How does perinatal maternal mental health explain early social inequalities in child behavioural and emotional problems? Findings from the Wirral Child Health and Development Study

Evaluation of parenting interventions for those with additional health and social care needs during pregnancy: THRIVE a multi-arm RCT with embedded economic and process components

Background

Women who have additional social and care needs in pregnancy (e.g. social adversity, maternal depression and anxiety) are likely to produce high levels of stress hormones. This has the potential to affect fetal brain development, increase infant reactivity to stress, and impair sensitive mother-infant bonds from developing. These in turn may have long-term effects on children's health, social and educational outcomes. Parenting interventions show promising improvements to child outcomes; however, there is little evidence of their efficacy in the UK.

Objective(s)

THRIVE compared the impact of taking part in one of two antenatal parenting support programmes both incorporating cognitive-behavioural therapy (Enhanced Triple P for Baby or Mellow Bumps) with care-as-usual alone on the mental health and maternal attunement of vulnerable mothers-to-be, as well as the socioemotional and behavioural development of their children.

Design

THRIVE is a three-arm randomised controlled trial. Pregnant women with additional social and care needs in pregnancies were invited to participate. Participants were randomly allocated to Enhanced Triple P for Baby, Mellow Bumps or care-as-usual.

Setting

The study took place in National Health Service Greater Glasgow and Clyde and National Health Service Ayrshire and Arran health board areas. Intervention sessions were predominantly in community settings.

Participants

Women identified as having additional social and care needs in pregnancies during pregnancy based on the National Health Service Greater Glasgow and Clyde's Special Needs in Pregnancy criteria were recruited to THRIVE (n = 485), slightly below the target of 500 women. Participants were block-randomised 5 : 5 : 2 to Enhanced Triple P for Baby, Mellow Bumps or care-as-usual. Subsequently their babies and accompanying person of choice were also invited.

Interventions

Enhanced Triple P for Baby consists of four weekly group-based antenatal sessions followed by up to three postnatal home visits and one postnatal group session. It aims to provide babies with a healthy start to life by combining parenting skills training with strategies to enhance individual well-being and couple adjustment. Mellow Bumps in comparison, comprises of seven weekly antenatal sessions and one postnatal session. It aims to decrease maternal stress, increase understanding of neonates' capacity for social interaction, and emphasise the importance of early interaction for brain development and attachment. Recruitment to the trial took place between early 2014 and May 2018.

Main outcome measures

Our two primary outcomes were the Hospital Anxiety and Depression Scale, plus outwardly directed irritability from the Adult Wellbeing Scale, and CARE Index mother-infant dyadic interaction synchrony.

Results

There were no significant differences in the change from baseline in Hospital Anxiety and Depression Scale and outwardly expressed irritability score between the combined active intervention groups and care-as-usual only [effect size (95% confidence interval) 0.03 (-0.24 to 0.29)], or between either Enhanced Triple P for Baby and Care-as-usual only [0.04 (-0.24 to 0.32)] or Mellow Bumps and care-as-usual only [0.01 (-0.27 to 0.30)]. Mellow Bumps holds promise for cost-effectiveness due to its potential for cost-savings relating to routine healthcare resource use.

Limitations

The main limitation of THRIVE was poor attendance of the groups (under 42%) offered to our Enhanced Triple P for Baby and Mellow Bumps participants. However, subgroup analysis adjusted for level of attendance suggested the results would not have been any different with increased participation.

Conclusions

With the population THRIVE involved, at a stage of pregnancy when a lot of support is offered (with many parenting interventions being offered without rigorous evaluation), we do not have evidence to recommend the rollout of Enhanced Triple P for Baby or Mellow Bumps.

Future work

Future work could explore the timing and intensity of interventions, intervention group composition, co-produced programmes, online sessions, and impact of addressing inequalities.

Trial registration

This trial is registered as Current Controlled Trials ISRCTN21656568 (www.isrctn.com/ISRCTN21656568).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref. 11/3002/01) and is published in full in Public Health Research; Vol. 13, No. 4. See the NIHR Funding and Awards website for further award information.

Environmental variables influence the relationship between maternal depressive symptoms and toddlers' neurocognitive and affective outcomes

Motherhood is often associated with joy, but it can pose significant challenges, and in some instances lead to perinatal mental health problems. Maternal depressive symptoms can hinder a mother's ability to attune to her infant's needs, potentially affecting caregiving quality and emotional support. This study examines how parenting style and a cognitively stimulating home environment (i.e., individual level) and relative social deprivation (i.e., area level) contribute to the relationship between maternal depressive symptoms and offspring's neurocognitive and affective outcomes at 18 months. Participants were 479 mothers and children recruited as part of the Developing Human Connectome Project. Maternal postnatal depressive symptoms were assessed at term with the Edinburgh Postnatal Depression Scale. At a median corrected age of 18.4 months (range 17.3-24.3) children's outcomes were evaluated with the Bayley Scales of Infant and Toddler Development, Third Edition, the parent-rated Child Behaviour Checklist 1½ - 5 and the Early Childhood Behaviour Questionnaire. The Parenting Scale measured dysfunctional parenting in discipline situations; the Cognitively Stimulating Parenting Scale assessed experiences promoting cognitive stimulation in the home. Family socioeconomic status was evaluated using the Index of Multiple Deprivation. Toddler's outcomes were summarised into latent dimensions labelled 'neurocognitive' and 'affective'. Results from bootstrapped-based mediation analysis showed that a permissive parenting style and a less cognitively stimulating home environment modified the relationship between depressive symptoms and toddlers' neurocognitive outcomes. However, other factors, such as relative social deprivation and parental over-reactivity, did not alter this. Results also showed that an over-reactive parenting style modified the relationship between maternal depressive symptoms and toddlers' reduced capacity for effective emotional regulation, while relative social deprivation, permissive parenting and a cognitively stimulating home environment did not. These findings highlight the importance of understanding how environmental factors interact with parenting styles, and influence child development. The study emphasizes the need for interventions that create stable and supportive environments, mitigating the impact of suboptimal parenting on children's developmental outcomes.

Neighbourhood characteristics and socioeconomic inequalities in child mental health: Cross-sectional and longitudinal findings from the Growing Up in Ireland study

This study examined the role of neighbourhood characteristics in explaining socioeconomic inequalities in child mental health (the total difficulties score from the Strengths and Difficulties Questionnaire) using data from Cohort '08 of Growing Up in Ireland Waves 3 (age 5; baseline) and 5 (age 9; follow-up). Twenty neighbourhood items were grouped into neighbourhood safety, built environments, cohesion, interaction, and disorder. Data were analysed using regression, single and multiple mediation, and network psychometric analyses. We found that neighbourhood safety, cohesion, interaction, and disorder were associated with child mental health. These four domains separately (by up to 18 %) or in concert (by up to 23 %) partially explained socioeconomic inequalities in child mental health. Built environments may explain socioeconomic inequalities in mental health in urban children only. Findings from network analysis indicated that specific concerns over "people being drunk or taking drugs in public" and "this is a safe neighbourhood" had the strongest connections with child mental health. Improving neighbourhood characteristics may be important to reduce socioeconomic inequalities in child mental health in Ireland.

Prenatal stress and externalizing behaviors in childhood and adolescence: A systematic review and meta-analysis

Accumulating evidence suggests that psychological distress during pregnancy is linked to offspring risk for externalizing outcomes (e.g., reactive/aggressive behaviors, hyperactivity, and impulsivity). Effect sizes across studies have varied widely, however, due to differences in study design and methodology, including control for the confounding continuation of distress in the postnatal period. Clarifying these inconsistencies is necessary to guide the precision of prevention efforts and inform public health policies. A meta-analysis was conducted with 55 longitudinal studies to investigate the association between prenatal psychological distress (anxiety, depression, and perceived stress) and offspring externalizing behaviors. Results revealed a significant but small effect (r = .160) of prenatal distress on externalizing behaviors. The magnitude of the prenatal effect size remained largely unchanged after adjusting for postnatal distress (r = .159), implicating a unique effect of psychological distress during the prenatal period in the etiology of externalizing behaviors. Moderation tests showed that prenatal effects did not vary based on type and timing of psychological distress during pregnancy. Greater instability of distress from prenatal to postnatal periods predicted larger effects. Prenatal effects were comparable across most externalizing outcomes, consistent with the common comorbidity of externalizing spectrum disorders, although effects appeared smaller for nonaggressive rule-breaking (vs. aggressive) behaviors. Significant associations persisted across all developmental periods, appearing slightly larger in early childhood. We discuss these results in the context of developmental and psychobiological theories of externalizing behavior, offer preliminary clinical and public health implications, and highlight directions for future research including the need for longitudinal studies with more racially and socioeconomically diverse families. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A longitudinal comparison of emotional, behavioral and attention problems in autistic and typically developing children

BACKGROUND

Mental health problems are elevated in autistic individuals but there is limited evidence on the developmental course of problems across childhood. We compare the level and growth of anxious-depressed, behavioral and attention problems in an autistic and typically developing (TD) cohort.

METHODS

Latent growth curve models were applied to repeated parent-report Child Behavior Checklist data from age 2-10 years in an inception cohort of autistic children (Pathways, N = 397; 84% boys) and a general population TD cohort (Wirral Child Health and Development Study; WCHADS; N = 884, 49% boys). Percentile plots were generated to quantify the differences between autistic and TD children.

RESULTS

Autistic children showed elevated levels of mental health problems, but this was substantially reduced by accounting for IQ and sex differences between the autistic and TD samples. There was small differences in growth patterns; anxious-depressed problems were particularly elevated at preschool and attention problems at late childhood. Higher family income predicted lower base-level on all three dimensions, but steeper increase of anxious-depressed problems. Higher IQ predicted lower level of attention problems and faster decline over childhood. Female sex predicted higher level of anxious-depressed and faster decline in behavioral problems. Social-affect autism symptom severity predicted elevated level of attention problems. Autistic girls' problems were particularly elevated relative to their same-sex non-autistic peers.

CONCLUSIONS

Autistic children, and especially girls, show elevated mental health problems compared to TD children and there are some differences in predictors. Assessment of mental health should be integrated into clinical practice for autistic children.

Child mental health and income gradient from early childhood to adolescence: Evidence from the UK

Background

Children from low income families are likely to have poorer mental health than their more affluent peers. However, it is unclear how this association varies at different developmental stages and what the potential underpinning mechanisms are. This study investigates the relationship between family income and mental health problems from early childhood to adolescence in the UK, and examines the potential mediating role of family-related factors over time.

Methods

Data were drawn from the UK Millennium Cohort Study at ages 3, 5, 7, 11, 14 and 17 years. Child mental health was measured by the Strengths and Difficulties Questionnaire Total Difficulties Score, and the Internalising and Externalising subscales. Family income was operationalised as permanent income. Cross-sectional analyses were conducted at each age to examine the association between income and mental health problems, and to examine potential mechanisms based on the Parental Stress and Parental Investment theories.

Results

The samples included 8096 children aged up to 14 years, of which 5667 remained in the study at age 17. Results indicated a statistically significant association between lower family income and poorer mental health in all age groups after adjusting for confounding factors. The strength of the association was reduced after adjustment for Parental Stress and Parental Investment factors, with the larger attenuation driven by Parental Stress factors in most cases. Fully adjusted models suggested an increased independent association between maternal psychological distress and children's mental health as children grew older.

Conclusions

While lower family income is associated with a child's poorer mental health, much of this association is explained by other factors such as maternal psychological distress, and therefore the direct association is relatively small. This suggests that policies targeting income redistribution may reduce child mental health problems, and also benefit the wider family, reducing the prevalence of other associated risk factors.

Toward a dimensional model of risk and protective factors influencing children's early cognitive, social, and emotional development during the COVID-19 pandemic

Variation in infants' home environment is implicated in their cognitive and psycho-social development. The pandemic has intensified variations in home environments through exacerbating socioeconomic inequalities, and increasing psychological stressors for some families. This study investigates the effects of parental (predominantly maternal) mental health, enriching activities and screen use on 280 24- to 52-month-olds' executive functions, internalising and externalising problems, and pro-social behaviour; with socioeconomic status and social support as contextual factors. Our results indicate that aspects of the home environment are differentially associated with children's cognitive and psycho-social development. Parents who experienced sustained mental distress during the pandemic tended to report higher child externalising and internalising problems, and executive function difficulties at follow-up. Children who spent more time engaged in enriching activities with their parents showed stronger executive functions and social competence six months later. Screen use levels during the first year of the pandemic were not associated with outcomes. To mitigate the risk of persistent negative effects for this 'pandemic generation' of infants, our study highlights the importance of supporting parents' mental health. As our results demonstrate the impact of social support on mental health, investing in support services and interventions promoting building support networks are likely to be beneficial.

How do early-life factors explain social inequalities in adolescent mental health? Findings from the UK Millennium Cohort Study

BACKGROUND

Reducing inequalities in adolescent mental health is a public health priority, yet the pathways that link social conditions to mental health outcomes in the early years are unclear. We aimed to evaluate the extent to which early years risk factors explain social inequalities in adolescent mental health in the UK.

METHODS

We analysed data from 6509 children captured in the UK Millennium Cohort Study. Mental health was assessed through the socioemotional behavioural problems at age 14 (Strengths and Difficulties Questionnaire). The main exposure was maternal education at birth, used as a measure of childhood socioeconomic conditions (SECs), and used to calculate the relative index of inequality. Using causal mediation analysis, we assessed how perinatal, individual child, family, peer relation and neighbourhood-level factors measured up to age 3-mediated the total effect (TE) of SECs on adolescent socioemotional behavioural problems, estimating the proportion mediated and natural indirect effect (NIE) via each block of mediators, and all mediators together.

RESULTS

Children of mothers with no qualification were almost four times as likely to have socioemotional behavioural problems compared with degree plus level (relative risk (RR) 3.82, 95% CI 2.48 to 5.88). Overall, 63.9% (95% CI 50.2% to 77.6%) (NIE RR 1.97, 95% CI 1.63 to 2.37) of the TE (RR 4.40, 95% CI 3.18 to 6.07) of social inequalities on risk of adolescent socioemotional behavioural problems was mediated by early-life factors.

CONCLUSIONS

About two-thirds of the social inequality in adolescent mental health was explained by early risk factors measured by age 3, highlighting the importance of public health interventions in this period.