major depressive episode (MDE) or moderate-to-severe anxiety for women randomized to the intervention (adjusted odds ratio (aOR) = 0.19, 95% CI 0.14-0.28). Overall, 12% of women in the intervention group developed MDE at 6 weeks postpartum, versus 41% in the control group. We found reductions of 81% and 74% in the odds of postnatal MDE (aOR = 0.19, 95% CI 0.13-0.28) and of moderate-to-severe anxiety (aOR = 0.26, 95% CI 0.17-0.40), respectively. The Happy Mother-Healthy Baby program early prenatal intervention focusing on anxiety symptoms reduced postpartum CMDs. ClinicalTrials.gov identifier NCT03880032 .

Prevalence of maternal depression and anxiety symptoms and associations with child mental health outcomes in rural Nepal

OBJECTIVES

This study describes the prevalence, associated factors and child mental health outcomes related to symptoms of maternal depression and anxiety within 5 years after childbirth in a rural district in Nepal. This association is not well-understood in rural, community-based settings in low- and middle-income countries (LMIC).

METHODS

A sample of 347 women with children under 5 years was recruited in September 2019 for a cross-sectional study in the rural Saptari district in Nepal. Multivariable logistic regression was used to investigate the association between maternal depressive or anxiety symptoms and children's experience and impact of emotional and behavioural difficulties.

RESULTS

In total, 144 women (41.5%) had moderate or severe depression symptoms and 118 (34%) had anxiety symptoms. Mothers with a lower income were more likely to have anxiety symptoms than the highest income group (OR: 1.8, 95% CI: 1.1-3.0). An association existed between maternal depressive symptoms and the impact of emotional or behavioural difficulties in children (OR: 2.44, 95% CI: 1.02-5.84). In contrast, there was no association between maternal anxiety and child outcomes.

CONCLUSIONS

Our findings suggest that the prevalence of probable maternal anxiety and depression symptoms was relatively high in this rural, low-resourced and community-based setting in Nepal. Maternal depressive symptoms were associated with the degree of impact on children's mental health post-infancy, emphasising the importance of improving maternal mental health in the early years of a child's life.

Prenatal stress and child externalizing behavior: effects of maternal perceived stress and cortisol are moderated by child sex

BACKGROUND

Externalizing behavior problems are related to social maladjustment. Evidence indicates associations between prenatal stress and child behavioral outcomes. It remains unclear how psychological distress vs. biological correlates of stress (cortisol) differentially predict externalizing behavior, and how their effects might differ as a function of child sex.

METHOD

108 pregnant women from the community collected salivary cortisol and reported their perceived stress during each trimester of pregnancy. At child age 9 years (M = 9.01, SD = 0.55), 70 mothers and children reported on child behavior. Structural equation modelling was used to analyze how cortisol levels and perceived stress during pregnancy predicted current child externalizing behavior, considering the moderating effect of child sex.

RESULTS

Perceived stress predicted higher externalizing behavior in boys (β = 0.42, p = 0.009) and lower externalizing behavior in girls (β = - 0.56, p = 0.014). Cortisol predicted lower externalizing behavior in boys (β = - 0.81, p < .001) and was not related to girls' externalizing behavior (β = 0.37, p = 0.200).

DISCUSSION/CONCLUSION

Prenatal stress affected externalizing behavior differently in girls vs. boys. These response patters in turn differed for indicators of psychological vs. biological maternal stress, encouraging an integrated approach. Findings indicate that perceived stress and cortisol may affect child development via different trajectories.

A Multi-Cohort Examination of the Independent Contributions of Maternal Childhood Adversity and Pregnancy Stressors to the Prediction of Children's Anxiety and Depression

Women's social experiences can have long-term implications for their offspring's health, but little is known about the potential independent contributions of multiple periods of stress exposures over time. This study examined associations of maternal exposure to adversity in childhood and pregnancy with children's anxiety and depression symptoms in a large, sociodemographically diverse sample. Participants were 1389 mother-child dyads (child age M = 8.83 years; SD = 0.66; 42% Black, 42% White; 6% Hispanic) in the ECHO-PATHWAYS Consortium's three U.S. pregnancy cohorts. Women reported their exposure to childhood traumatic events (CTE) and pregnancy stressful life events (PSLE). Children self-reported on their symptoms of anxiety and depression at age 8-9 years. Regression analyses estimated associations between maternal stressors and children's internalizing problems, adjusting for confounders, and examined child sex as a modifier. Exploratory interaction analyses examined whether geospatially-linked postnatal neighborhood quality buffered effects. In adjusted models, PSLE counts positively predicted levels of children's anxiety and depression symptoms ([ßAnxiety=0.08, 95%CI [0.02, 0.13]; ßDepression=0.09, 95%CI [0.03, 0.14]); no significant associations were observed with CTE. Each additional PSLE increased odds of clinically significant anxiety symptoms by 9% (95%CI [0.02, 0.17]). Neither sex nor neighborhood quality moderated relations. Maternal stressors during pregnancy appear to have associations with middle childhood anxiety and depression across diverse sociodemographic contexts, whereas maternal history of childhood adversity may not. Effects appear comparable for boys and girls. Policies and programs addressing prevention of childhood internalizing symptoms may benefit from considering prenatal origins and the potential two-generation impact of pregnancy stress prevention and intervention.

Risks to Child Development and School Readiness Among Children Under Six in Pakistan: Findings from a Nationally Representative Phone Survey

This paper analyzes the risks to child development and school readiness among children under age 6 in Pakistan. Drawing on a nationally representative telephone survey conducted in the midst of a global pandemic, between December 2021 and February 2022, we present the first nationally representative estimates of child development for children under 3 years of age and school readiness for children 3-6 years of age, using internationally validated instruments. The paper examines how risk factors that were exacerbated due to the COVID-19 pandemic, such as parental distress, lack of psychosocial stimulation, food insecurity, low maternal education, no enrollment in early childhood education, and living in a rural area, are associated with children's outcomes. The data indicate that more than half (57 percent) of parents with children under age 3 were distressed and that 61 percent of households reported cutting down on the size of or skipping meals since the start of the pandemic. The data reveal that over half of parents fail to engage in adequate psychosocial stimulation with their child and enrollment in early childhood education is very low (39 percent). The paper finds that child development outcomes decline rapidly as the number of risks increase. Specifically, for children under 3 years, lack of psychosocial stimulation at home and higher levels of parental distress were most significantly associated with lower child development levels. For a child aged 3-6 years, early childhood education enrollment and the amount of psychosocial stimulation the child received at home had the strongest association with school readiness scores.

Resilience and prenatal mental health in Pakistan: a qualitative inquiry

Background

Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention.

Methods

The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes.

Result

A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health.

Conclusion

In conclusion, these themes were the core components of pregnant women’s resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.

NICU-based stress response and preterm infant neurobehavior: exploring the critical windows for exposure

BACKGROUND

Exposure to maternal stress in utero negatively impacts cognitive and behavioral outcomes of children born at term. The neonatal intensive care unit (NICU) can be stressful for preterm infants during a developmental period corresponding to the third trimester of gestation. It is unknown whether stress in the NICU contributes to adverse neurodevelopment among NICU graduates. The aim was to examine the association between salivary cortisol and early neurodevelopment in preterm infants.

METHODS

We examined the association between cortisol levels during the NICU hospitalization and subsequent performance on the NICU Network Neurobehavioral Scales (NNNS), estimating time-specific associations and considering sex differences.

RESULTS

Eight hundred and forty salivary cortisol levels were measured from 139 infants. Average cortisol levels were inversely associated with NNNS Regulation scores for both male and female infants (β = -0.19; 95% CI: -0.44, -0.02). Critical developmental windows based on postmenstrual age were identified, with cortisol measured <30 weeks PMA positively associated with Habituation and Lethargy scores (β = 0.63-1.04). Critical developmental windows based on chronological age were identified, with cortisol measured in the first week of life inversely associated with Attention score (β = -1.01 for females; -0.93 for males).

CONCLUSIONS

Stress in the NICU at specific developmental time points may impact early preterm infant neurodevelopment.

IMPACT

Stress in the neonatal intensive care unit can impact the neurodevelopmental trajectory of premature infants. The impact of stress is different at different points in development. The impact of stress is sexually dimorphic.

A scoping review of community-based mental health intervention for children and adolescents in South Asia

Children and adolescents in South Asia are exposed to significant mental health risks. Yet, policy to prevent or treat youth mental health problems in this context is underdeveloped, and services are difficult to access. Community-based mental health treatment may offer a potential solution, by increasing resource capacity in deprived settings. However, little is known about the current community-based mental health provision for South Asian youth. A scoping review was conducted across six scientific databases and hand searching of reference lists to identify relevant studies. Study selection and data extraction were performed by three independent reviewers using predefined criteria, an adapted version of the template for intervention description and replication checklist and the Cochrane Risk of Bias Tool. The search identified 19 relevant studies published from January 2000 to March 2020. Studies most frequently addressed PTSD and autism, were conducted in India and Sri Lanka, used education-based intervention and were based in urban school settings. Community-based mental health provision for the South Asian youth is in its infancy, but holds promise for providing essential resources to treat or prevent mental health disorder. New insights on approaches are discussed, which are valuable for South Asian settings, primarily task-shifting and stigma reduction, with implications for policy, practice and research.

Mental Health of Mothers of Children with Neurodevelopmental and Genetic Disorders in Pakistan

This study examined maternal mental health in mothers of children with neurodevelopmental and genetic disorders in Pakistan; maternal education and affiliate stigma were also tested. It was hypothesised that mothers of children with neurodevelopmental and genetic disorders would experience high levels of depression, anxiety and affiliate stigma, and that these variables would be mediated by the level of maternal education. Seventy-five mothers of children with neurodevelopmental and genetic disorders were recruited from “Special Needs” schools in Lahore and Islamabad. The results showed that the majority of mothers were clinically depressed and a large majority of mothers were clinically anxious. The distribution of mothers with clinical anxiety was significantly different among mothers with different levels of education (p < 0.05). Furthermore, mothers with higher levels of education had less affiliate stigma. This result suggests that maternal education may be a protective factor of mental health in mothers of children with neurodevelopmental and genetic disorders. Limitations, implications and future research are discussed.

The COVID-19 infection in children and its association with the immune system, prenatal stress, and neurological complications

The Coronavirus disease 2019 (COVID-19)” caused by the “severe acute respiratory syndrome corona virus 2 (SARS-CoV-2)” has caused huge losses to the world due to the unavailability of effective treatment options. It is now a serious threat to humans as it causes severe respiratory disease, neurological complications, and other associated problems. Although COVID-19 generally causes mild and recoverable symptoms in children, it can cause serious severe symptoms and death causing complications. Most importantly, SARS-CoV-2 can cause neurological complications in children, such as shortness of breath, myalgia, stroke, and encephalopathy. These problems are highly linked with cytokine storm and proinflammatory responses, which can alter the physiology of the blood-brain barrier and allow the virus to enter the brain. Despite the direct infection caused by the virus entry into the brain, these neurological complications can result from indirect means such as severe immune responses. This review discusses viral transmission, transport to the brain, the associated prenatal stress, and neurological and/or immunological complications in children.

Associations between caregiver mental health and young children's behaviour in a rural Kenyan sample

Background: Research shows that caregiver mental health problems have direct, significant effects on child behaviour. While these risks are amplified in low-resource settings, limited evidence exists from these places, especially sub-Saharan Africa.

Objective: We measured associations between caregiver mental health and child behaviour in a rural Kenyan sample, hypothesizing that higher rates of caregiver mental health would be associated with increased child behavioural problems. We also sought to provide an overview of caregiver mental health symptoms in our sample.

Method: Cross-sectional data were collected from caregivers of children ages 4–5 years old enrolled in a community-based early child development programme in western Kenya. 465 caregivers were recruited and assessed at baseline, and answered questions about child behaviour, mental health symptoms (depression, anxiety, stress), and help-seeking. A multivariate linear regression model was used to assess significance of each mental health factor.

Results: Caregiver anxiety (p = 0.01) and parenting stress (p < 0.001) were significantly associated with child behavioural problems. 245 caregivers (52.9%) had high levels of symptoms of depression, anxiety, or both; furthermore, 101 caregivers (21.7%) scored above the cut-off for both of these scales. A high proportion of our sample (60.6%) reported seeking some formal or informal psychosocial support services; however, less than one-third of these caregivers were symptomatic (30.9%).

Conclusion: Anxiety and stress were associated with poorer child behavioural outcomes. Our sample reflected a higher prevalence of caregiving adults with mental health symptomology than previous estimates from Kenya, with few high-symptom caregivers seeking support. We discuss further implications for programming and health services delivery.

The association of physical fitness with mental health in children: A serial multiple mediation model

There is growing interest in the association between physical fitness and mental health. This study aimed to extend current knowledge by investigating the potential mediating roles of resilience and anxiety in the association between physical fitness and mental health in children. A total of 269 children were selected by stratified random sampling from three primary schools in China. Physical fitness was scored using the Chinese National Student Physical Fitness Standard. Resilience, anxiety, and mental health data were collected using the following questionnaires: Resilience Scale for Chinese Adolescents, Multidimensional Anxiety Scale for Children, and the Mental Health Test. The PROCESS macro developed by Hayes was used to conduct serial multiple mediation analysis. We found that physical fitness, resilience, anxiety, and mental health were significantly correlated. Children with higher physical fitness had lower mental health problems; however, this statistical significance was not detectable after controlling for resilience and anxiety. Serial multiple mediation analysis revealed that the association of physical fitness with mental health was partially mediated by resilience and anxiety. These results indicate that the positive association of physical fitness with mental health in children may be changed through resilience and anxiety, which appear to play serial multiple mediating roles in this association. These findings contribute to deeper understanding of the associations between these factors and suggest that promoting physical fitness independent of considering resilience and anxiety may be insufficient to achieve good mental health in children.

Cultural Adaptation of Community Informant Tool for Detection of Maternal Depression in Rural Pakistan

Background: Evidence indicates that mental health issues like depression, epilepsy, and substance misuse can be detected with reasonable accuracy in resource-poor settings. The Community Informant Detection Tool (CIDT) is one such approach used for detecting mental health problems, including depression. We adapted this community informant approach for detecting maternal depression in Pakistan. Methods: Adaptation of Community Informant Detection Tool for Maternal Depression (CIDT-MD) involved five steps. First, a scoping review of the literature was conducted to select an appropriate tool for adaptation. Second, in-depth interviews were conducted to explore the idioms of depression and distress, perceived causes, and the effects of maternal depression among currently depressed and recovered mothers (n = 11), mothers in law (n = 6), and Primary Care Providers (Primary Care Physicians and Lady Health Supervisors) (n = 6). Third, case vignettes and illustrations were created with input from a panel of mental health experts, incorporating the idioms of depression and distress used, causes, and effects for each symptom described. Fourth, to assess the comprehensibility of the illustrations and level of understanding, Focus Group Discussions (n = 4) were done with purposely selected community health workers (Lady Health Workers and Lay Peers, n = 28) trained in delivering maternal depression intervention. The final step was reflection and inputs by a panel of mental health experts on all steps to finalize the content of the tool. Results: Context-specific cultural adaptation in the presentation and format of CIDT-MD was conducted successfully. Lady Health Workers (LHW) and Lay Peers (LP) were found to be the most appropriate persons to use the tool and function as the informants. The adapted tool with all its vignettes and illustrations was found to be easily understandable, comprehensible, and culturally appropriate, meaningful, and contextually relevant by the community health workers and peers working in the relevant settings. They easily relate to and identify potentially depressed such women lining up with the tool. Lastly, the coding of the tool was found easy to follow as well. Conclusion: The Community Informant Detection Tool for Maternal Depression (CIDT-MD) is a culturally acceptable, easy to use, and comprehensible tool for detecting maternal depression in community settings of Pakistan. The community informants found the content and approach highly relevant to the local needs.

Measuring functional disability in children with developmental disorders in low-resource settings: validation of Developmental Disorders-Children Disability Assessment Schedule (DD-CDAS) in rural Pakistan

BACKGROUND

Developmental disorders (DDs) in children are a priority condition and guidelines have been developed for their management within low-resource community settings. However, a key obstacle is lack of open access, reliable and valid tools that lay health workers can use to evaluate the impact of such programmes on child outcomes. We adapted and validated the World Health Organization's Disability Assessment Schedule for children (WHODAS-Child), a lay health worker-administered functioning-related tool, for children with DDs in Pakistan.

METHODS

Lay health workers administered a version of the WHODAS-Child to parents of children with DDs (N = 400) and without DDs (N = 400), aged 2-12 years, after it was adapted using qualitative study. Factor analysis, validity, reliability and sensitivity to change analyses were conducted to evaluate the psychometric properties of the adapted outcome measure.

RESULTS

Among 800 children, 58% of children were male [mean (s.d.) age 6.68 (s.d. = 2.89)]. Confirmatory Factor Analysis showed a robust factor structure [χ2/df 2.86, RMSEA 0.068 (90% CI 0.064-0.073); Tucker-Lewis Index (TLI) 0.92; Comparative Fit Index (CFI) 0.93; Incremental Fit Index (IFI) 0.93]. The tool demonstrated high internal consistency (α 0.82-0.94), test-retest [Intra-class Correlation Coefficient (ICC) 0.71-0.98] and inter-data collector (ICC 0.97-0.99) reliabilities; good criterion (r -0.71), convergent (r -0.35 to 0.71) and discriminative [M (s.d.) 52.00 (s.d. = 21.97) v. 2.14 (s.d. = 4.00); 95% CI -52.05 to -47.67] validities; and adequate sensitivity to change over time (ES 0.19-0.23).

CONCLUSIONS

The lay health worker administrated version of adapted WHODAS-Child is a reliable, valid and sensitive-to-change measure of functional disability in children aged 2-12 years with DDs in rural community settings of Pakistan.

The relationship between maternal mental health and communication skills in children in Shiraz, Iran

OBJECTIVES

Child development is a significant issue in global public health, and maternal mental health (MMH) can have a remarkable effect on children’s development of communication skills. We aimed to investigate the association between MMH and communication skills in a sample of Iranian children.

METHODS

This study was conducted in Shiraz, Iran during 2016. In total, 640 mothers who lived in Shiraz and were registered in the Fars Birth Cohort (FBC) study were invited to attend the FBC clinic with their children. A trained physician evaluated MMH using the General Health Questionnaire (GHQ). Additionally, a trained nurse assessed the children’s communication development status using the Ages and Stages Questionnaire for 60-month old children.

RESULTS

The majority of the mothers were homemakers (82.8%) and had high school diplomas (38.9%). The mothers’ mean age was 33.7±4.6 years. Seventy-nine (12.3%) children had delayed communication skills, but no significant association was found between children’s communication skills and the mothers’ total GHQ score (p=0.43). In total, 493 mothers (77.0%) had abnormal somatic symptoms, 497 (77.7%) had abnormal anxiety/insomnia, 337 (52.7%) had social dysfunction, and 232 (36.3%) suffered from depression. Logistic regression indicated that after adjusting for confounders, the odds of delayed communication skills were 3-fold higher among the children of mothers with abnormal somatic symptoms than among other children (p=0.01).

CONCLUSIONS

The study results confirmed that MMH had a significant impact on children’s communication skills. Moreover, maternal abnormal somatic symptoms exerted the strongest impact on the development of communication skills in 5-yearold children.

Cohort Profile: Perinatal depression and child socioemotional development ; the Bachpan cohort study from rural Pakistan

PURPOSE

This is a prospective pregnancy-birth cohort designed to investigate the effects of depression on socioemotional development of children. Perinatal depression is a risk factor for poor child development and for many it has a recurring chronic course. Thus, the exposure to depression can continue through the early years of the child with detrimental developmental outcomes.

PARTICIPANTS

Between October 2014 and February 2016, we recruited 1154 pregnant women from a rural subdistrict of Pakistan. Data include longitudinal and repeated measures of maternal psychosocial measures and child growth, cognitive and socioemotional measures. Follow-up include mother-child dyad assessments at 3rd, 6th, 12th, 24th and 36th months of child age. All these follow-ups are community based at the household level. We have competed baseline assessment.

FINDINGS TO DATE

Of the eligible dyads, we followed 885 (76.6%), 929 (91%) and 940 (93.3%) at 3, 6 and 12 months post-childbirth. We include a subsample mother-child dyad DNA and inflammatory biomarkers, 73 and 104, respectively.

FUTURE PLANS

While we continue to do 24-month and 36-month follow-up assessments, we plan to follow these mother-child dyads up to the age of 7-8 years with some children being exposed to at least 1 year of school environment. Investigators interested in learning more about the study can contact (jmaselko@unc.edu) and (siham.sikander@hdrfoundation.org).

Measuring and understanding social-emotional behaviors in preschoolers from rural Pakistan

The Strengths and Difficulties Questionnaire (SDQ) is widely-used to measure symptoms of common childhood behavioral problems that may lead to mental health difficulties. In a sample of 1,302 highly-disadvantaged mothers and their preschoolers, we evaluated the factor structure and reliability of the parent-report version of the SDQ in rural Pakistan. Confirmatory factor analyses suggested that the original structure of the SDQ was not appropriate for our data. We created conceptually- and empirically-coherent measures of children's externalizing behavior problems and prosocial skills. Child and family correlates of social-emotional behaviors were similar to those found in other countries, supporting the validity of our new composites. Girls and children with more siblings had fewer externalizing behavior problems and more prosocial behaviors at four years. Further, maternal depressive symptoms and food insecurity were uniquely linked to more externalizing behavior problems at four years. In contrast, maternal education, home environment quality, and social-emotional skills at two years were associated with more prosocial behaviors at four years.

Prenatal maternal stress, fetal programming, and mechanisms underlying later psychopathology-A global perspective

There is clear evidence that the mother's stress, anxiety, or depression during pregnancy can alter the development of her fetus and her child, with an increased risk for later psychopathology. We are starting to understand some of the underlying mechanisms including the role of the placenta, gene-environment interactions, epigenetics, and specific systems including the hypothalamic-pituitary-adrenal axis and cytokines. In this review we also consider how these effects may be different, and potentially exacerbated, in different parts of the world. There can be many reasons for elevated prenatal stress, as in communities at war. There may be raised pregnancy-specific anxiety with high levels of maternal and infant death. There can be raised interpersonal violence (in Afghanistan 90.2% of women thought that "wife beating" was justified compared with 2.0% in Argentina). There may be interactions with nutritional deficiencies or with extremes of temperature. Prenatal stress alters the microbiome, and this can differ in different countries. Genetic differences in different ethnic groups may make some more vulnerable or more resilient to the effects of prenatal stress on child neurodevelopment. Most research on these questions has been in predominantly Caucasian samples from high-income countries. It is now time to understand more about prenatal stress and psychopathology, and the role of both social and biological differences, in the rest of the world.

Sex Differences in Vulnerability to Prenatal Stress: a Review of the Recent Literature

PURPOSE OF REVIEW

To evaluate the degree to which recent studies provide evidence that the effects of prenatal maternal stress (PNMS) on child health outcomes vary depending on the child's biological sex. In this review, we used a broad definition of stress, including negative life events, psychological stress, and established stress biomarkers. We identified 50 peer-reviewed articles (published January 2015-December 2017) meeting the inclusion criteria.

RECENT FINDINGS

Most articles (k = 35) found evidence of either sex-specific associations (significant in one sex but not the other) or significant PNMSxstress interactions for at least one child health outcome. Evidence for sex-dependent effects was strongest in the group of studies evaluating child neural/nervous system development and temperament as outcomes. There is sufficient evidence of sex-dependent associations to recommend that researchers always consider the potential role of child sex in PNMS programming studies and report descriptive statistics for study outcomes stratified by child biological sex.

Emotional and behavioral problems in children of depressed mothers: a school-based study in Southern Brazil

The present study aimed to verify the association between maternal depression and emotional and behavioral problems in school children in Pelotas, Southern Brazil, considering that maternal depression increases children's vulnerability for developing psychiatric disorders. This is a cross-sectional study with a school-based sample conducted between August 2015 and November 2016 and it is part of a major project entitled 'Healthy Childhood in Context: A Multidisciplinary Investigation'. Schoolchildren aged between 7 and 8 years and one of their respective parents or a primary caregiver were included in the study. Maternal depression was assessed using the Mini International Neuropsychiatric Interview (MINI). The presence of emotional and behavioral problems in children was verified by the Strengths and Difficulties Questionnaire (SDQ) - parents version. Children of depressed mothers exhibited higher mean scores in all SDQ domains and in the total score when compared to children of non-depressed mothers. Lower socio-economic status was also associated with higher SDQ scores. Our results showed the effects of both maternal depression and poverty on children emotional and behavioral problems, which evidence the need for child mental health preventive care, and free quality assistance for both mothers and their children.

Psychological Problems and Socioemotional Wellbeing among Children of Mothers with Depression and Their Association with Sociodemographic Factors in a Sri Lankan Setting

BACKGROUND

Maternal depression is known to be associated with anxiety, depression, oppositional and conduct disorders, neurocognitive deficits, ADHD, substance abuse, and personality disorder in the offspring. We aimed to describe the proportion of psychological problems among children of mothers with depression in Sri Lanka and to describe the associated sociodemographic factors.

METHODS

A cross-sectional descriptive study was conducted on 100 children and adolescents between 4 and 16 years, whose mothers have a diagnosis of depression and are currently in remission. Specifically designed instruments were used to extract sociodemographic details and data on mother's illness. Strengths and Difficulties Questionnaire (SDQ) was used to detect psychological problems in children.

RESULTS

14% of the children scored abnormally high in hyperactivity, 13% in conduct problems, 12% in emotional problems, 9% in peer problems, and 10% in total difficulties. Children (4-12 years) scored significantly higher than the adolescents in hyperactivity and externalizing problems (p < 0.05). Significant differences were also found in peer problems (p < 0.05), internalizing problems (p < 0.05), and total difficulties (p < 0.05) in relation to the age of the mother.

CONCLUSION

Screening the children of mothers with depression for psychological problems and developing a holistic management plan, which includes measures to ensure their wellbeing, is important.

[Gender-specific Differences in the Degree of Burden on Children and Adolescents Taken into Custody]

Gender-specific Differences in the Degree of Burden on Children and Adolescents Taken into Custody Children and adolescents who were taken into care are a high-risk group for mental disorders such as externalizing problems or conduct disorders. 95 children and adolescents who were taken into care were tested with the Screening Child Trauma Questionnaire (CTQ) and the Massachusetts Youth Screening Instrument 2 (MAYSI-2). In a large proportion of those children and adolescents emotional and physical neglect and abuse was identified. There were sex differences in suicidal thoughts, somatoform disorders, and emotional abuse. The knowledge of mental disorders as well as the gender-specific characteristics is important for specialists of inhospital institutions, in order to optimize their quality of care.

Socioeconomic status indicators and common mental disorders: Evidence from a study of prenatal depression in Pakistan

There is growing interest in the relationship between socioeconomic status (SES), poverty, and mental health in low and middle-income countries (LMIC). However, it is not clear whether a gradient approach focused on a wider SES distribution or a binary poverty approach is more salient for mental health in LMIC. Yet this distinction has implications for interventions aimed at improving population health. We contribute to the literature by examining how multiple indicators of socioeconomic status, including gradient SES and binary poverty indicators, contribute to prenatal depression symptoms in a LMIC context. Prenatal depression is an important public health concern with negative sequela for the mother and her children. We use data on assets, education, food insecurity, debt, and depression symptoms from a sample of 1154 pregnant women residing in rural Pakistan. Women who screened positive for depression participated in a cluster randomized controlled trial of a perinatal depression intervention; all women were interviewed October 2015-February 2016, prior to the start of the intervention. Cluster-specific sampling weights were used to approximate a random sample of pregnant women in the area. Findings indicate that fewer assets, experiencing food insecurity, and having household debt are independently associated with worse depression symptoms. The association with assets is linear with no evidence of a threshold effect, supporting the idea of a gradient in the association between levels of SES and depression symptoms. A gradient was also initially observed with woman’s educational attainment, but this association was attenuated once other SES variables were included in the model. Together, the asset, food insecurity, and debt indicators explain 14% of the variance in depression symptoms, more than has been reported in high income country studies. These findings support the use of multiple SES indicators to better elucidate the complex relationship between socioeconomic status and mental health in LMIC.

•

We compare the association between poverty, gradient measures of SES, and depression.

•

Above the poverty level, SES predict depression in a low income country.

•

Relying on simple, dichotomous, poverty measures in studies of mental health is not recommended.

Social Epidemiology and Global Mental Health: Expanding the Evidence from High-Income to Low- and Middle-Income Countries

PURPOSE OF THE REVIEW

The vast majority of research on the social determinants of mental health has been generated from high-income country (HIC) populations, even as the greatest health disparities, and greatest disease burden, is observed in lower- and middle-income countries (LMICs). The goal of this review is to examine the evidence base on how key social epidemiology constructs relate to mental health in LMIC contexts. A special focus is on points of departure from the HIC knowledge base, gaps in overall understanding, and opportunities for social epidemiology to make a significant contribution.

RECENT FINDINGS

A growing body of literature suggests that there is significant heterogeneity, both in the direction and magnitude, of association between factors such as socioeconomic status, income inequality, gender, and social networks/supports and mental health in LMIC. For example, higher levels of education and being married can be risk factors for worse mental health among women in certain contexts. However, many studies have methodological limitations that make causal inference difficult. Poverty alleviation interventions offer a unique opportunity to examine the impact of improving economic resources and mental health.

SUMMARY

Much remains unknown about the impact of key social factors on mental health in LMIC. Findings from HICs may not apply to LMIC populations, since the meaning and distribution of a given social variable may differ significantly from what is commonly observed in HICs. These points of departure point to opportunities for social epidemiology to make a contribution to the field of global mental health.