First 1,000 days: enough for mothers but not for children? Long-term outcomes of an early intervention on maternal depressed mood and child cognitive development: follow-up of a randomised controlled trial

Long-term associations between early attachment and parenting and adolescent susceptibility to post-traumatic distress in a South African high-risk sample

BACKGROUND

It has been proposed that children and young people living in low- and middle-income countries (LMICs) are not only exposed more frequently to trauma but also have a higher likelihood of encountering traumas of greater severity than those living in high-income countries (HICs). This may lead to higher rates of post-traumatic stress symptoms (PTSS). However, developmental pathways to risk or resilience after trauma exposure in LMICs are underresearched.

METHODS

We examined early parenting and attachment as potentially important formative factors for later stress reactivity in a longitudinal cohort of South African children (N = 449). Parenting and attachment were assessed at child age 18 months, and interpersonal trauma exposure, PTSS and parenting stress were measured at 13 years (N = 333; core sample with data on all measures: N = 213). Following a vulnerability-stress approach, separate regression models were run to investigate whether parent-child attachment at 18 months, parental sensitivity and intrusiveness during play at 12 months, and current parenting stress at 13 years, interacted with adolescents' extent of interpersonal trauma exposure to predict their PTSS levels at 13 years.

RESULTS

We found no predictive effects of either early attachment or current parenting stress in relation to child PTSS. There was some evidence for predictive influences of parental early intrusiveness and sensitivity on adolescent outcomes, though associations were unexpectedly positive for the latter. No interaction effects supporting a vulnerability-stress model were found.

CONCLUSIONS

Overall, we found limited evidence that elements of the early parent-child environment predict child risk/resilience to trauma in LMIC children. Future studies should include more frequent assessments of relevant constructs to capture changes over time and consider further what comprises adaptive parenting in high-risk contexts.

Community-based models of care for adolescent and adult depression, suicidal behavior, anxiety, trauma, and substance use in Africa: a scoping review

Background

Community-based care (CBC), where care is delivered outside of the traditional health facility setting, has been proposed to narrow the mental health (MH) and substance use (SU) treatment gap in Africa.

Objective

This scoping review aims to comprehensively summarize CBC models addressing adolescent and adult MH (depression, anxiety, trauma, suicidal behavior) and (non-tobacco) SU problems in Africa.

Methods

We searched PsycINFO, Embase, Scopus, CINAHL, and Medline Ovid. Studies and protocols were included if they reported on CBC intervention's effects on MH or SU symptoms/ diagnoses, acceptability, feasibility, or patient engagement in care, regardless of whether the intervention itself was designed specifically for MH or SU.

Results

Among 11,477 screened publications, 217 were eligible. Of the unique intervention studies (n = 206), CBC models were classified into the following approaches (non-mutually exclusive): psychotherapeutic (n = 144), social (n = 81), lifestyle/physical health (n = 55), economic (n = 26), and psychopharmacological (n = 2). While quantitative results suggest possible efficacy of CBC models, description of CBC location was often poor. Fewer interventions addressed suicidal behavior (n = 12), the needs of adolescents (n = 49), or used traditional healers or religious figures as providers (n = 3).

Conclusion

Many CBC models have been tested on MH and SU in Africa and should be critically appraised and meta-analyzed in subsequent reviews, where possible.

Measuring the cost-effectiveness of a home-visiting intervention to promote early child development among rural families linked to the Rwandan social protection system

Early childhood development (ECD) programmes are heralded as a way to improve children's health and educational outcomes. However, few studies in developing countries calculate the effectiveness of quality early childhood interventions. This study estimates the cost and cost-effectiveness of the Sugira Muryango (SM) trial, a home-visiting intervention to improve ECD outcomes through positive parent-child relationships. Cost-effectiveness analysis of ECD interventions is challenging given their potential to have multiple benefits. We propose a cost-effectiveness method using a single outcome, in this case the improvement in cognitive development per home-visit session, as an indication of efficiency comparable across similar interventions. The trial intervention cost US$456 per family. This cost will likely fall below US$200 if the intervention is scaled through government systems. The cost-effectiveness analysis suggests that while SM generated a relatively small impact on markers of early development, it did so efficiently. The observed improvements in cognitive development per home-visit are similar to other home-visiting interventions of longer duration. SM by focusing on the family had benefits beyond ECD, including reductions in violence against children and intermate partner violence, further analysis is needed to include these returns in the economic evaluation.

Adverse childhood experiences and lifelong health

With the advent of the sustainable development goals, the field of global child health has shifted its focus from reducing mortality to improving health, nutrition and development outcomes - often measured as human capital. A growing knowledge of the biology of development and neuroscience has highlighted the importance of adverse environmental exposures, collectively termed adverse childhood experiences (ACEs) on health outcomes. ACEs are associated with short-term, medium-term and long-term negative consequences for health and development and their effects may be multiplicative, especially during critical periods of sensitivity and developmental plasticity. Some of these effects are compounded by emerging global threats such as climate change, conflict and population displacement. In this Review, we discuss the key mechanisms linking ACEs to health outcomes and consider promising strategies to prevent and mitigate their effects, highlighting evidence from programs in low-income and middle-income countries. Finally, we emphasize the need for early recognition of ACEs and delivery of packages of interventions spanning key sectors such as health, education, women's empowerment and social protection.

Protocol for the OCAY study: a cohort study of orphanhood and caregiver loss in the COVID-19 era to explore the impact on children and adolescents

INTRODUCTION

Globally, no person has been untouched by the COVID-19 pandemic. Yet, little attention has been given to children and adolescents in policy, provision and services. Moreover, there is a dearth of knowledge regarding the impact of COVID-19-associated orphanhood and caregiver loss on children. This study aims to provide early insights into the mental health and well-being of children and adolescents experiencing orphanhood or caregiver loss in South Africa.

METHODS AND ANALYSIS

Data will be drawn from a quantitative longitudinal study in Cape Town, South Africa. A sample of children and adolescents between the ages of 9 and 18 years, experiencing parental or caregiver loss from COVID-19, will be recruited together with a comparison group of children in similar environments who did not experience loss. The study aims to recruit 500 children in both groups. Mental health and well-being among children will be explored through the use of validated and study-specific measures. Participants will be interviewed at two time points, with follow-up data being collected 12-18 months after baseline. A combination of analytical techniques (including descriptive statistics, regression modelling and structural equation modelling) will be used to understand the experience and inform future policy and service provision.

ETHICS AND DISSEMINATION

This study received ethical approval from the Health Research Ethics Committee at Stellenbosch University (N 22/04/040). Results will be disseminated via academic and policy publications, as well as national and international presentations including high-level meetings with technical experts. Findings will also be disseminated at a community level via various platforms.

Does pre-COVID impulsive behaviour predict adherence to hygiene and social distancing measures in youths following the COVID-19 pandemic onset? Evidence from a South African longitudinal study

BACKGROUND

Engagement in protective behaviours relating to the COVID-19 pandemic has been proposed to be key to infection control. This is particularly the case for youths as key drivers of infections. A range of factors influencing adherence have been identified, including impulsivity and risk taking. We assessed the association between pre-COVID impulsivity levels and engagement in preventative measures during the COVID-19 pandemic in a longitudinal South African sample, in order to inform future pandemic planning.

METHODS

Data were collected from N = 214 youths (mean age at baseline: M = 17.81 (SD = .71), 55.6% female) living in a South African peri-urban settlement characterised by high poverty and deprivation. Baseline assessments were taken in 2018/19 and the COVID follow-up was conducted in June-October 2020 via remote data collection. Impulsivity was assessed using the Balloon Analogue Task (BART), while hygiene and social distancing behaviours were captured through self-report. Stepwise hierarchical regression analyses were performed to estimate effects of impulsivity on measure adherence.

RESULTS

Self-rated engagement in hygiene behaviours was high (67.1-86.1% "most of the time", except for "coughing/sneezing into one's elbow" at 33.3%), while engagement in social distancing behaviours varied (22.4-57.8% "most of the time"). Higher impulsivity predicted lower levels of hygiene (β = .14, p = .041) but not social distancing behaviours (β = -.02, p = .82). This association was retained when controlling for a range of demographic and COVID-related factors (β = .14, p = .047) and was slightly reduced when including the effects of a life-skills interventions on hygiene behaviour (β = -.13, p = .073).

CONCLUSIONS

Our data indicate that impulsivity may predict adolescent engagement in hygiene behaviours post COVID-19 pandemic onset in a high risk, sub-Saharan African setting, albeit with a small effect size. For future pandemics, it is important to understand predictors of engagement, particularly in the context of adversity, where adherence may be challenging. Limitations include a small sample size and potential measure shortcomings.

Adapting Attachment and Biobehavioral Catch-up for infants and young children with intellectual disabilities and developmental delays in South Africa: Reflections and recommendations from local stakeholders

Attachment and Biobehavioral Catch-up (ABC) is an intervention targeted at enhancing the socioemotional and regulatory functioning of at-risk infants. However, to use the ABC for infants/toddlers with intellectual disabilities/developmental delays (ID/DD) and in novel cultural contexts, such as South Africa, adaptations may be required. This study aimed, therefore, to explore the opinions of clinical experts and perceptions of caregivers regarding the use of ABC for children with ID/DD in South Africa. It also sought to incorporate the experiences of families of children with ID/DD who received, and intervenors who delivered, ABC in its first implementation in South Africa. Semi-structured interviews were conducted with 18 participants. Thematic analysis explicated 12 main themes: Intervention Strengths, Points of Concern, and Recommendations (Experts); Focus on Caregiver-child Relationship, and Intervention Targets and Duration (Caregivers); Benefits of ABC, and Cultural Considerations (ABC Recipients); Focused and Targeted, Value of Feedback, Supportive Supervision, Working Alliance, and Challenges Experienced (ABC Intervenors). Practice and training recommendations include psychoeducation for parents and training for intervenors that is ID/DD-specific, expanding supervision capacity, building intervenors' cultural/linguistic sensitivity and competence, accessing referral networks, including local Community Health Workers as intervenors, and greater flexibility in how the sessions are organized.

Learning to love the null

Children's behaviour and mental health has the power to surprise us, readers and authors of the Journal of Child Psychology and Psychiatry and laymen alike, if not for the endless variation among people, then for the ever-changing context in which they develop. The hypothetico-deductive method in combination with null-hypothesis significance testing has turned surprise into scientific knowledge. Null effects may in themselves also be surprising and informative, but appear less well represented in the literature. This editorial highlights emerging methodological practices for studying null effects in the most informative way.

Accelerating progress towards improved mental health and healthy behaviours in adolescents living in adversity: findings from a longitudinal study in South Africa

Adolescents exposed to high levels of adversity are vulnerable to developing mental health challenges, with long-lasting adverse consequences. Promoting the psychological well-being of adolescents and protecting them from adverse experiences is crucial for their quality of life. There is a need for evidence on which combinations of protective factors can improve the wellbeing of adolescents to inform future programming efforts. We used data from a longitudinal study that took place in Khayelitsha, South Africa, a semi-urban impoverished community in Cape Town. Data were collected from adolescents when they were 12-14 years of age (n = 333) and again at follow-up when they were aged 16-19 years (n = 314). A path analysis was used to estimate associations between access to service, food security, safe environment, family support, and social support and five outcomes related to adolescent mental health and risky behaviours. The fitted model was used to calculate adjusted mean differences comparing different combinations of risk factors. Two protective factors (food security and safe environment) were positively associated with three outcomes relating to mental health and the absence of risky behaviours. Further investigation revealed that the presence of high food security and safer environments was associated with higher adjusted mean scores: +16.2% (p < .0001) in no substance use; +16.5% (p < .0001) in no internalising behaviour, +19.5% (p < .0001) in self-esteem; +12.2% (p < .0001) in positive peer relationships; and +11.4% (p < .0001) in no suicidal ideation. Interventions targeting adolescents, that aim to improve food security together with improving the safety of their environment, are likely to impact their well-being.

Predictors of COVID-related changes in mental health in a South African sample of adolescents and young adults

The COVID-19 pandemic has substantially affected the lives of young people living in sub-Saharan Africa (SSA), leading to poorer short-term mental health outcomes. However, longitudinal data investigating changes in mental health from pre-COVID levels and their predictors are lacking. Our longitudinal sample comprised N = 233 young people (mean age: 17.8 years at baseline, 55.6% female) living in a deprived neighbourhood near Cape Town, South Africa. Symptoms of depression (PHQ-9), anxiety (GAD-7) and alcohol use (AUDIT) were assessed during two waves of data collection, pre-pandemic (2018/19) and via phone interviews in June to October 2020, during South Africa's first COVID wave and subsequent case decline. Latent change score models were used to investigate predictors of changes in mental health. Controlling for baseline levels, we found increases in depression and anxiety but not alcohol use symptoms during the COVID-19 pandemic. Higher baseline symptoms were associated with smaller increases on all measures. Socio-economic deprivation (lack of household income, food insecurity) before and during COVID were associated with higher anxiety and depression symptom increases. Having had more positive experiences during COVID was associated with lower post-COVID onset anxiety and depression increases, and marginally with less alcohol use, while negative experiences (household arguments, worries) were linked to stronger symptom increases. Overall, in a sample of young people from an adverse environment in South Africa, we found increased mental health difficulties during the COVID-19 pandemic, though higher baseline symptoms did not necessarily predict stronger increases. Several factors pre- and post-COVID onset were identified that could be relevant for determining risk and resilience. In the long term, it will be key to address these structural drivers of well-being and to ensure mental health needs of young people are being met to support SSA countries in building back successfully from COVID-19 and preparing for future shock events.