Maternal and paternal stimulation: Mediators of parenting intervention effects on preschoolers' development

Effects of multi-component parenting and parental mental health interventions on early childhood development and parent outcomes: a systematic review and meta-analysis

BACKGROUND

Interventions supporting parents of young children often target parenting or parental mental health separately. Multi-component parenting and parental mental health interventions have the potential to improve parenting practices, mental health, and early childhood development. We aimed to examine their impact on child and parent outcomes.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science Core Collection, APA PsycINFO, CINAHL Complete, the Cochrane Central Register of Controlled Trials, and the Global Health Database from inception to Jan 23, 2024. Eligible studies were randomised controlled trials of interventions explicitly targeting parenting behaviours and parental mental health antenatally or in children's first 3 years of life. Screening, extraction, and quality assessment were done independently by two authors. Primary outcomes were cognitive and social-emotional functioning in children and depressive symptoms in parents, meta-analysed as standardised mean differences (SMDs), relative to control. This study is registered with PROSPERO, CRD42022302848.

FINDINGS

We found 5843 records. After screening 2636 (45·1%) titles and abstracts, we manually identified and screened three additional articles and excluded 2177 records. After screening 462 full-length articles, 25 articles, representing a sample size of 8520 children and caregivers, were included. At baseline, mean caregiver age was 27·7 years (SD 5·9) and mean child age (excluding those enrolled during pregnancy) was 14·4 months (8·0). Interventions lasted a mean of 14 months (SD 11) and used a mean of 3·7 behaviour change techniques (2·0). Most interventions dedicated more time to parenting behaviours than to parental mental health. We found significant intervention effects on children's cognitive (SMD 0·19 [95% CI 0·04 to 0·34]; I2=69%) and social-emotional (0·26 [0·17 to 0·34]; I2=47%) outcomes but not on depressive symptoms in female caregivers (-0·18 [-0·36 to 0·002]; I2=86%) relative to control conditions. Risk of bias across studies was moderate, and we found heterogeneity across results.

INTERPRETATION

Multi-component parenting and mental health interventions had a positive effect on child cognitive and social-emotional outcomes, but not on depressive symptoms in parents, suggesting that other factors might contribute to positive ECD outcomes. Interventions might lack adequate focus on mental health to make a discernible impact, highlighting a need for future studies to differentiate and assess contributions of parenting and mental health components to understand independent and collective effects on family outcomes.

FUNDING

Canadian Institutes of Health Research.

Effects of engaging fathers and bundling parenting and nutrition interventions on early child development and maternal and paternal parenting in Mara, Tanzania: a factorial cluster-randomized controlled trial

BACKGROUND

Multicomponent interventions are needed to address the various co-occurring risks that compromise early child nutrition and development. We compared the independent and combined effects of engaging fathers and bundling parenting components into a nutrition intervention on early child development (ECD) and parenting outcomes.

METHODS

We conducted a 2×2 factorial cluster-randomized controlled trial across 80 villages in Mara Region, Tanzania, also known as EFFECTS (Engaging Fathers for Effective Child Nutrition and Development in Tanzania; ClinicalTrials.gov, NCT03759821). Households with children under 18 months of age residing with their mother and father were enrolled. Villages were randomly assigned to one of five groups: a nutrition intervention for mothers, a nutrition intervention for couples, a bundled nutrition and parenting intervention for mothers, a bundled intervention for couples, and a standard-of-care control. Interventions were delivered by trained community health workers through peer groups and home visits over 12 months. Mothers, fathers, and children were assessed at baseline, midline, and endline or postintervention. We used a difference-in-difference approach with intention-to-treat analysis to estimate intervention effects on ECD (Bayley Scales of Infant and Toddler Development, third edition) and maternal and paternal parenting and psychosocial well-being.

RESULTS

Between October 29, 2018, and May 24, 2019, 960 households were enrolled (n = 192 per arm). Compared to nutrition interventions, bundled interventions improved children's cognitive (β = .18 [95% CI: 0.01, 0.36]) and receptive language development (β = .23 [0.04, 0.41]). There were no differences between interventions for other ECD domains. Compared to nutrition interventions, bundled interventions achieved additional benefits on maternal stimulation (β = .21 [0.04, 0.38]) and availability of home learning materials (β = .25 [0.07-0.43]) and reduced paternal parenting distress (β = -.34 [-0.55, -0.12]). Compared to interventions with mothers only, interventions that engaged fathers improved paternal stimulation (β = .45 [0.27, 0.63]).

CONCLUSIONS

Jointly bundling parenting components into nutrition interventions while also engaging both mothers and fathers is most effective for improving maternal and paternal parenting and ECD outcomes.

Relationships Between Mental Health, Negative Feelings of COVID-19, and Parenting Among Pregnant Women in Fortaleza, Brazil

INTRODUCTION

During the COVID-19 pandemic, the literature highlighted an increased risk of child abuse and the use of negative parenting practices. Furthermore, pregnancy during this time may have been challenging and generated different feelings regarding the pandemic and motherhood. Many pregnant women had other young children, underscoring the need to understand this scenario better. Therefore, the present study examined the predictive effect of indicators of mental health disorders, emotional discomfort with motherhood, and negative perceptions of COVID-19 on negative parenting practices.

METHODS

The study used a cross-sectional design. Pregnant women (n = 303) who had other children younger than six years answered an online questionnaire during the physical distancing period due to COVID-19 in Fortaleza. A partially latent structural equation model (SEM) was used to test direct and indirect relations between the variables.

RESULTS

The results revealed a direct positive relation between maternal mental health and the variables COVID-19 feelings, emotional discomfort with motherhood, and negative parenting practices. The stronger relationship was between maternal mental health and emotional discomfort with motherhood. The COVID-19 negative feelings also showed a direct positive relation to emotional discomfort with motherhood. Additionally, older mothers and those with fewer children tended to have less mental health disorders. Furthermore, being in a later trimester of pregnancy was linked to more negative feelings about motherhood.

DISCUSSION

The study suggests that mothers experiencing mental health challenges are more likely to feel discomfort with motherhood and use negative parenting practices, highlighting a need for intervention.

Parenting in 2 Worlds: Testing improved parent-adolescent communication about sexuality in Urban American Indian families

Urban American Indian (AI) adolescents are more likely than non-Natives to have early sexual debut, teen pregnancies, sexually transmitted infections, and inadequate sexual health information. A RCT in three Arizona cities, with 585 parents of urban AI adolescents, tested whether a culturally tailored parenting intervention for urban AI families, Parenting in 2 Worlds (P2W), increased parent-adolescent communication about sexuality, compared to an informational family health intervention that was not culturally tailored. P2W produced significantly larger increases on two measures: communication about general sexual health and about sexual decision-making. The desired effects of P2W on the first measure were stronger short-term for cross-gender dyads, while for the second measure, they were stronger long-term for both mothers and fathers of adolescent sons.

Promoting responsive care and early learning practices in Northern Ghana: results from a counselling intervention within nutrition and health services

OBJECTIVE

This study assesses change in caregiver practices after integrating responsive care and early learning (RCEL) in nutrition and health services and community platforms in northern Ghana.

DESIGN

We trained health facility workers and community health volunteers to deliver RCEL counselling to caregivers of children under 2 years of age through existing health facilities and community groups. We assessed changes in caregivers' RCEL practices before and after the intervention with a household questionnaire and caregiver-child observations.

SETTING

The study took place in Sagnarigu, Gushegu, Wa East and Mamprugu-Moagduri districts from April 2022 to March 2023. Study sites included seventy-nine child welfare clinics (CWC) at Ghana Health Service facilities and eighty village savings and loan association (VSLA) groups.

PARTICIPANTS

We enrolled 211 adult caregivers in the study sites who had children 0-23 months at baseline and were enrolled in a CWC or a VSLA.

RESULTS

We observed improvements in RCEL and infant and young child feeding practices, opportunities for early learning (e.g. access to books and playthings) in the home environment and reductions in parental stress.

CONCLUSIONS

This study demonstrates the effectiveness of integrating RCEL content into existing nutrition and health services. The findings can be used to develop, enhance and advocate for policies integrating RCEL into existing services and platforms in Ghana. Future research may explore the relationship between positive changes in caregiver behaviour and improvements in child development outcomes as well as strategies for enhancing paternal engagement in care practices, improving child supervision and ensuring an enabling environment.

Family responsive care mediating the home visiting effects on left-behind children's early development in rural China

BACKGROUND

The early development of left-behind children requires great concern and improvement. Yet, current interventions for left-behind children are mainly focussed on children older than 3. This study aims to assess the effectiveness of a home visiting programme on family responsive care and early development of rural left-behind children and examine whether family responsive care mediates the effects of intervention on child development.

METHODS

A quasi-experimental study design was utilized in this study. A stratified clustered sampling was employed to choose villages in programme towns into intervention group. A control village was matched with every intervention village. All of the left-behind children and their caregivers meeting the inclusion criteria in the chosen villages were enrolled in the survey. The outcomes included child development, caregiver's early stimulation, parent-child communication, and learning materials. Baseline assessments were conducted in 2018, and endline assessments were conducted in 2020.

RESULTS

In the endline survey, we enrolled 608 children with 258 in the intervention group and 350 in the control group. Left-behind children in the intervention group were less likely to have development delay compared with the control group (odds ratio [OR] = 0.59, 95% confidence interval [CI]: 0.36, 0.96). Migrant parents of children in the intervention group showed higher proportion of expressing emotional support to their children when communicating (OR = 1.69, 95% CI: 1.05, 2.72). Children who received home visits more than once per 2 months had lower level of suspected development delay than children in the control group (OR = 0.34, 95% CI: 0.18, 0.68). Caregiver's early stimulation and migrant parents' emotional support to left-behind children mediated the intervention dose and left-behind children's development.

CONCLUSION

Caregiver's early stimulation mediates the intervention and child's development. The findings suggest a promising future for scaling similar early childhood development interventions for left-behind children in rural settings.

Maternal stimulation and early child development in sub-saharan Africa: evidence from Kenya and Zambia

BACKGROUND

Despite major improvements in child survival over the past decade, many children in low and middle-income countries (LMICs) remain at risk of not reaching their developmental potential due to malnutrition, poor health, and a lack of stimulation. Maternal engagement and stimulation have been identified as some of the most critical inputs for healthy development of children. However, relatively little evidence exists on the links between maternal stimulation and child development exists in sub-Saharan Africa (SSA). This current paper aims to identify the associations between maternal stimulation and child development in Kenya and Zambia, as well as the activities that are most predictive of developmental outcomes in these settings.

METHODS

We conducted a descriptive study using data from a prospective study in Kenya and Zambia. The study included three rounds of data collection. Children were on average 10 months old in round one, 25 months old in round two, and 36 months old in round three. The primary exposure variable of interest was maternal stimulation activities, which we grouped into cognitive, language, motor, and socio-emotional activities. The outcome of interest was child development measured through the Third Edition of the Ages and Stages Questionnaire (ASQ-3). Linear regression models were used to estimate the associations between overall maternal stimulation and domain-specific maternal stimulation and child development across the three rounds of the survey.

RESULTS

Higher maternal stimulation scores were associated with higher ASQ scores (effect size = 0.25; 95% CI: 0.19, 0.31) after adjusting for other confounders. For domain specific and child development (ASQ scores), the largest effect size (ES) was found for language stimulation (ES = 0.15) while weakest associations were found for socio-emotional domain activities (ES= -0.05). Overall maternal stimulation was most strongly associated with gross motor development (ES = 0.21) and the least associated with problem-solving (ES = 0.16).

CONCLUSION

Our study findings suggest a strong positive link between maternal stimulation activities and children's developmental outcomes among communities in poor rural settings.

TRIAL REGISTRATION

NA (not a clinical trial).

Do childhood depressive symptoms interfere with intelligence in adulthood?

OBJECTIVE

To investigate the effects of depressive symptoms in childhood on the intellectual development of young adults.

METHODS

Study conducted with a birth cohort of São Luís, Maranhão, Brazil, composed of 339 participants evaluated between 7 and 9 years and between 18 and 19 years. Structural equation modeling (young adult education, sex, race/color) and childhood variables (nutritional status, depressive symptoms, cognitive function, head of household's and mother's education, family income) were used. In addition, head of household's occupation, mother's age, and presence of partner were tested as determinants of adults' intelligence quotient (IQ).

RESULTS

Presence of depressive symptoms in childhood triggered a reduction of 0.342 in standard deviation (SD) and -3.83 points in the average IQ of adults (p-value < 0.001). Cognitive function in childhood had a total and direct positive effect (standardized coefficient [SC] = 0.701; p-value < 0.001) on IQ, increasing 7.84 points with each increase in level. A positive indirect effect of child nutritional status (SC = 0.194; p-value = 0.045), head of household's (SC = 0.162; p-value = 0.036), and mother's education was identified, the latter mediated by cognitive function in childhood (SC = 0.215; p-value = 0.012) on the IQ of young people.

CONCLUSION

Presence of depressive symptoms in childhood triggered a long-term negative effect on intelligence, reducing the IQ score in adulthood.

The Reach Up Parenting Program, Child Development, and Maternal Depression: A Meta-analysis

BACKGROUND AND OBJECTIVES

Evidence is needed on effective approaches to build parents' ability to promote child development feasible in low- and middle-income countries. Our objective was to synthesize impact of the Reach Up early childhood parenting program in several low- and middle-income countries and examine moderation by family and implementation characteristics.

METHODS

Systematic search using PubMed and Academic Search Elite/EBSCO Host. Randomized controlled trials of the Reach Up program from 1985 to February 2022 were selected. Data were extracted by 2 independent researchers. Primary outcomes were child cognitive, language, and motor development. Secondary outcomes were home stimulation and maternal depressive symptoms. We synthesized pooled effect sizes using random effect inverse-variance weighting and effect modification by testing pooled subgroup effect estimates using the χ2 test for heterogeneity.

RESULTS

Average effect size across 18 studies ranged from 0.49 (95% confidence interval [CI] 0.32 to 0.66) for cognition, 0.38 (CI 0.24 to 0.51) for language, 0.27 (CI 0.13 to 0.40) for motor development, 0.37 (CI 0.21 to 0.54) for home stimulation, and -0.09 (CI -0.19 to 0.01) for maternal depressive symptoms. Impacts were larger in studies targeted to undernourished children, with mean enrollment older than age 12 months and intervention duration 6 to 12 months. Quality of evidence assessed with the Cochrane Assessment of Risk of Bias and GRADE system was moderate. Instruments used to assess child development varied. In moderator analyses, some subgroups included few studies.

CONCLUSIONS

Reach Up benefits child development and home stimulation and is adaptable across cultures and delivery methods. Child and implementation characteristics modified the effects, with implications for scaling.

Positive Parenting and Early Childhood Cognition: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This review examines the effectiveness of positive parenting interventions aimed at improving sensitivity, responsiveness, and/or non-harsh discipline on children's early cognitive skills, in four meta-analyses addressing general mental abilities, language, executive functioning, and pre-academics. The objectives are to assess the magnitude of intervention effectiveness and identify moderators of effectiveness. We include randomized controlled trials of interventions targeting positive parenting to improve cognition in children < 6 years. Studies that include children with neurodevelopmental and/or hearing disorders were excluded. MEDLINE, PsycINFO, ERIC, and ProQuest Dissertations & Theses (October 2021) and citation chaining identified relevant records. Five reviewers completed screening/assessments, extraction, and risk of bias. Pooled analysis in Comprehensive Meta-Analysis (Version 3) used random effects modeling, with moderation via Q-statistics and meta-regression. Positive parenting interventions led to significant improvements in mental abilities (g = 0.46, N = 5746; k = 33) and language (g = 0.25, N = 6428; k = 30). Effect sizes were smaller and nonsignificant for executive functioning (g = 0.07, N = 3628; k = 14) and pre-academics (g = 0.16, N = 2365; k = 7). Robust moderators emerged for language and cognition. For cognition, studies with higher risk of bias scores yielded larger intervention effects. For language, studies with younger children had larger effect sizes. Studies mitigated selection and detection bias, though greater transparency of reporting is needed. Interventions that promote parental sensitivity, responsiveness, and non-harsh discipline improve early mental abilities and language. Studies examining executive functioning and pre-academics are needed to examine moderators of intervention effectiveness. Trial registration Systematic review PROSPERO registration. CRD42020222143.

Urban-rural differences in the relationship between stunting, preschool attendance, home learning support, and school readiness: A study in Côte d'Ivoire

Background

Stunted physical growth during early childhood is a marker of chronic undernutrition, and the adverse life circumstances that underlie it. These have the potential to disrupt normal brain development and the acquisition of foundational cognitive, language, social and motor skills. Stunting is prevalent in most low-and middle-income countries. Because the prevention of stunting requires large-scale structural and attitudinal changes, several psycho-educational interventions have been developed to mitigate the adverse association between early stunting and skill development. However, the resource-intensive nature of custom-designed interventions limit their sustainability and scalability in resource-limited settings. This study explored the possibility that available resources that promote positive development (existing preschool education programs, and no- or low-cost home-based learning activities and resources) may protect against any negative association between stunting and the acquisition of foundational skills required for academic learning and adaptation at school.

Method

Data for 36-to 59-month-old children (n = 3,522; M = 46.7 months; 51.2% male; 74.1% rural) were drawn from the most recent Multiple Indicator Cluster Survey conducted in Côte d'Ivoire (MICS5, 2016). Stunting was assessed using the WHO Child Growth Standards. Preschool attendance and home learning activities and resources were assessed by maternal report. School readiness was assessed using the 8-item form of the Early Child Development Index (ECDI).

Results

A high percentage of children met the criteria for stunting (28.5%; 19.7% moderate; 8.8% severe). There were marked urban-rural differences in the prevalence of stunting, rates of preschool attendance, home learning activities and resources, children's school readiness scores, and the relationships between stunting, the protective factors and school readiness scores. These urban-rural differences in ECDI scores could be fully explained by differences between these settings in stunting and the protective factors. However, only two protective factors (access to books and home-based activities that promote learning) made independent contributions to variance in ECDI scores. There was tentative evidence that stunted children whose homes provided highly diverse learning activities and multiple types of learning resources were more likely than those who did not to have a high level of school readiness.

Conclusion

Capitalizing on the existing practices of families that show positive deviance in caregiving may provide a basis for culturally appropriate, low-cost interventions to improve school readiness among children in low- and middle-income countries, including children with stunted growth.

Exploring the feasibility of integrating health, nutrition and stimulation interventions for children under three years in Nepal's health system: A qualitative study

Community-based primary care settings are a potential entry point for delivering Early Childhood Development (ECD) interventions in Nepal. Past studies have suggested that integrating stimulation with nutrition interventions is an effective way to deliver multiple benefits for children, but there is limited knowledge of how to do this in Nepal. We conducted a qualitative study in Nepal's Dhanusha district to explore how stimulation interventions for early learning could be integrated into existing health and nutrition programmes within the public health system. Between March and April 2021, we completed semi-structured interviews with caregivers (n = 18), health service providers (n = 4), district (n = 1) and national stakeholders (n = 4), as well as policymakers (n = 3). We also carried out focus group discussions with Female Community Health Volunteers (FCHVs) (n = 2) and health facility operation and management committee members (n = 2). We analysed data using the framework method. Respondents were positive about introducing stimulation interventions into maternal and child health and nutrition services. They thought that using health system structures would help in the implementation of integrated interventions. Respondents also highlighted that local governments play a lead role in decision-making but must be supported by provincial and national governments and external agencies. Key factors impeding the integration of stimulation into national programmes included a lack of intersectoral collaboration, poor health worker competency, increased workload for FCHVs, financial constraints, a lack of prioritisation of ECD and inadequate capacity in local governments. Key barriers influencing the uptake of intervention by community members included lack of knowledge about stimulation, caregivers' limited time, lack of paternal engagement, poverty, religious or caste discrimination, and social restrictions for newlywed women and young mothers. There is an urgent need for an effective coordination mechanism between ministries and within all three tiers of government to support the integration and implementation of scalable ECD interventions in rural Nepal.

Environmental opportunities facilitating cognitive development in preschoolers: development of a multicriteria index

Access to environmental opportunities can favor children's learning and cognitive development. The objectives is to construct an index that synthesizes environmental learning opportunities for preschoolers considering the home environment and verify whether the index can predict preschoolers' cognitive development. A quantitative, cross-sectional, exploratory study was conducted with 51 preschoolers using a multi-attribute utility theory (MAUT). The criteria used for drawing up the index were supported by the literature and subdivided in Group A "Resources from the house" extracted from HOME Inventory including: (1) to have three or more puzzles; (2) have at least ten children's books; (3) be encouraged to learn the alphabet; (4) take the family out at least every 2 weeks. Group B "Screens" (5) caution with using television; (6) total screen time in day/minutes. Group C "Parental Schooling" (7) maternal and paternal education. Pearson correlation analyses and univariate linear regression were performed to verify the relationship between the established index with cognitive test results. The index correlated with the total score of the mini-mental state exam (MMC) and verbal fluency test (VF) in the category of total word production and word production without errors. Multicriteria index explained 18% of the VF (total word production), 19% of the VF (total production of words without errors) and 17% of the MMC. The present multicriteria index has potential application as it synthesizes the preschooler's environmental learning opportunities and predicts domains of child cognitive development.

Effect of parenting intervention through "Care for Child Development Guideline" on early child development and behaviors: a randomized controlled trial

BACKGROUND

Several studies showed that parenting intervention programs play a core component in early child development. Considering the limited healthcare resources in developing countries, group-session intervention based on care for child development (CCD) guideline might be cost-effective.

METHODS

This randomized controlled trial was conducted at an outpatient public Pediatrics clinic in Isfahan, Iran. We included 210 pregnant women aged 18-45 years in their third trimester and followed their children for 18 months. The intervention group underwent 5 educational group sessions, each lasting for almost 45 minutes. The main outcomes were the children's development and socio-emotional behavior problems based on Bayley Scales of Infant and Toddler Development-III (BSID-III) at 12 months and the Children Behavior Checklist (CBCL) at 18 months.

RESULTS

Overall, data of 181 children were included in the current study, including 80 in the intervention group and 101 controls. The adjusted median/mean differences between intervention and control groups using median/linear regression were not significant for all BSID-III domains except for median differences for cognitive score based on BSID-III (β (SE): - 4.98(2.31), p:0.032) and mean differences for anxiety/depression score based on CBCL (β (SE): - 2.54(1.27), p:0.046).

CONCLUSION

In this study, parenting interventions through CCD group sessions were significantly effective on just one subscale of children's socio-emotional behavior domains based on CBCL and one domain of children's development based on BSID-III. There might be a ceiling or floor effects for the BSID-III and CBCL assessment, respectively, leaving little room for improvement as almost all children have achieved their full developmental potential in our study.

TRIAL REGISTRATION

IRCT20190128042533N2, Date of registration: 16/01/2020, www.irct.ir.

Association of Exposure to Intimate Partner Violence With Maternal Depressive Symptoms and Early Childhood Socioemotional Development Among Mothers and Children in Rural Tanzania

IMPORTANCE

Approximately 1 in 4 women experience intimate partner violence (IPV) or nonpartner sexual violence during their lifetime. Mothers exposed to IPV are more likely to experience depressive symptoms and to discipline their children harshly, which may affect their children's socioemotional development; however, there is limited evidence on these outcomes.

OBJECTIVE

To examine the association between IPV, maternal depressive symptoms, harsh child discipline, and child stimulation with child socioemotional development.

DESIGN, SETTING, AND PARTICIPANTS

This study used cross-sectional follow-up data collected from February 19 to October 10, 2014, from a birth cohort of children aged 18 to 36 months who were enrolled in a randomized, double-blind, placebo-controlled trial of neonatal vitamin A supplementation in the Morogoro region of Tanzania. Data analysis occurred between September 10, 2019, and January 20, 2020.

EXPOSURES

Lifetime experience of IPV was assessed using an abbreviated module of the Tanzania Demographic and Health Survey, maternal depressive symptoms were assessed with the Patient Health Questionnaire, and data on harsh child discipline and maternal stimulation of their children were collected using modules of the United Nations Children's Fund Multiple Indicator Cluster Survey.

MAIN OUTCOMES AND MEASURES

Child socioemotional development was measured by the Caregiver-Reported Early Childhood Development Instruments.

RESULTS

A total of 981 mother-child dyads were included in the analytic sample; 388 children (39.6%) were between ages 18 and 24 (mean [SD] age, 27.06 [6.08]) months, and 515 (52.5%) were male children. A negative association was observed between maternal report of physical IPV only (mean difference, -0.022; 95% CI, -0.045 to -0.006) and physical and sexual IPV (mean difference, -0.045; 95% CI, -0.077 to -0.013) with child socioemotional scores, but neither was statistically significant after including depressive symptoms in the model, which is consistent with mediation. Furthermore, a negative association was observed between maternal mild to severe depressive symptoms and child socioemotional development, including adjustment for IPV (mean difference, -0.073; 95% CI, -0.103 to -0.043). Harsh disciplinary practices and stimulation were not associated with child socioemotional development after adjusting for IPV, maternal depressive symptoms, and other factors.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that maternal depressive symptoms may explain the negative association between IPV and child socioemotional development.

Parenting centers and caregiver mental health: Evidence from a large-scale randomized controlled trial in China

This study conducts an exploratory analysis of the impacts of a center-based early childhood development intervention on the mental health of caregivers, using data from a cluster-randomized controlled trial of 1664 caregivers (M_age  = 36.87 years old) of 6- to 24-month-old children in 100 villages in rural China. Caregivers and children in 50 villages received individual parenting training, group activities and open play space in village parenting centers. The results show no significant overall change in caregiver-reported mental health symptoms after 1 year of intervention. Subgroup analyses reveal heterogeneous effects by caregiver socioeconomic status and identity (mother vs. grandmother). Findings suggest that early childhood development interventions without targeted mental health components may not provide sufficient support to improve caregiver mental health.

Child diet and mother-child interactions mediate intervention effects on child growth and development

This study examined whether child diet and mother-child interactions mediated the effects of a responsive stimulation and nutrition intervention delivered from 2009 to 2012 to 1324 children aged 0-24 months living in rural Pakistan. Results showed that the intervention improved children's cognitive, language and motor development through child diet and mother-child interactions. Although the intervention did not improve child growth or socio-emotional development, we observed positive indirect effects on child growth via child diet and on socio-emotional development via both child diet and mother-child interactions. In addition, child diet emerged as a shared mechanism to improve both child growth and development, whereas mother-child interactions emerged as a distinct mechanism to improve child development. Nevertheless, our results suggest the two mechanisms were mutually reinforcing and that interventions leveraging both mechanisms are likely to be more effective at improving child outcomes than interventions leveraging only one of these mechanisms.

Relationships between paternal attitudes, paternal involvement, and infant-feeding outcomes: Mixed-methods findings from a global on-line survey of English-speaking fathers

The breastfeeding intention-behaviour gap remains wide in developed countries. Current studies have focused on maternal attitudes and behaviours concerning infant feeding in order to explore barriers to breastfeeding continuation. There has been limited consideration of the impact of paternal attitudes and behaviours, despite contemporary parenthood evolving and evidence indicating that there are greater levels of paternal involvement in routine childcare tasks. This mixed-methods study used a triangulation design to examine the associations between paternal attitudes towards parenthood and infant-feeding methods, levels of paternal involvement, infant-feeding outcomes, and father-infant relationships. Fathers of infants <52 weeks completed an online survey providing quantitative data (N = 212) and qualitative data (N = 208). For the quantitative data, fathers completed validated measures about their attitude towards parenthood and infant feeding, levels of paternal involvement, and infant-feeding history. For the qualitative data, questions explored influences on paternal attitudes towards infant feeding and the father-infant relationship. After controlling for covariates, regression analyses found egalitarian attitudes towards parenthood were positively associated with both attitudes towards breastfeeding and levels of paternal involvement. Positive paternal attitudes towards breastfeeding were significantly associated with increased likelihood of breastfeeding. A thematic framework analysis indicated fathers' attitudes towards infant feeding were largely influenced by their families and partners or healthcare professionals. Polarised views were expressed about the impact infant-feeding methods had on the father-infant relationship, although fathers were united in their desire to bond with their infant. Addressing paternal attitudes and the importance of father-infant involvement in domains other than feeding maybe beneficial in supporting breastfeeding and the father-infant relationship.

Effect of a home-visiting parenting program to promote early childhood development and prevent violence: a cluster-randomized trial in Rwanda

Introduction

Families living in extreme poverty require interventions to support early-childhood development (ECD) due to broad risks. This longitudinal cluster randomised trial examines the effectiveness of Sugira Muryango (SM), a home-visiting intervention linked to Rwanda’s social protection system to promote ECD and reduce violence compared with usual care (UC).

Methods

Families with children aged 6–36 months were recruited in 284 geographical clusters across three districts. Cluster-level randomisation (allocated 1:1 SM:UC) was used to prevent diffusion. SM was hypothesised to improve child development, reduce violence and increase father engagement. Developmental outcomes were assessed using the Ages and Stages Questionnaire (ASQ-3) and the Malawi Development Assessment Tool (MDAT) and anthropometric assessments of growth. Violence was assessed using questions from UNICEF Multiple Indicators Cluster Survey (MICS) and Rwanda Demographic and Health Surveys (DHS). Father engagement was assessed using the Home Observation for Measurement of the Environment. Blinded enumerators conducted interviews and developmental assessments.

Results

A total of 541 SM families and 508 UC families were enrolled and included in the analyses. Study attrition (2.0% children; 9.6% caregivers) was addressed by hot deck imputation. Children in SM families improved more on gross motor (d=0.162, 95% CI 0.065 to 0.260), communication (d=0.081, 95% CI 0.005 to 0.156), problem solving (d=0.101, 95% CI 0.002 to 0.179) and personal-social development (d=0.096, 95% CI −0.015 to 0.177) on the ASQ-3. SM families showed increased father engagement (OR=1.592, 95% CI 1.069 to 2.368), decreased harsh discipline (incidence rate ratio, IRR=0.741, 95% CI 0.657 to 0.835) and intimate partner violence (IRR=0.616, 95% CI:0.458 to 0.828). There were no intervention-related improvements on MDAT or child growth.

Conclusion

Social protection programmes provide a means to deliver ECD intervention.

Trial registration number

NCT02510313.

Maternal depression is associated with less dietary diversity among rural Nepali children

Maternal depression has been associated with adverse child growth and development; less is known about its relation to children's diet. In a cross-sectional study embedded at endline of a longitudinal community development intervention, mothers of 629 children (age 23-66 months) in rural Nepal responded to household and children's diet questionnaires and were screened for depression. Child anthropometry and development (Ages and Stages Questionnaire) were assessed. Regression models examined children's diet, growth and development, adjusting for household, child and maternal characteristics. The prevalence of maternal depression was 21%. Maternal depression was associated with 11% lower likelihood that the child consumed one additional food group [Poisson regression, adjusted relative risk (aRR) 0.89, 95% confidence intervals (95% CI 0.81, 0.99), p = 0.024] and 13% lower likelihood that the child consumed one additional animal source food (ASF) [aRR 0.87, (95% CI 0.76, 1.01), p = 0.061] compared with children of nondepressed mothers. However, maternal depression was not associated with either child anthropometry or development: these outcomes were strongly associated with better home child-rearing quality. Stunting also related to child age and intervention group; child development related to mother's education and household wealth. This study suggests a correlation between maternal depression and child dietary diversity. This association could be due to unmeasured confounders, and therefore, further research is warranted. Understanding the relationship of depression to child outcomes-and the role of other potentially compensatory household factors-could help address some of the earliest, modifiable influences in a child's life and contribute to innovative approaches to improve child well-being.

Parenting interventions to promote early child development in the first three years of life: A global systematic review and meta-analysis

BACKGROUND

Parents are the primary caregivers of young children. Responsive parent-child relationships and parental support for learning during the earliest years of life are crucial for promoting early child development (ECD). We conducted a global systematic review and meta-analysis to evaluate the effectiveness of parenting interventions on ECD and parenting outcomes.

METHODS AND FINDINGS

We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Global Health Library for peer-reviewed, published articles from database inception until November 15, 2020. We included randomized controlled trials (RCTs) of parenting interventions delivered during the first 3 years of life that evaluated at least 1 ECD outcome. At least 2 reviewers independently screened, extracted data, and assessed study quality from eligible studies. ECD outcomes included cognitive, language, motor, and socioemotional development, behavior problems, and attachment. Parenting outcomes included parenting knowledge, parenting practices, parent-child interactions, and parental depressive symptoms. We calculated intervention effect sizes as the standardized mean difference (SMD) and estimated pooled effect sizes for each outcome separately using robust variance estimation meta-analytic approaches. We used random-effects meta-regression models to assess potential effect modification by country-income level, child age, intervention content, duration, delivery, setting, and study quality. This review was registered with PROSPERO (CRD42018092458 and CRD42018092461). Of the 11,920 articles identified, we included 111 articles representing 102 unique RCTs. Pooled effect sizes indicated positive benefits of parenting interventions on child cognitive development (SMD = 0.32, 95% CI [confidence interval]: 0.23, 0.40, P < 0.001), language development (SMD = 0.28, 95% CI: 0.18 to 0.37, P < 0.001), motor development (SMD = 0.24, 95% CI: 0.15 to 0.32, P < 0.001), socioemotional development (SMD = 0.19, 95% CI: 0.10 to 0.28, P < 0.001), and attachment (SMD = 0.29, 95% CI: 0.18 to 0.40, P < 0.001) and reductions in behavior problems (SMD = -0.13, 95% CI: -0.18 to -0.08, P < 0.001). Positive benefits were also found on parenting knowledge (SMD = 0.56, 95% CI: 0.33 to 0.79, P < 0.001), parenting practices (SMD = 0.33, 95% CI: 0.22 to 0.44, P < 0.001), and parent-child interactions (SMD = 0.39, 95% CI: 0.24 to 0.53, P < 0.001). However, there was no significant reduction in parental depressive symptoms (SMD = -0.07, 95% CI: -0.16 to 0.02, P = 0.08). Subgroup analyses revealed significantly greater effects on child cognitive, language, and motor development, and parenting practices in low- and middle-income countries compared to high-income countries; and significantly greater effects on child cognitive development, parenting knowledge, parenting practices, and parent-child interactions for programs that focused on responsive caregiving compared to those that did not. On the other hand, there was no clear evidence of effect modification by child age, intervention duration, delivery, setting, or study risk of bias. Study limitations include considerable unexplained heterogeneity, inadequate reporting of intervention content and implementation, and varying quality of evidence in terms of the conduct of trials and robustness of outcome measures used across studies.

CONCLUSIONS

Parenting interventions for children during the first 3 years of life are effective for improving ECD outcomes and enhancing parenting outcomes across low-, middle-, and high-income countries. Increasing implementation of effective and high-quality parenting interventions is needed globally and at scale in order to support parents and enable young children to achieve their full developmental potential.

Short-term, medium-term and long-term effects of early parenting interventions in low- and middle-income countries: a systematic review

INTRODUCTION

Parenting interventions during early childhood are known to improve various child development outcomes immediately following programme implementation. However, less is known about whether these initial benefits are sustained over time.

METHODS

We conducted a systematic literature review of parenting interventions in low- and middle-income countries (LMICs) that were delivered during the first 3 years of life and had completed a follow-up evaluation of the intervention cohort at least 1 year after the primary postintervention endpoint. We summarized intervention effects over time by child-level and parent-level outcomes as well as by timing of follow-up rounds in the short-term (1-3 years after programme completion), medium-term (4-9 years), and long-term (10+ years). We also conducted exploratory meta-analyses to compare effects on children's cognitive and behavioral development by these subgroups of follow-up rounds.

RESULTS

We identified 24 articles reporting on seven randomised controlled trials of parenting interventions delivered during early childhood that had at least one follow-up study in seven LMICs. The majority of follow-up studies were in the short-term. Three trials conducted a medium-term follow-up evaluation, and only two trials conducted a long-term follow-up evaluation. Although trials consistently supported wide-ranging benefits on early child development outcomes immediately after programme completion, results revealed a general fading of effects on children's outcomes over time. Short-term effects were mixed, and medium-term and long-term effects were largely inconclusive. The exploratory meta-analysis on cognitive development found that pooled effects were significant at postintervention and in the short-term (albeit smaller in magnitude), but the effects were not significant in the medium-term and long-term. For behavioural development, the effects were consistently null over time.

CONCLUSIONS

There have been few longer-term follow-up studies of early parenting interventions in LMICs. Greater investments in longitudinal intervention cohorts are needed in order to gain a more comprehensive understanding of the effectiveness of parenting interventions over the life course and to improve the design of future interventions so they can have greater potential for achieving and sustaining programme benefits over time.

Mothers' and Fathers' Parenting Stress, Responsiveness, and Child Wellbeing Among Low-Income Families

Robust research shows that parenting stress is associated with reduced parental sensitivity toward their children (i.e., parental responsiveness), thus negatively influencing child outcomes. While there is strong research supporting these associations, most studies utilize self-report measures of responsiveness and exclude fathers. This study examines whether observed parental responsiveness mediates the relationship between parenting stress and child cognitive development, prosocial behavior, and behavior problems in a large sample of diverse low-income families. Data were obtained from the Building Strong Families Project (N=1,173). Dyadic bootstrapped mediation models were estimated in Mplus. For mothers and fathers, parenting stress was negatively associated with responsiveness (B = -.08, 95% CI = [-.14, -.02], p = .012), and responsiveness was positively associated with child cognitive development (B = .15, 95% CI = [.11, .19], p < .001) and child prosocial behavior (B = .12, 95% CI = [.08, .15], p < .001). Mothers' responsiveness was negatively associated with child behavior problems (B = -.07, 95% CI = [-.13, -.01], p = .020), but fathers' responsiveness was not (B = -.01, 95% CI = [-.06, .05], p = .814). For mothers and fathers, parenting stress was indirectly related to child cognitive development and prosocial behavior via responsiveness. Indirect effects were not found for mothers or fathers when predicting child behavior problems. To improve children's wellbeing, interventions may consider strengthening responsiveness and reducing parental stress among both mothers and fathers.

Maternal, paternal, and other caregivers' stimulation in low- and- middle-income countries

Background and objectives

Globally, studies have shown associations between maternal stimulation and early child development. Yet, little is known about the prevalence of paternal and other caregivers’ stimulation practices, particularly in low- and- middle-income countries (LMICs).

Methods

Data from the Multiple Indicators Cluster Survey (MICS) and the Demographic and Health Survey (DHS) were combined across 62 LMICs (2010–2018). The sample included 205,150 mothers of children aged 3 and 4 years. High levels of stimulation were defined as caregiver engagement in at least 4 out of 6 possible activities with the child. The proportion of mothers, fathers, and other caregivers providing high levels of stimulation was calculated by country, region, and for the whole sample. Socioeconomic disparities within and between countries were estimated.

Results

On average, 39.8% (95% CI 37.4 to 42.2) of mothers, 11.9% (95% CI 10.1 to 13.8) of fathers, and 20.7% (95% CI 18.4 to 23.0) of other adult caregivers provided high levels of stimulation. Stimulation varied by region, country income group, and Human Development Index (HDI), with higher levels of maternal and paternal–but not other caregivers’–stimulation in high-income and high-HDI countries. Within countries, stimulation levels were, on average, lower in the poorest relative to the richest households, and some but not all countries exhibited differences by child sex (i.e., boys vs. girls) or area (i.e., urban vs. rural).

Conclusions

Results suggest a need for intervention efforts that focus on increasing caregiver stimulation in LMICs, particularly for fathers and in low-income contexts.

Intimate Partner Violence, Maternal and Paternal Parenting, and Early Child Development

BACKGROUND AND OBJECTIVES

Previous research has demonstrated associations between maternal experience of intimate partner violence (IPV) and a range of adverse outcomes among women and their young children. However, few studies have examined the associations between maternal experience of IPV and early child development (ECD) outcomes in low- and middle-income countries (LMIC). Our objectives in this study were to examine the association between IPV victimization and ECD and assess whether the association was mediated by maternal and paternal stimulation.

METHODS

We combined cross-sectional data from the Demographic and Health Surveys for 15 202 households representing mothers and fathers of children aged 36 to 59 months in 11 LMIC. We used multivariable linear regression models to estimate the association between IPV victimization in the year preceding the survey and ECD, which we measured using the Early Child Development Index. We used path analysis to determine if the association between IPV victimization and ECD was mediated through maternal and paternal stimulation.

RESULTS

After adjusting for sociodemographic variables, IPV victimization was negatively associated with ECD (β = -.11; 95% confidence interval = -.15 to -.07). Path analysis indicated that the direct association between IPV victimization and ECD was partially and independently mediated through maternal and paternal stimulation.

CONCLUSIONS

Interventions that include components to prevent IPV may be effective for improving ECD in LMIC.

Agreement between Fathers' and Mothers' Reported Stimulation and Associations with Observed Responsive Parenting in Pakistan

Parental stimulation and responsiveness are associated with improved early child development outcomes. However, the majority of studies have relied on maternal-reported measures of only mothers’ parenting practices. The purpose of this study was to assess the agreement between fathers’ and mothers’ reports of their own and their partner’s engagement in stimulation and assess the degree to which parents’ reported stimulation correlated with their observed responsive caregiving behaviors. Data were collected from 33 couples (33 fathers and 32 mothers) who had a child under 5 years of age in rural Pakistan. Paternal and maternal stimulation were measured based on reports of their own and their partner’s practices in play and learning activities with the child. Paternal and maternal responsiveness were observed in a subsample of 18 families. Moderate agreement was found between paternal and maternal reports of their own and their partner’s practices. Moderate associations were also found between self-reported measures of stimulation and observed responsive caregiving for both fathers and mothers. The strengths of agreement and associations were greater among couples who had higher quality coparenting relationships. Findings highlight the feasibility, reliability, and promise of assessing fathers’ parenting in a low-resource setting, using similar methods as for mothers’ parenting, to triangulate measures between reported and observed parenting and gain a deeper understanding of fathers’ and mothers’ unique caregiving contributions.

Low risk of neurodevelopmental impairment among perinatally acquired HIV-infected preschool children who received early antiretroviral treatment in Thailand

INTRODUCTION

Antiretroviral therapy (ART) is recommended in perinatally HIV-infected (PHIV) infants immediately upon diagnosis. We aimed to compare neurodevelopmental outcomes between PHIV children who initiated ART within 12 months of life and perinatally HIV-exposed uninfected (PHEU) children and to assess neurodevelopmental outcomes by timing of ART.

METHODS

This prospective cohort study included Thai children aged 12 to 56 months who were assessed with the Mullen Scales of Early Learning (MSEL) at enrolment and at 48 weeks. Global Developmental Impairment (GDI) was defined as Early Learning Composite (ELC) ≤ 70 on the MSEL; typical developmental pattern was defined as ELC > 70 at both visits. Logistic regression was used to compare prevalence of any GDI. Predictors of changing ELC scores were analysed with generalized estimating equations linear regression model.

RESULTS

From 2016 to 2017, 50 PHIV (twenty-seven early ART within three months and twenty-three standard ART within three to twelve months) and 100 PHEU children were enrolled. Median (IQR) age at first assessment was 28 (19 to 41) months. PHIV children had lower age-relevant Z scores for weight, height and head circumference compared to the PHEU group (p < 0.05). The prevalence of overall GDI was 18% (95% CI 11 to 27) and 32% (95% CI 20 to 47) in PHEU and PHIV children respectively (p = 0.06). In subgroup analysis, 22% (95% CI 9 to 42) of early ART PHIV children and 44% (95% CI 23 to 66) of standard ART PHIV children had overall GDI. There was a higher rate of GDI in standard ART PHIV children (p = 0.01), but not in the early ART group (p = 0.62) when compared with PHEU children. The standard ART PHIV group demonstrated lower typical developmental pattern than both the early ART PHIV group and the PHEU group (57% vs. 77% vs. 82% respectively). Non-attendance at nursery school was associated with changes in ELC score during study participation (adjusted coefficient -3.8; 95% CI -6.1 to -1.6, p = 0.001).

CONCLUSIONS

Preschool children with HIV who initiated ART in the first three months of life had a similar rate of GDI as PHEU children. Lack of nursery school attendance predicted poor developmental trajectory outcomes among PHIV children.