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Malin AJ, Eckel SP, Hu H, Martinez-Mier EA, Hernandez-Castro I, Yang T, Farzan SF, Habre R, Breton CV, Bastain TM. Maternal Urinary Fluoride and Child Neurobehavior at Age 36 Months. JAMA Netw Open 2024; 7:e2411987. [PMID: 38767917 PMCID: PMC11107298 DOI: 10.1001/jamanetworkopen.2024.11987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/18/2024] [Indexed: 05/22/2024] Open
Abstract
Importance Recent studies in Canadian and Mexican populations suggest an association of higher prenatal fluoride exposure with poorer neurobehavioral development, but whether this association holds for US-based populations is unknown. Objective To examine associations of third trimester maternal urinary fluoride (MUF) with child neurobehavior at age 3 years in the US. Design, Setting, and Participants This prospective cohort study utilized urine samples archived from 2017 to 2020 and neurobehavioral data assessed from 2020 to 2023 from the Maternal and Developmental Risks from Environmental and Social Stressors (MADRES) pregnancy cohort, which consisted of predominately Hispanic women residing in Los Angeles, California. Cohort eligibility criteria at recruitment included being 18 years of age or older, less than 30 weeks' gestation, and a fluent English or Spanish speaker. Exclusion criteria included having a disability preventing participation or provision of informed consent, being HIV positive or incarcerated, and having a multiple gestation pregnancy. There were 263 mother-child pairs who completed the 3-year study visit. In this analysis, women who reported prenatal smoking were excluded. Data analysis was conducted from October 2022 to March 2024. Exposure Specific gravity-adjusted MUF (MUFSG), a biomarker of prenatal fluoride exposure. Main Outcomes and Measures Neurobehavior was quantified using the Preschool Child Behavior Checklist (CBCL), which included composite scores for Total Problems, Internalizing Problems, and Externalizing Problems. CBCL composite T scores range from 28 to 100. T scores from 60 to 63 are in the borderline clinical range, whereas scores above 63 are in the clinical range. Linear and logistic regression models adjusted for covariates were conducted. Results A total of 229 mother-child pairs (mean [SD] maternal age, 29.45 [5.67] years; 116 female children [50.7%] and 113 male children [49.3%]) who had MUFSG measured were included in the study. Median (IQR) MUFSG was 0.76 (0.51-1.19) mg/L, and 32 participants (14.0%) had a Total Problems T score in the borderline clinical or clinical range. A 1-IQR (0.68 mg/L) increase in MUFSG was associated with nearly double the odds of the Total Problems T score being in the borderline clinical or clinical range (odds ratio, 1.83; 95% CI, 1.17-2.86; P = .008), as well as with a 2.29-point increase in T score for the Internalizing Problems composite (B = 2.29; 95% CI, 0.47-4.11; P = .01) and a 2.14-point increase in T score for the Total Problems composite (B = 2.14; 95% CI, 0.29-3.98; P = .02). Conclusions and Relevance In this prospective cohort study of mother-child pairs in Los Angeles, California, prenatal fluoride exposure was associated with increased neurobehavioral problems. These findings suggest that there may be a need to establish recommendations for limiting fluoride exposure during the prenatal period.
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Affiliation(s)
- Ashley J. Malin
- Department of Epidemiology, College of Public Health and Health Professions University of Florida, Gainesville
- College of Medicine, University of Florida, Gainesville
| | - Sandrah P. Eckel
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles
| | - Howard Hu
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles
| | - E. Angeles Martinez-Mier
- Department of Dental Public Health and Dental Informatics, School of Dentistry, Indiana University, Indianapolis
| | - Ixel Hernandez-Castro
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles
| | - Tingyu Yang
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles
| | - Shohreh F. Farzan
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles
| | - Rima Habre
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles
| | - Carrie V. Breton
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles
| | - Theresa M. Bastain
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles
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Neuhaus E, Rea H, Jones E, Benavidez H, Miles C, Whiting A, Johansson M, Eayrs C, Kurtz-Nelson EC, Earl R, Bernier RA, Eichler EE. Shared and divergent mental health characteristics of ADNP-, CHD8- and DYRK1A-related neurodevelopmental conditions. J Neurodev Disord 2024; 16:15. [PMID: 38622540 PMCID: PMC11017562 DOI: 10.1186/s11689-024-09532-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/01/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Neurodevelopmental conditions such as intellectual disability (ID) and autism spectrum disorder (ASD) can stem from a broad array of inherited and de novo genetic differences, with marked physiological and behavioral impacts. We currently know little about the psychiatric phenotypes of rare genetic variants associated with ASD, despite heightened risk of psychiatric concerns in ASD more broadly. Understanding behavioral features of these variants can identify shared versus specific phenotypes across gene groups, facilitate mechanistic models, and provide prognostic insights to inform clinical practice. In this paper, we evaluate behavioral features within three gene groups associated with ID and ASD - ADNP, CHD8, and DYRK1A - with two aims: (1) characterize phenotypes across behavioral domains of anxiety, depression, ADHD, and challenging behavior; and (2) understand whether age and early developmental milestones are associated with later mental health outcomes. METHODS Phenotypic data were obtained for youth with disruptive variants in ADNP, CHD8, or DYRK1A (N = 65, mean age = 8.7 years, 40% female) within a long-running, genetics-first study. Standardized caregiver-report measures of mental health features (anxiety, depression, attention-deficit/hyperactivity, oppositional behavior) and developmental history were extracted and analyzed for effects of gene group, age, and early developmental milestones on mental health features. RESULTS Patterns of mental health features varied by group, with anxiety most prominent for CHD8, oppositional features overrepresented among ADNP, and attentional and depressive features most prominent for DYRK1A. For the full sample, age was positively associated with anxiety features, such that elevations in anxiety relative to same-age and same-sex peers may worsen with increasing age. Predictive utility of early developmental milestones was limited, with evidence of early language delays predicting greater difficulties across behavioral domains only for the CHD8 group. CONCLUSIONS Despite shared associations with autism and intellectual disability, disruptive variants in ADNP, CHD8, and DYRK1A may yield variable psychiatric phenotypes among children and adolescents. With replication in larger samples over time, efforts such as these may contribute to improved clinical care for affected children and adolescents, allow for earlier identification of emerging mental health difficulties, and promote early intervention to alleviate concerns and improve quality of life.
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Affiliation(s)
- Emily Neuhaus
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.
- Center On Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Hannah Rea
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Elizabeth Jones
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Hannah Benavidez
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Conor Miles
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Alana Whiting
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Margaret Johansson
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Curtis Eayrs
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Rachel Earl
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Raphael A Bernier
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Evan E Eichler
- Department of Genome Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Howard Hughes Medical Institute, Seattle, WA, USA
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Yu MWL, Au CT, Yuen HM, Chan NY, Chan JW, Wing YK, Li AM, Chan KCC. Effects of childhood obstructive sleep apnea with and without daytime sleepiness on behaviors and emotions. Sleep Med 2024; 115:93-99. [PMID: 38350308 DOI: 10.1016/j.sleep.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/26/2024] [Accepted: 01/26/2024] [Indexed: 02/15/2024]
Abstract
OBJECTIVE To investigate the relationship between obstructive sleep apnea (OSA) with and without excessive daytime sleepiness (EDS) and behavioral and emotional outcomes in non-obese prepubertal children. METHODS This was a retrospective analysis of children aged 5-11 years who presented to our unit for assessment of their sleep-related complaints. All children underwent polysomnography (PSG). They also completed the Pediatric Daytime Sleepiness Scale (PDSS) and a sleep diary. OSA was diagnosed if the obstructive apnea-hypopnea index (OAHI) was ≥1 event/hour. EDS was defined as PDSS >15. Behavioral and emotional outcomes were assessed using the Child Behavioral Checklist (CBCL). RESULTS Data from 391 children (mean age of 8.6 ± 1.7 years; 67 % male) were analyzed. Seventy children did not have OSA or EDS, 137 had OSA, 50 had reported having EDS but without OSA, and 134 children had both OSA and EDS. There were significantly higher CBCL total problems score in the combined group (61 ± 9) compared to the non-OSA/EDS group (54 ± 10), and the OSA-only group (54 ± 10) (p < 0.001). The presence of EDS was significantly associated with higher CBCL T score and higher odds for clinically significant behavioral problems (T score ≥65) after adjusting for age, sex, BMI z-score and average sleep duration (p < 0.001). CONCLUSION Excessive daytime sleepiness is an important contributory factor associated with suboptimal behavioral and emotional outcomes in children with OSA.
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Affiliation(s)
- Michelle Wai-Ling Yu
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chun-Ting Au
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China; Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hoi-Man Yuen
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ngan-Yin Chan
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Joey Wy Chan
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yun-Kwok Wing
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Albert Martin Li
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China; Laboratory for Paediatric Respiratory Research, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; Hong Kong Hub of Paediatric Excellence, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kate Ching-Ching Chan
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China; Laboratory for Paediatric Respiratory Research, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; Hong Kong Hub of Paediatric Excellence, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Woodford EC, McLay LK, France KG, Blampied NM. The Lighter Touch: Less-Restriction in Sequentially Implemented Behavioral Sleep Interventions for Children with Rare Genetic Neurodevelopmental Conditions. J Autism Dev Disord 2024:10.1007/s10803-024-06234-4. [PMID: 38324170 DOI: 10.1007/s10803-024-06234-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/08/2024]
Abstract
PURPOSE The prevalence of sleep difficulties among children with rare genetic neurodevelopmental conditions (RGNC) is high. Behavioral interventions are commonly used in the treatment of sleep difficulties in children with neurodevelopmental conditions such as autism, however, research is scarce in children with RGNC. The range of co-occurring complexities within this population, means there is a need for research to not only determine the effectiveness of behavioral sleep interventions, but also which components might be the least restrictive (i.e., intensive/aversive) and minimally sufficient. METHODS This study used a single-case multiple baseline design to investigate the effectiveness and acceptability of behavioral sleep interventions, indicated within a Functional Behavior formulation in eight children with RGNC (M = 7.3 years). Intervention components were sequentially administered across up to three phases, based on the principle of less restriction (from least to relatively more intensive) to determine what might be minimally sufficient. RESULTS Results showed an improvement in sleep onset latency, night wakings, early morning waking and unwanted bed-sharing for 7/7, 6/7, 3/3 and 3/3 children respectively. Improvement was observed for most participants following the less restrictive phases of intervention (circadian modifications, antecedent modifications and positive reinforcement), however, more restrictive, albeit modified, extinction procedures were still implemented for five participants. Improvements were maintained at follow-up and interventions were deemed acceptable to parents. CONCLUSIONS Less restrictive function-based behavioral strategies are an effective, and in some cases sufficient, contribution to a sequence of interventions for a range of sleep difficulties. They should be implemented first, before more restrictive strategies.
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Affiliation(s)
- Emma C Woodford
- Faculty of Health, Te Kaupeka Oranga, University of Canterbury, Christchurch, New Zealand.
| | - Laurie K McLay
- Faculty of Health, Te Kaupeka Oranga, University of Canterbury, Christchurch, New Zealand
- Child Wellbeing Research Institute, University of Canterbury, Christchurch, New Zealand
| | - Karyn G France
- Faculty of Health, Te Kaupeka Oranga, University of Canterbury, Christchurch, New Zealand
| | - Neville M Blampied
- Psychology Speech & Hearing, Faculty of Science, Te Kaupeka Pūtaiao, University of Canterbury, Christchurch, New Zealand
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Ilic T, Porter MA, Reeve JL. Internalising and Externalising Symptoms and Their Association with the Family Environment in Young Children with Williams Syndrome: A Longitudinal Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1717. [PMID: 37892382 PMCID: PMC10605142 DOI: 10.3390/children10101717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023]
Abstract
Williams Syndrome (WS) involves high rates of psychopathology across the lifespan. However, little is known about the early, longitudinal trajectory of internalising/externalising symptoms or the association between these and the family environment in WS. WS (n = 16; aged 2 years, 2 months to 9 years, 5 months) and typically developing or TD (n = 46; aged 2 years, 2 months to 11 years, 1 month) children were assessed on two occasions over 2.5 years utilising parent report questionnaires-the Child Behaviour Checklist and the Family Environment Scale. No statistically significant changes were found in CBCL/psychopathology profiles across timepoints, on average, for either WS or TD children. However, reliable change scores showed WS children had considerable variability in CBCL scores over time. Cross-sectionally, the WS group showed higher scores (reflecting more psychopathology) compared to TD controls at both time points across most CBCL subscales, with elevated overall psychopathology problems identified in 56-68% of WS children (versus 8% in TD controls). Psychopathology was not associated with sex, chronological age, or cognitive ability in WS. Conflict in the family environment was positively associated with higher Attention Problems at Time 1 in the WS group, whilst the TD group showed associations between family conflict and total psychopathology problems at both time points and between family cohesion and total psychopathology problems at Time 2. Family environment did not differ between groups, except for lower engagement in intellectual and cultural activities in WS. Findings highlight variable Internalising and Externalising Problems in young WS children over time, with greater biological than environmental contributions to psychopathology in WS.
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Affiliation(s)
| | - Melanie A. Porter
- School of Psychological Sciences, Macquarie University, Balaclava Road, Marsfield, Sydney, NSW 2109, Australia; (T.I.); (J.L.R.)
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Stankova M, Kamenski T, Ivanov I, Mihova P. Emotional and Behavioral Problems of Children with ASD-The Lessons That We Learned from the Pandemic. CHILDREN (BASEL, SWITZERLAND) 2023; 10:969. [PMID: 37371201 PMCID: PMC10297218 DOI: 10.3390/children10060969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
The data available for changes in the behavior and emotional state of children with ASD (autism spectrum disorder) in lockdown situations are controversial and scarce. In our research, we compare results before the first COVID-19 lockdown of 21 children with ASD and 21 typically developing children, four to five years of age with those obtained immediately after. The study attempts to answer the question of whether there are changes in the levels of emotional and behavioral problems in children with ASD after the lockdown and how these new living conditions affect some aspects of their functioning. The instruments used for data analysis are the Childhood Autism Spectrum Test (CAST); Child Behavior Checklist (CBCL); Survey on the consequences of COVID-19 on the life and development of the participants. No significant differences in the emotional and behavioral state of the participants were found, except for attention deficit/hyperactivity problems where ASD children showed lower levels after the lockdown. ASD group parents' answers to the survey pointed towards more positive consequences of staying at home. Some reported they had more time for learning together, communicating, playing, and assisting the learning process through online therapy. As negatives, the parents of ASD children reported low physical activity, increased time with electronic devices, and time spent with the same people. Caregivers of typically developing children agreed that the lockdown had only negative effects. To conclude, for children with ASD in the study, the lockdown period demonstrated that more time spent with parents in structured everyday activities is an opportunity that can lead to positive results in their behavior.
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Affiliation(s)
- Margarita Stankova
- Department of Health Care and Social Work, New Bulgarian University, 1618 Sofia, Bulgaria; (T.K.); (P.M.)
| | - Tsveta Kamenski
- Department of Health Care and Social Work, New Bulgarian University, 1618 Sofia, Bulgaria; (T.K.); (P.M.)
| | - Ivan Ivanov
- College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA;
| | - Polina Mihova
- Department of Health Care and Social Work, New Bulgarian University, 1618 Sofia, Bulgaria; (T.K.); (P.M.)
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Mo A, Snyder LG, Babington O, Chung WK, Sahin M, Srivastava S. Neurodevelopmental profile of HIVEP2-related disorder. Dev Med Child Neurol 2022; 64:654-661. [PMID: 34704275 PMCID: PMC8986546 DOI: 10.1111/dmcn.15100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022]
Abstract
AIM To characterize the neurodevelopmental profile and systemic features of HIVEP2-related disorder. METHOD This study used retrospective medical history and standardized assessment data from Simons Searchlight to describe the clinical characteristics of 12 individuals (eight males, four females; age range 3y 3mo-12y 8mo; mean age [SD] 7y 7mo [2y 11mo]) with pathogenic HIVEP2 variants, focusing on their levels of adaptive functioning, autism symptomology, and emotional and behavioral characteristics. RESULTS Common features included neonatal complications, hypotonia, developmental delay, intellectual disability, language impairment, gastroesophageal reflux, and strabismus. A minority of individuals had epilepsy, microcephaly, or a movement disorder. Based on the Vineland Adaptive Behavior Scales, Second Edition, affected individuals showed impairments in adaptive behavior (mean composite standard score [SD] 56.4 [10.2]; n=8). The cohort also had significant impairments in social problems, as measured by the Social Responsiveness Scale, Second Edition (mean total score [SD] 76.4 [11.3]; n=10) and clinically significant emotional and behavioral difficulties, as measured by the Child Behavior Checklist for ages 6-18 (mean total T score [SD] 66.9 [8.2]; n=8). INTERPRETATION These results show that individuals with HIVEP2-related disorder have impairments in adaptive and social-related behaviors as well as difficulties in emotional and behavioral symptoms.
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Affiliation(s)
- Alisa Mo
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | | | | | - Wendy K Chung
- Simons Foundation, New York, NY, USA.,Columbia University, New York, NY, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
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Externalizing behavior in preschool children in a South African birth cohort: Predictive pathways in a high-risk context. Dev Psychopathol 2022; 35:982-999. [PMID: 35287770 DOI: 10.1017/s095457942200027x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Mental health problems often begin in early childhood. However, the associations of various individual and contextual risk factors with mental health in the preschool period are incompletely understood, particularly in low- to middle-income countries (LMICs) where multiple risk factors co-exist. To address this gap, we prospectively followed 981 children in a South African birth cohort, the Drakenstein Child Health Study, assessing pre-and postnatal exposures and risk factors. The predictive value of these factors for child mental health (assessed by the Child Behavior Checklist) was modeled using structural equation modeling. We identified two key pathways to greater externalizing behavior: (1) prenatal exposure to substances (alcohol and smoking) directly predicted increased externalizing behavior (β = 0.24, p < 0.001); this relationship was partially mediated by an aspect of infant temperament (negative emotionality; β = 0.05, p = 0.016); (2) lower socioeconomic status and associated maternal prenatal depression predicted more coercive parenting, which in turn predicted increased externalizing behavior (β = 0.18, p = 0.001). Findings in this high-risk LMIC cohort cohere with research from higher income contexts, and indicate the need to introduce integrated screening and intervention strategies for maternal prenatal substance use and depression, and promoting positive parenting across the preschool period.
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