Self-reported neighborhood stressors and sleep quality among Puerto Rican young adults

OBJECTIVE

To examine the association between changes in self-reported neighborhood stressors and sleep quality and determine whether this varied by sociocultural context among Puerto Rican young adults.

METHODS

Data come from the Boricua Youth Study Health Assessment, a sample of Puerto Rican young adults from San Juan, Puerto Rico, and South Bronx, New York (n = 818; mean age=22.9years). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Neighborhood social stressors (disorder, social cohesion, and safety) were parent-reported in childhood and self-reported in young adulthood and categorized into: low in childhood/young adulthood (reference group), high in childhood/low in young adulthood, low in childhood/high in young adulthood, and high in childhood/young adulthood. Sociocultural context was based on participant residence during childhood (San Juan vs. South Bronx).

RESULTS

Adjusting for sociodemographic factors, living with high neighborhood stressors in both childhood and young adulthood (prevalence ratios=1.30, 95% CI: 1.01, 1.66) was associated with overall poor sleep (PSQI score >5). Among PSQI components, living with high neighborhood stressors in young adulthood only or in both time periods was associated with worse subjective sleep quality and daytime dysfunction. Additionally, there were various associations between the neighborhood stressor measures and PSQI components. Results did not differ by sociocultural context.

CONCLUSION

Findings suggest that living with high levels of neighborhood stressors during childhood and young adulthood may have a cumulative adverse impact on sleep quality in young adulthood.

Maternal childhood trauma and observed maternal care behaviors with 4-month-old infants

OBJECTIVE

To examine the relationship between maternal childhood trauma and early maternal caregiving behaviors (MCB).

METHOD

Participants included 74 mother-infant dyads (maternal age 20-45 years; ethnicity 64.9% Latina) from a longitudinal pregnancy cohort study. Maternal childhood trauma was assessed during pregnancy with the childhood trauma questionnaire (CTQ). Observed mother-infant interactions at infant age 4 months were coded utilizing modified Ainsworth's MCB rating scales that assessed a range of behaviors (e.g., acceptance, soothing, and delight) which we analyze grouped together and will summarize using the term "maternal sensitivity." Linear regressions tested the associations between maternal childhood trauma and MCB. Primary analyses examined the relationships of MCB with (a) any maternal childhood trauma (moderate or greater exposure to physical abuse, sexual abuse, emotional abuse, physical neglect, and/or emotional neglect) and (b) cumulative childhood trauma. Secondary analyses examined the relationships between each type of childhood trauma and MCB.

RESULTS

Exposure to childhood trauma was not associated with MCB (p = .88). Cumulative childhood trauma score was associated with lower scores on MCB (β = -1.88, p < .05). Emotional abuse and emotional neglect were individually associated with lower scores on MCB (β = -1.78, p = .04; β = -1.55, p = .04, respectively). Physical abuse, sexual abuse, and physical neglect were not associated with MCB.

CONCLUSIONS

Many mothers exposed to childhood trauma may be resilient to negative effects on parenting behaviors, while specific experiences of childhood trauma (emotional abuse, emotional neglect, and cumulative childhood trauma) may predict less sensitive early parenting behaviors. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sociocultural Risk and Resilience in the Context of Adverse Childhood Experiences

Importance

Knowledge about childhood resilience factors relevant in circumstances of marginalization and high numbers of adverse childhood experiences (ACEs) can improve interventions.

Objective

To identify sociocultural resilience factors in childhood that are associated with better young adult mental health in the context of ACEs.

Design, Setting, and Participants

This cohort study examined 4 waves of data from the Boricua Youth Study, which included Puerto Rican children from the South Bronx, New York, and San Juan, Puerto Rico. Participants were aged 5 to 17 years at waves 1 through 3 (2000-2003) and aged 15 to 29 years at wave 4 (2013-2017). Linear and logistic regression models tested the associations of 7 childhood resilience factors and their interaction with ACEs on young adult mental health outcomes. Data were analyzed from June 2021 to October 2023.

Main Outcomes and Measures

Perceived stress, major depressive disorder and/or generalized anxiety disorder (MDD/GAD), and substance use disorder (SUD) in young adulthood.

Results

Among a total 2004 participants, the mean (SD) age at wave 4 was 22.4 (2.9) years; 1024 participants (51.1%) were female, and 980 (48.9%) were male. Positive parent-child relationships and nonparental adult support during childhood were associated with both lower perceived stress (β = -0.14; SE = 0.02; P < .001; β = -0.08; SE = 0.03; P = .003, respectively) and lower odds of MDD/GAD (adjusted odds ratio [aOR], 0.84; 95% CI, 0.73 to 0.97; aOR = 0.81; 95% CI, 0.69 to 0.95, respectively) in young adulthood. Maternal warmth reported during childhood was also associated with lower young adult perceived stress (β = -0.11; SE = 0.02; P < .001). None of the resilience factors were associated with SUD. The resilience factors familism, friendships, and family religiosity were not associated with any of the mental health outcomes. ACEs were associated with poorer mental health outcomes; however, none of the resilience factors exhibited interactions consistent with being protective for ACEs. Unexpectedly, higher family religiosity was associated with more perceived stress in the presence of higher ACEs.

Conclusions and Relevance

The results of this study suggest that promoting positive relationships with adults during childhood may reduce later young adulthood stress and MDD/GAD. However, there is still a need to identify sociocultural childhood protective factors for ACEs. Caution should be taken in assuming what resilience factors are relevant for a given group, as higher family religiosity (one postulated resilience factor) was unexpectedly associated with a stronger, rather than a weaker, association between ACEs and perceived stress in young adulthood.

Adverse Childhood Experiences and Sleep Disturbances Among Puerto Rican Young Adults

Importance

Sleep quality is a known marker of overall health. Studies suggest that adverse childhood experiences (ACEs) are associated with sleep disturbances among children and adults.

Objective

To examine the association of retrospective and prospective ACEs with sleep quality among a cohort of Puerto Rican young adults from 2 sociocultural contexts.

Design, Setting, and Participants

This prospective cohort study used data from the Boricua Youth Study (BYS), a population-based study representing Puerto Rican children from the South Bronx, New York, and Puerto Rico conducted from August 2000 to August 2003. Participants who were 5 to 9 years of age at enrollment in the BYS and who participated in wave 4 of the BYS took part in the Health Assessment (HA) when they were 18 to 29 years of age, from April 2013 to August 2017. Of the eligible 982 participants, 813 (82.8%) participated in the HA. Statistical analysis was conducted from January 2023 to January 2024.

Exposures

Prospective ACEs measured from parent and youth responses and retrospective ACEs measured among young adults using questions from the validated ACE questionnaire from the original ACEs study conducted by Kaiser Permanente and the Centers for Disease Control and Prevention and published in 1998. Analysis included 8 overlapping items from both questionnaires.

Outcomes

Sleep quality was assessed in the HA with the Pittsburgh Sleep Quality Index. The summary score included 7 components of the Pittsburgh Sleep Quality Index. The hypothesis was formulated after data collection. Sleep quality information was gathered at the same time as retrospective ACEs in the HA.

Results

Of the 813 participants, 438 (53.9%) lived in Puerto Rico as children, 411 (50.6%) identified as female, and the mean (SE) age of participants was 22.9 (0.07) years. After adjusting for sociodemographic factors, retrospective ACEs had a significant association with worse sleep outcomes (β [SE] = 0.29 [0.07]; 95% CI, 0.15-0.44; P < .001). Prospective ACEs did not have a significant association with sleep quality, after adjusting for sociodemographic factors (β [SE] = 0.05 [0.10]; 95% CI, -0.14 to 0.24; P = .59).

Conclusions and Relevance

This study suggests that there is a significant association between retrospective ACEs and sleep quality among Puerto Rican young adults, after adjusting for sociodemographic factors. Prospective ACEs were not significantly associated with sleep disturbances, after adjusting for sociodemographic factors. Addressing ACEs reported in young adulthood may help reduce sleep disorders.

Prevalence of cardiometabolic risk and health factors among Puerto Rican young adults in the Boricua Youth Study - Health Assessment

We describe and compare the prevalence of cardiometabolic risk factors and ideal cardiovascular health (CVH) among Puerto Rican young adults in the San Juan metro area in Puerto Rico and the South Bronx, NY. As part of the Boricua Youth Study - Health Assessment, (mean age 23 ± 0.1 years) objective anthropometric, blood pressure and blood samples were collected. Information on diet, physical activity and sleep were collected via surveys. Life's Essential 8 metrics were characterized as continuous with higher scores indicating more optimal CVH and categorically (80-100 scores for ideal CVH). Mean CVH score among NY participants was lower (61.9) than in PR (68.9). No participant had all ideal health metrics, 36% of participants in PR had 5 or more ideal CVH; while only 16% in NY met this criterion. The prevalence of cardiometabolic risk factors was high for obesity (35% in NY, 19% in PR) and diabetes (17% NY, 20% PR). In this ethnically homogenous population, we found low levels of ideal CVH that varied across study site, suggesting differences by sociocultural context. Interventions to maintain and improve CVH across the life course, tailored to sociocultural environments, are necessary for the prevention of cardiovascular disease.

Associations between COVID-19-related family hardships/distress and children's Adverse Childhood Experiences during the pandemic: The Environmental influences on Child Health Outcomes (ECHO) program

BACKGROUND

Economic hardships imposed by the pandemic could have implications for children's experiences of adversity in the home, or Adverse Childhood Experiences (ACEs).

OBJECTIVE

This observational cohort study examined associations between COVID-19-related hardships and distress (e.g., job loss, caregiver stress) and the cumulative number of child ACEs reported by caregivers during the pandemic (i.e., March 1, 2020-February 28, 2022).

PARTICIPANTS AND SETTING

The study included children (N = 4345; median age = 6.0 years, interquartile range = 4-9 years) and their parents/caregivers who participated in the NIH-funded Environmental influences in Child Health Outcomes (ECHO) Program.

METHODS

We described socio-demographic characteristics and pandemic-related family hardships/distress and cumulative child ACE scores reported during pre-pandemic and pandemic periods. We used negative binomial regression models to evaluate associations between pandemic-related family hardships and cumulative child ACE scores reported during the pandemic.

RESULTS

Each caregiver-reported hardship/distress was associated with higher child ACE scores reported during the pandemic. After accounting for pre-pandemic child ACE scores, moderate and severe symptoms of pandemic-related traumatic stress among caregivers were associated with 108 % and 141 % higher child ACE scores reported during the pandemic, respectively, compared with no or low caregiver symptoms. In addition, finance-related stress during the pandemic was associated with 47 % higher child ACE scores. After adjusting for pre-pandemic child experiences of neglect, most sources of stress remained significantly associated with higher child ACE scores reported during the pandemic, particularly severe/very severe symptoms of pandemic-related traumatic stress among caregivers. Findings held for children with no known pre-pandemic ACEs.

CONCLUSIONS

This research suggests that caregivers experiencing financial hardships and those with severe pandemic-related traumatic stress may require additional support systems during stressful events.

Association of maternal education, neighborhood deprivation, and racial segregation with gestational age at birth by maternal race/ethnicity and United States Census region in the ECHO cohorts

Background

In the United States, disparities in gestational age at birth by maternal race, ethnicity, and geography are theorized to be related, in part, to differences in individual- and neighborhood-level socioeconomic status (SES). Yet, few studies have examined their combined effects or whether associations vary by maternal race and ethnicity and United States Census region.

Methods

We assembled data from 34 cohorts in the Environmental influences on Child Health Outcomes (ECHO) program representing 10,304 participants who delivered a liveborn, singleton infant from 2000 through 2019. We investigated the combined associations of maternal education level, neighborhood deprivation index (NDI), and Index of Concentration at the Extremes for racial residential segregation (ICERace) on gestational weeks at birth using linear regression and on gestational age at birth categories (preterm, early term, post-late term relative to full term) using multinomial logistic regression.

Results

After adjustment for NDI and ICERace, gestational weeks at birth was significantly lower among those with a high school diploma or less (-0.31 weeks, 95% CI: -0.44, -0.18), and some college (-0.30 weeks, 95% CI: -0.42, -0.18) relative to a master's degree or higher. Those with a high school diploma or less also had an increased odds of preterm (aOR 1.59, 95% CI: 1.20, 2.10) and early term birth (aOR 1.26, 95% CI: 1.05, 1.51). In adjusted models, NDI quartile and ICERace quartile were not associated with gestational weeks at birth. However, higher NDI quartile (most deprived) associated with an increased odds of early term and late term birth, and lower ICERace quartile (least racially privileged) associated with a decreased odds of late or post-term birth. When stratifying by region, gestational weeks at birth was lower among those with a high school education or less and some college only among those living in the Northeast or Midwest. When stratifying by race and ethnicity, gestational weeks at birth was lower among those with a high school education or less only for the non-Hispanic White category.

Conclusion

In this study, maternal education was consistently associated with shorter duration of pregnancy and increased odds of preterm birth, including in models adjusted for NDI and ICERace.

Prenatal sleep health and risk of offspring ADHD symptomatology and associated phenotypes: a prospective analysis of timing and sex differences in the ECHO cohort

Background

Sleep difficulties are common in pregnancy, yet poor prenatal sleep may be related to negative long-term outcomes for the offspring, including risk for attention-deficit/hyperactivity disorder (ADHD). Existing studies are few and have not examined timing of exposure effects or offspring sex moderation. We thus aimed to test the hypotheses that poor sleep health in pregnancy is associated with increased risk for ADHD symptoms and offspring sleep problems at approximately 4 years of age.

Methods

Participants were 794 mother-child dyads enrolled in the NIH Environmental Influences on Child Health Outcomes Study (ECHO). Participants self-reported on sleep duration, quality, and disturbances during pregnancy and on children's ADHD symptoms and sleep problems on the Child Behaviour Checklist.

Findings

Pregnant participants were 32.30 ± 5.50 years and children were 46% female. 44 percent of pregnant participants identified as Hispanic or Latine; 49% identified as White. Second-trimester sleep duration was associated with offspring ADHD symptoms (b = -0.35 [95% CI = -0.57, -0.13], p = 0.026), such that shorter duration was associated with greater symptomatology. Poorer sleep quality in the second trimester was also associated with increased ADHD symptomatology (b = 0.66 [95% CI = 0.18, 1.14], p = 0.037). Greater sleep disturbances in the first trimester were associated with offspring ADHD (b = 1.03 [95% CI = 0.32, 1.03], p = 0.037) and in the second trimester with sleep problems (b = 1.53 [95% CI = 0.42, 2.92], p = 0.026). We did not document substantial offspring sex moderation.

Interpretation

Poor prenatal sleep health, particularly quality and duration in the second trimester, may be associated with offspring risk of neurodevelopmental disorders and sleep problems in early childhood. Further research is needed to understand mechanisms, yet our study suggests that prenatal maternal sleep may be a modifiable target for interventions aimed at optimizing early neurodevelopment.

Funding

NIH grants U2COD023375, U24OD023382, U24OD023319, UH3OD023320, UH3OD023305, UH3OD023349, UH3OD023313, UH3OD023272, UH3OD023328, UH3OD023290, K08MH117452 and NARSAD Young Investigator Award 28545.

Development and psychometric validation of the Pandemic-Related Traumatic Stress Scale for children and adults

To assess the public health impact of the COVID-19 pandemic on mental health, investigators from the National Institutes of Health Environmental influences on Child Health Outcomes (ECHO) research program developed the Pandemic-Related Traumatic Stress Scale (PTSS). Based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) acute stress disorder symptom criteria, the PTSS is designed for adolescent (13-21 years) and adult self-report and caregiver-report on 3-12-year-olds. To evaluate psychometric properties, we used PTSS data collected between April 2020 and August 2021 from non-pregnant adult caregivers (n = 11,483), pregnant/postpartum individuals (n = 1,656), adolescents (n = 1,795), and caregivers reporting on 3-12-year-olds (n = 2,896). We used Mokken scale analysis to examine unidimensionality and reliability, Pearson correlations to evaluate relationships with other relevant variables, and analyses of variance to identify regional, age, and sex differences. Mokken analysis resulted in a moderately strong, unidimensional scale that retained nine of the original 10 items. We detected small to moderate positive associations with depression, anxiety, and general stress, and negative associations with life satisfaction. Adult caregivers had the highest PTSS scores, followed by adolescents, pregnant/postpartum individuals, and children. Caregivers of younger children, females, and older youth had higher PTSS scores compared to caregivers of older children, males, and younger youth, respectively. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Parental psychopathology and posttraumatic stress in Puerto Ricans: the role of childhood adversity and parenting practices

BACKGROUND

Parental psychopathology is associated with their children's posttraumatic stress symptoms (PTSS). However, the mechanisms through which this occurs remain unclear. We hypothesized that exposure to childhood adversities is the mechanism linking parental psychopathology to child PTSS and that parenting practices moderated these associations.

METHODS

Participants (N = 1,402) with an average age of 24.03 years old (SD = 2.20), were all Puerto Ricans (50% Male and 50% Female) from the Boricua Youth Study, which is a four-wave longitudinal study spanning almost 20 years, following individuals from childhood (ages 5-13 at Wave 1) to young adulthood. Measured variables include parental psychopathology at Wave 1, childhood adversities and parenting practices at Waves 2-3, and PTSS at Wave 4. A traditional mediation model estimated the association between parental psychopathology and child PTSS via childhood adversities. A moderated mediation model was used to examine whether parenting practices moderated this mediation model.

RESULTS

Results showed that the total effect of parental psychopathology at Wave 1 on PTSS at Wave 4 was fully mediated by childhood adversities at Waves 2-3 (direct effect b = 1.72, 95% CI = [-0.09, 3.83]; indirect effect b = 0.40, 95% CI = [0.15, 0.81]). In addition, the magnitude of this pathway varied by levels of parenting practices (i.e. parental monitoring and parent-child relationship quality). Specifically, the indirect effect of additional adversities in the psychopathology-PTSS link was stronger with higher levels of parental monitoring but weaker with higher parent-child relationship quality scores.

CONCLUSIONS

Intergenerational continuity of psychopathology may be mitigated through the prevention of additional childhood adversities via upstream interventions, emphasizing providing parents with mental health needs with parenting tools. Family-based interventions focused on providing families with the tools to improve parent-child relationships may reduce the negative impact of childhood adversities on mental health across the life course.

Stage 2 Registered Report: Epigenetic Intergenerational Transmission: Mothers' Adverse Childhood Experiences and DNA Methylation

OBJECTIVE

Individual differences in risk for mental disorders over the lifespan are shaped by forces acting before the individual is born-in utero, but likely even earlier, during the mother's own childhood. The environmental epigenetics hypothesis proposes that sustained effects of environmental conditions on gene expression are mediated by epigenetic mechanisms. Recent human studies have shown that adversities in childhood are correlated with DNA methylation (DNAm) in adulthood. In the current study, we tested the following pre-registered hypotheses: Mothers' adverse childhood experiences (ACEs) are correlated with DNAm in peripheral blood during pregnancy (hypothesis 1) and in cord blood samples from newborn infants (hypothesis 2), and women's depression and anxiety symptoms during pregnancy mediate the association between mothers' ACE exposure and prenatal/neonatal DNA methylation (hypothesis 3).

METHOD

Data were from the Avon Longitudinal Study of Parents and Children Accessible Resource for Integrated Epigenomic Studies substudy. Women provided retrospective self-reports during pregnancy of ACE exposure. We conducted an epigenome-wide association study testing whether mothers' ACE exposure, cumulative score (0-10), was associated with DNAm in maternal antenatal blood and infant cord blood in more than 450,000 CpG (point on DNA sequence where cytosine and guanine base pairs are linked by a phosphate, where methylation usually occurs) sites on the Illumina 450K BeadChip. Analyses for cord blood were separated by infant sex, a pre-registered analysis.

RESULTS

Hypothesis 1: In 896 mother-infant pairs with available methylation and ACE exposure data, there were no significant associations between mothers' ACE score and DNAm from antenatal peripheral blood, after controlling for covariates. Hypothesis 2: In infant cord blood, there were 5 CpG sites significantly differentially methylated in relation to mothers' ACEs (false discovery rate [FDR] < .05), but only in male offspring. Effect sizes were medium, with partial eta squared values ranging from 0.060 to 0.078. CpG sites were in genes related to mitochondrial function and neuronal development in the cerebellum. Hypothesis 3: There was no mediation by maternal anxiety/depression symptoms found between mothers' ACEs score and DNAm in the significant CpG sites in male cord blood. Mediation was not tested in antenatal peripheral blood, because no direct association between mothers' ACE score and antenatal peripheral blood was found.

CONCLUSION

Our results show that mothers' ACE exposure is associated with DNAm in male offspring, supporting the notion that DNAm could be a marker of intergenerational biological embedding of mothers' childhood adversity.

STUDY REGISTRATION INFORMATION

Epigenetic Intergenerational Transmission: Mothers' Adverse Childhood Experiences and DNA Methylation; https://doi.org/10.1016/j.jaac.2020.03.008.

Maternal childhood maltreatment: associations to offspring brain volume and white matter connectivity

The deleterious effects of adversity are likely intergenerational, such that one generation's adverse experiences can affect the next. Epidemiological studies link maternal adversity to offspring depression and anxiety, possibly via transmission mechanisms that influence offspring fronto-limbic connectivity. However, studies have not thoroughly disassociated postnatal exposure effects nor considered the role of offspring sex. We utilized infant neuroimaging to test the hypothesis that maternal childhood maltreatment (CM) would be associated with increased fronto-limbic connectivity in infancy and tested brain-behavior associations in childhood. Ninety-two dyads participated (32 mothers with CM, 60 without; 52 infant females, 40 infant males). Women reported on their experiences of CM and non-sedated sleeping infants underwent MRIs at 2.44 ± 2.74 weeks. Brain volumes were estimated via structural MRI and white matter structural connectivity (fiber counts) via diffusion MRI with probabilistic tractography. A subset of parents (n = 36) reported on children's behaviors at age 5.17 ± 1.73 years. Males in the maltreatment group demonstrated greater intra-hemispheric fronto-limbic connectivity (b = 0.96, p= 0.008, [95%CI 0.25, 1.66]), no differences emerged for females. Fronto-limbic connectivity was related to somatic complaints in childhood only for males (r = 0.673, p = 0.006). Our findings suggest that CM could have intergenerational associations to offspring brain development, yet mechanistic studies are needed.

Adverse Childhood Experiences and Risk Patterns of Alcohol and Cannabis Co-Use: A Longitudinal Study of Puerto Rican Youth

PURPOSE

Adverse childhood experiences (ACEs) are common in Puerto Rican youths. Few large longitudinal studies of Latine youth examined what predicts co-use of alcohol and cannabis in late adolescence and young adulthood. We investigated the prospective association between ACEs with alcohol/cannabis co-use in Puerto Rican youth.

METHODS

Participants from a longitudinal study of Puerto Rican youth (n = 2,004) were included. Using multinomial logistic regressions to test associations between prospectively reported ACEs (11 types, reported by parents and/or children, categorized as 0-1, 2-3, and 4+ ACEs) with young adult alcohol/cannabis use patterns in the past month (i.e., no lifetime use, low-risk [no binge drinking and cannabis use < 10], binge-drinking only, regular cannabis use only, and alcohol/cannabis co-use). Models were adjusted for sociodemographic variables.

RESULTS

In this sample, 27.8% reported 4+ ACEs, 28.6% endorsed binge drinking, 4.9% regular cannabis use, and 5.5% alcohol/cannabis co-use. Compared to individuals with no lifetime use, those reporting 4+ (vs. 0-1) ACEs had greater odds of low-risk use (adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI] = 1.04-2.45), regular cannabis use (aOR 3.13 95% CI = 1.44-6.77), and alcohol/cannabis co-use (aOR 3.57, 95% CI = 1.89-6.75). In relation to low-risk use, reporting 4+ ACEs (vs. 0-1) was associated with 1.96 odds (95% CI = 1.01-3.78) of regular cannabis use and 2.24 odds (95% CI = 1.29-3.89) of alcohol/cannabis co-use.

DISCUSSION

Exposure to 4+ ACEs was associated with the occurrence of adolescent/young adulthood regular cannabis use and alcohol/cannabis co-use. Importantly, ACEs exposure differentiated young adults who were co-using compared to those engaged in low-risk use. Preventing ACE or interventions for Puerto Rican youth experiencing 4+ ACEs may mitigate negative consequences associated with alcohol/cannabis co-use.

The Environmental Influences on Child Health Outcomes (ECHO)-Wide Cohort

The Environmental Influences on Child Health Outcomes (ECHO)-Wide Cohort Study (EWC), a collaborative research design comprising 69 cohorts in 31 consortia, was funded by the National Institutes of Health (NIH) in 2016 to improve children's health in the United States. The EWC harmonizes extant data and collects new data using a standardized protocol, the ECHO-Wide Cohort Data Collection Protocol (EWCP). EWCP visits occur at least once per life stage, but the frequency and timing of the visits vary across cohorts. As of March 4, 2022, the EWC cohorts contributed data from 60,553 children and consented 29,622 children for new EWCP data and biospecimen collection. The median (interquartile range) age of EWCP-enrolled children was 7.5 years (3.7-11.1). Surveys, interviews, standardized examinations, laboratory analyses, and medical record abstraction are used to obtain information in 5 main outcome areas: pre-, peri-, and postnatal outcomes; neurodevelopment; obesity; airways; and positive health. Exposures include factors at the level of place (e.g., air pollution, neighborhood socioeconomic status), family (e.g., parental mental health), and individuals (e.g., diet, genomics).

Sociodemographic Differences in COVID-19 Pandemic Experiences Among Families in the United States

Importance

Few population-based studies in the US collected individual-level data from families during the COVID-19 pandemic.

Objective

To examine differences in COVID-19 pandemic-related experiences in a large sociodemographically diverse sample of children and caregivers.

Design, Setting, and Participants

The Environmental influences on Child Health Outcomes (ECHO) multi-cohort consortium is an ongoing study that brings together 64 individual cohorts with participants (24 757 children and 31 700 caregivers in this study) in all 50 US states and Puerto Rico. Participants who completed the ECHO COVID-19 survey between April 2020 and March 2022 were included in this cross-sectional analysis. Data were analyzed from July 2021 to September 2022.

Main Outcomes and Measures

Exposures of interest were caregiver education level, child life stage (infant, preschool, middle childhood, and adolescent), and urban or rural (population <50 000) residence. Dependent variables included COVID-19 infection status and testing; disruptions to school, child care, and health care; financial hardships; and remote work. Outcomes were examined separately in logistic regression models mutually adjusted for exposures of interest and race, ethnicity, US Census division, sex, and survey administration date.

Results

Analyses included 14 646 children (mean [SD] age, 7.1 [4.4] years; 7120 [49%] female) and 13 644 caregivers (mean [SD] age, 37.6 [7.2] years; 13 381 [98%] female). Caregivers were racially (3% Asian; 16% Black; 12% multiple race; 63% White) and ethnically (19% Hispanic) diverse and comparable with the US population. Less than high school education (vs master's degree or more) was associated with more challenges accessing COVID-19 tests (adjusted odds ratio [aOR], 1.88; 95% CI, 1.06-1.58), lower odds of working remotely (aOR, 0.04; 95% CI, 0.03-0.07), and more food access concerns (aOR, 4.14; 95% CI, 3.20-5.36). Compared with other age groups, young children (age 1 to 5 years) were least likely to receive support from schools during school closures, and their caregivers were most likely to have challenges arranging childcare and concerns about work impacts. Rural caregivers were less likely to rank health concerns (aOR, 0.77; 95% CI, 0.69-0.86) and social distancing (aOR, 0.82; 95% CI, 0.73-0.91) as top stressors compared with urban caregivers.

Conclusions

Findings in this cohort study of US families highlighted pandemic-related burdens faced by families with lower socioeconomic status and young children. Populations more vulnerable to public health crises should be prioritized in recovery efforts and future planning.

Acculturation and suicide-related risk in ethnoracially minoritized youth in the US: a scoping review and content analysis of the empirical evidence

PURPOSE

Among Asian-American/Pacific Islander, Hispanic/Latinx, and Black youth, the US born have higher risk of suicidal thoughts and behaviors (attempts and death-by-suicide) than first-generation migrants. Research has focused on the role of acculturation, defined as the sociocultural and psychological adaptations from navigating multiple cultural environments.

METHODS

Using content analysis, we conducted a scoping review on acculturation-related experiences and suicide-related risk in Asian-American/Pacific Islander, Hispanic/Latinx, and Black youth (henceforth described as "ethnoracially minoritized adolescents"), identifying 27 empirical articles in 2005-2022.

RESULTS

Findings were mixed: 19 articles found a positive association between acculturation and higher risk for suicide ideation and attempts, namely when assessed as acculturative stress; 3 articles a negative association; and 5 articles no association. Most of the research, however, was cross-sectional, largely focused on Hispanic/Latinx youth, relied on demographic variables or acculturation-related constructs as proxies for acculturation, used single-item assessments for suicide risk, and employed non-random sampling strategies. Although few articles discussed the role of gender, none discussed the intersections of race, sexual orientation, or other social identities on acculturation.

CONCLUSION

Without a more developmental approach and systematic application of an intersectional research framework that accounts for racialized experiences, the mechanisms by which acculturation may influence the risk of suicidal thoughts and behavior remain unclear, resulting in a dearth of culturally responsive suicide-prevention strategies among migrant and ethnoracially minoritized youth.

Association of sociocultural stressors with bipolar disorder onset in Puerto Rican youth growing up as members of a minoritized ethnic group: results from the Boricua Youth Longitudinal Study

Background

The development of bipolar disorder is currently explained by a complex interaction of genetic and environmental factors. Less is known regarding the influence of sociocultural factors. This study aims to evaluate the incidence and impact of sociocultural factors on bipolar disorder onset in two comparable samples of youth growing up in different social settings.

Methods

We leveraged data from two urban population-based cohorts representative of Puerto Rican children growing up in either San Juan (Puerto Rico) or the South Bronx (NYC) and followed up for 17 years. Bipolar disorder diagnoses were based on retrospective self-reports on the World Health Organization Composite International Diagnostic Interview. We used a causal inference approach to estimate associations of sociocultural factors with bipolar disorder onset after adjusting for potential confounders.

Findings

We found that South Bronx children, who grew up as a minoritized group, had twice the risk of bipolar disorder onset as young adults, with an incidence rate of 2.22 new cases per 1000 person-years compared to 1.08 new cases in San Juan (incidence rate difference, 1.13; 95% CI, 0.09-1.20). After adjusting for potential confounders, South Bronx children had the same lifetime hazard of bipolar disorder onset compared to San Juan children. However, our analysis demonstrated that caregivers' exposure to societal cultural stress partially explained the increased risk of bipolar disorder onset in the South Bronx, in addition to the potential contribution of genetics.

Interpretation

Our results provide evidence that societal cultural stress can increase the risk of lifetime bipolar disorder onset in youth growing up as a minoritized group. Addressing stress in minoritized groups might reduce the risk of bipolar disorder onset.

Funding

The Boricua Youth Study has been supported by the National Institutes of HealthMH56401, MH098374, DA033172, and AA020191. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

Developing a National-Scale Exposure Index for Combined Environmental Hazards and Social Stressors and Applications to the Environmental Influences on Child Health Outcomes (ECHO) Cohort

Tools for assessing multiple exposures across several domains (e.g., physical, chemical, and social) are of growing importance in social and environmental epidemiology because of their value in uncovering disparities and their impact on health outcomes. Here we describe work done within the Environmental influences on Child Health Outcomes (ECHO)-wide Cohort Study to build a combined exposure index. Our index considered both environmental hazards and social stressors simultaneously with national coverage for a 10-year period. Our goal was to build this index and demonstrate its utility for assessing differences in exposure for pregnancies enrolled in the ECHO-wide Cohort Study. Our unitless combined exposure index, which collapses census-tract level data into a single relative measure of exposure ranging from 0-1 (where higher values indicate higher exposure to hazards), includes indicators for major air pollutants and air toxics, features of the built environment, traffic exposures, and social determinants of health (e.g., lower educational attainment) drawn from existing data sources. We observed temporal and geographic variations in index values, with exposures being highest among participants living in the West and Northeast regions. Pregnant people who identified as Black or Hispanic (of any race) were at higher risk of living in a "high" exposure census tract (defined as an index value above 0.5) relative to those who identified as White or non-Hispanic. Index values were also higher for pregnant people with lower educational attainment. Several recommendations follow from our work, including that environmental and social stressor datasets with higher spatial and temporal resolutions are needed to ensure index-based tools fully capture the total environmental context.

Maternal Mental Health and Offspring Brain Development: An Umbrella Review of Prenatal Interventions

The idea that risk for psychiatric disorders may be transmitted intergenerationally via prenatal programming places interest in the prenatal period as a critical moment during which intervention efforts may have a strong impact, yet studies testing whether prenatal interventions also protect offspring are limited. The present umbrella review of systematic reviews and meta-analyses (SRMAs) of randomized controlled trials aimed to synthesize the available evidence and highlight promising avenues for intervention. Overall, the literature provides mixed and limited evidence in support of prenatal interventions. Thirty SRMAs were included. Of the 23 SRMAs that reported on prenatal depression interventions, 16 found a significant effect (average standard mean difference = -0.45, SD = 0.25). Similarly, 13 of the 20 SRMAs that reported on anxiety outcomes documented significant reductions (average standard mean difference = -0.76, SD = 0.95 or -0.53/0.53 excluding one outlier). Only 4 SRMAs reported child outcomes, and only 2 (of 10) analyses showed significant effects of prenatal interventions (massage and telephone support on neonatal resuscitation [relative risk = 0.43] and neonatal intensive care unit admissions [relative risk = 0.91]). Notably missing, perhaps due to our strict inclusion criteria (inclusion of randomized controlled trials only), were interventions focusing on key facets of prenatal health (e.g., whole diet, sleep). Structural interventions (housing, access to health care, economic security) were not included, although initial success has been documented in non-SRMAs. Most notably, none of the SRMAs focused on offspring mental health or neurodevelopmental outcomes. Given the possibility that interventions deployed in this period will positively impact the next generation, randomized trials that focus on offspring outcomes are urgently needed.

Association between mental disorders and adherence to antiretroviral treatment in health facilities in two Mozambican provinces in 2018: a cross-sectional study

INTRODUCTION

Lower adherence to antiretroviral treatment (ART) has been found among people with HIV (PWH) who have comorbid mental disorders like depression and alcohol use in Sub-Saharan African. However, there has been less exploration with regards to other mental disorders.

METHODS

This study assessed the association of multiple mental disorders and adherence to ART based on the data from primary/tertiary health care facilities in Maputo and Nampula, Mozambique. We administered a sociodemographic questionnaire, Mini International Neuropsychiatric Interview (MINI) Plus 4.0.0 adapted for use in Mozambique to assess mental conditions, and a 3-item self-report to measure ART adherence.

RESULTS

395 HIV-positive (self-report) participants on ART, with an average age of 36.7 years (SD = 9.8), and 30.4% were male. The most common mental disorders were major depressive disorder (27.34%) followed by psychosis (22.03%), suicidal ideation/behavior (15.44%), and alcohol-use disorder (8.35%). Higher odds of missing at least one dose in the last 30 days (OR = 1.45, 95% CI: 1.01, 2.10) were found in participants with any mental disorder compared to those without a mental disorder. The highest levels of non-adherence were observed among those with drug use disorders and panic disorder.

CONCLUSIONS

In Mozambique, PWH with any co-occurring mental conditions had a lower probability of ART adherence. Integrating comprehensive mental health assessment and treatment and ART adherence interventions tailored to PWH with co-occurring mental disorders is necessary to attain optimal ART adherence and reach the UNAIDS ART target.

Does It Matter What Screener We Use? A Comparison of Ultra-brief PHQ-4 and E-mwTool-3 Screeners for Anxiety and Depression Among People With and Without HIV

The burden of depression and anxiety disorders is high in sub-Saharan Africa, especially for people with HIV (PWH). The Patient Health Questionnaire-4 (PHQ-4) and Electronic Mental Wellness Tool-3 (E-mwTool-3) are ultra-brief screening tools for these disorders. We compared the performance of PHQ-4 and E-mwTool-3 for screening MINI-International Neuropsychiatric Interview diagnoses of depression and anxiety among a sample of individuals with and without HIV in two primary care clinics and one general hospital in Maputo City, Mozambique. Areas-under-the-curve (AUC) were calculated along with sensitivities and specificities at a range of cutoffs. For PWH, at a sum score cutoff of ≥ 1, sensitivities were strong: PHQ-4:Depression = 0.843; PHQ-4:Anxiety = 0.786; E-mwTool-3:Depression = 0.843; E-mwTool-3:Anxiety = 0.929. E-mwTool-3 performance was comparable to PHQ-4 among people with and without HIV.

Changes in Body Mass Index Among School-Aged Youths Following Implementation of the Healthy, Hunger-Free Kids Act of 2010

Importance

The prevalence of obesity among youths 2 to 19 years of age in the US from 2017 to 2018 was 19.3%; previous studies suggested that school lunch consumption was associated with increased obesity. The Healthy, Hunger-Free Kids Act of 2010 (HHFKA) strengthened nutritional standards of school-based meals.

Objective

To evaluate the association between the HHFKA and youth body mass index (BMI).

Design, Setting, and Participants

This cohort study was conducted using data from the Environmental Influences on Child Health Outcomes program, a nationwide consortium of child cohort studies, between January 2005 and March 2020. Cohorts in the US of youths aged 5 to 18 years with reported height and weight measurements were included.

Exposures

Full implementation of the HHFKA.

Main Outcomes and Measures

The main outcome was annual BMI z-score (BMIz) trends before (January 2005 to August 2016) and after (September 2016 to March 2020) implementation of the HHFKA, adjusted for self-reported race, ethnicity, maternal education, and cohort group. An interrupted time-series analysis design was used to fit generalized estimating equation regression models.

Results

A total of 14 121 school-aged youths (7237 [51.3%] male; mean [SD] age at first measurement, 8.8 [3.6] years) contributing 26 205 BMI measurements were included in the study. Overall, a significant decrease was observed in the annual BMIz in the period following implementation of the HHFKA compared with prior to implementation (-0.041; 95% CI, -0.066 to -0.016). In interaction models to evaluate subgroup associations, similar trends were observed among youths 12 to 18 years of age (-0.045; 95% CI, -0.071 to -0.018) and among youths living in households with a lower annual income (-0.038; 95% CI, -0.063 to -0.013).

Conclusions and Relevance

In this cohort study, HHFKA implementation was associated with a significant decrease in BMIz among school-aged youths in the US. The findings suggest that school meal programs represent a key opportunity for interventions to combat the childhood obesity epidemic given the high rates of program participation and the proportion of total calories consumed through school-based meals.

Perinatal Outcomes during versus Prior to the COVID-19 Pandemic and the Role of Maternal Depression and Perceived Stress: A Report from the ECHO Program

OBJECTIVE

 We sought to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on perinatal outcomes while accounting for maternal depression or perceived stress and to describe COVID-specific stressors, including changes in prenatal care, across specific time periods of the pandemic.

STUDY DESIGN

 Data of dyads from 41 cohorts from the National Institutes of Health Environmental influences on Child Health Outcomes Program (N = 2,983) were used to compare birth outcomes before and during the pandemic (n = 2,355), and a partially overlapping sample (n = 1,490) responded to a COVID-19 questionnaire. Psychosocial stress was defined using prenatal screening for depression and perceived stress. Propensity-score matching and general estimating equations with robust variance estimation were used to estimate the pandemic's effect on birth outcomes.

RESULTS

 Symptoms of depression and perceived stress during pregnancy were similar prior to and during the pandemic, with nearly 40% of participants reporting mild to severe stress, and 24% reporting mild depression to severe depression. Gestations were shorter during the pandemic (B =  - 0.33 weeks, p = 0.025), and depression was significantly associated with shortened gestation (B =  - 0.02 weeks, p = 0.015) after adjustment. Birth weights were similar (B =  - 28.14 g, p = 0.568), but infants born during the pandemic had slightly larger birth weights for gestational age at delivery than those born before the pandemic (B = 0.15 z-score units, p = 0.041). More women who gave birth early in the pandemic reported being moderately or extremely distressed about changes to their prenatal care and delivery (45%) compared with those who delivered later in the pandemic. A majority (72%) reported somewhat to extremely negative views of the impact of COVID-19 on their life.

CONCLUSION

 In this national cohort, we detected no effect of COVID-19 on prenatal depression or perceived stress. However, experiencing the COVID-19 pandemic in pregnancy was associated with decreases in gestational age at birth, as well as distress about changes in prenatal care early in the pandemic.

KEY POINTS

· COVID-19 was associated with shortened gestations.. · Depression was associated with shortened gestations.. · However, stress during the pandemic remained unchanged.. · Most women reported negative impacts of the pandemic..

Impact of sedentary behavior and emotional support on prenatal psychological distress and birth outcomes during the COVID-19 pandemic

Abstract.

BACKGROUND

Studies have reported mixed findings regarding the impact of the coronavirus disease 2019 (COVID-19) pandemic on pregnant women and birth outcomes. This study used a quasi-experimental design to account for potential confounding by sociodemographic characteristics.

METHODS

Data were drawn from 16 prenatal cohorts participating in the Environmental influences on Child Health Outcomes (ECHO) program. Women exposed to the pandemic (delivered between 12 March 2020 and 30 May 2021) (n = 501) were propensity-score matched on maternal age, race and ethnicity, and child assigned sex at birth with 501 women who delivered before 11 March 2020. Participants reported on perceived stress, depressive symptoms, sedentary behavior, and emotional support during pregnancy. Infant gestational age (GA) at birth and birthweight were gathered from medical record abstraction or maternal report.

RESULTS

After adjusting for propensity matching and covariates (maternal education, public assistance, employment status, prepregnancy body mass index), results showed a small effect of pandemic exposure on shorter GA at birth, but no effect on birthweight adjusted for GA. Women who were pregnant during the pandemic reported higher levels of prenatal stress and depressive symptoms, but neither mediated the association between pandemic exposure and GA. Sedentary behavior and emotional support were each associated with prenatal stress and depressive symptoms in opposite directions, but no moderation effects were revealed.

CONCLUSIONS

There was no strong evidence for an association between pandemic exposure and adverse birth outcomes. Furthermore, results highlight the importance of reducing maternal sedentary behavior and encouraging emotional support for optimizing maternal health regardless of pandemic conditions.

Emotional contagion behavior in a group of young girls in a secondary school in Maputo, Mozambique

BACKGROUND

Emotional Contagion Behavior (ECB), the synchronized expression of emotional symptoms among members of a group, has been observed globally. In Mozambique, there have been numerous reports of ECB in recent years. Since 2010 several girls from a secondary school in Maputo City, Mozambique exhibited ECB which involved repeated fainting spells, sometimes including verbal aggression and threats to colleagues and teachers. We conducted a study to analyze sociodemographic and clinical characteristics associated with ECB.

METHODS

This cross-sectional study included 154 females aged from 16 to 24 years old. We considered emotional contagion behavior as repeated fainting spells, sometimes including verbal aggression and threats to others (colleagues and teachers). Participants responded to a sociodemographic questionnaire, the Beck Anxiety Scale, and the revised Eysenck Personality Questionnaire (EPQ-R). Bivariate and multivariate logistic regression models analyzed sociodemographic and clinical characteristics associated with EBC.

RESULTS

Among study participants, 57 presented ECB and 97 did not. The likelihood of ECB was higher among those with previous history of ECB (OR = 8.28, 95% CI [2.51, 27.30]; p ⩽ .001) and extroverted personality profile (OR = 1.15, 95% CI [1.01, 1.30]; p = .038). Having a romantic relationship was related to lower likelihood of having ECB (OR = 0.04, 95% CI [0.01, 0.19]; p = .001).

CONCLUSIONS

These results suggest that ECB may repeat over time and be related to challenges pertaining to personality development, the presence of sexual life, and close relationships with peers faced by adolescent girls.

Intergenerational transmission of the effects of maternal exposure to childhood maltreatment in the USA: a retrospective cohort study

BACKGROUND

Childhood maltreatment is associated with adverse health outcomes and this risk can be transmitted to the next generation. We aimed to investigate the association between exposure to maternal childhood maltreatment and common childhood physical and mental health problems, neurodevelopmental disorders, and related comorbidity patterns in offspring.

METHODS

We conducted a retrospective cohort study using data from the Environmental influences on Child Health Outcomes (ECHO) Program, which was launched to investigate the influence of early life exposures on child health and development in 69 cohorts across the USA. Eligible mother-child dyads were those with available data on maternal childhood maltreatment exposure and at least one child health outcome measure (autism spectrum disorder, attention-deficit hyperactivity disorder [ADHD], internalising problems, obesity, allergy, and asthma diagnoses). Maternal history of childhood maltreatment was obtained retrospectively from the Adverse Childhood Experiences or Life Stressor Checklist questionnaires. We derived the prevalence of the specified child health outcome measures in offspring across childhood and adolescence by harmonising caregiver reports and other relevant sources (such as medical records) across cohorts. Child internalising symptoms were assessed using the Child Behavior Checklist. Associations between maternal childhood maltreatment and childhood health outcomes were measured using a series of mixed-effects logistic regression models. Covariates included child sex (male or female), race, and ethnicity; maternal and paternal age; maternal education; combined annual household income; maternal diagnosis of depression, asthma, ADHD, allergy, or autism spectrum disorder; and maternal obesity. Two latent class analyses were conducted: to characterise patterns of comorbidity of child health outcomes; and to characterise patterns of co-occurrence of childhood maltreatment subtypes. We then investigated the association between latent class membership and maternal childhood maltreatment and child health outcomes, respectively.

FINDINGS

Our sample included 4337 mother-child dyads from 21 longitudinal cohorts (with data collection initiated between 1999 and 2016). Of 3954 mothers in the study, 1742 (44%) had experienced exposure to abuse or neglect during their childhood. After adjustment for confounding, mothers who experienced childhood maltreatment were more likely to have children with internalising problems in the clinical range (odds ratio [OR] 2·70 [95% CI 1·95-3·72], p<0·0001), autism spectrum disorder (1·70 [1·13-2·55], p=0·01), ADHD (2·09 [1·63-2·67], p<0·0001), and asthma (1·54 [1·34-1·77], p<0·0001). In female offspring, maternal childhood maltreatment was associated with a higher prevalence of obesity (1·69 [1·17-2·44], p=0·005). Children of mothers exposed to childhood maltreatment were more likely to exhibit a diagnostic pattern characterised by higher risk for multimorbidity. Exposure to multiple forms of maltreatment across all subtypes of maternal childhood maltreatment was associated with the highest risk increases for most offspring health outcomes, suggesting a dose-response relationship.

INTERPRETATION

Our findings suggest that maternal childhood maltreatment experiences can be a risk factor for disease susceptibility in offspring across a variety of outcomes and emphasise the need for policies focusing on breaking the intergenerational transmission of adversity.

FUNDING

Environmental influences on Child Health Outcomes Program, Office of the Director, National Institutes of Health.

Development, religious affiliation, and social context: Substance use disorders in Puerto Rican transitional age youth

Introduction

Transitional age youth (i. e., ages 16-24; TAY) use higher levels of substances than any age group in the United States. Understanding what factors increase substance use during TAY could suggest novel targets for prevention/intervention. Studies suggest that religious affiliation is inversely associated with substance use disorders (SUDs). However, the association of religious affiliation and SUD, including the role of gender and social context, has not been studied in TAY of Puerto Rican ethnicity.

Methods

Using data from N = 2,004 TAY of Puerto Rican ethnicity across two social contexts-Puerto Rico (PR) and the South Bronx, NY (SBx)-we tested the association of religious identity (Catholic, Non-Catholic Christian, Other/Mixed, and no religious affiliation, or "None"), and four SUD outcomes (alcohol use disorder, tobacco use disorder, illicit SUD, and any SUD). Logistic regression models were used to examine the association between religious identity and SUDs, then we tested for interaction by social context and gender.

Result

Half the sample identified as female; 30, 44, and 25% were 15-20, 21-24, and 25-29 years of age, respectively; 28% of the sample received public assistance. There was a statistically significant difference between sites for public assistance (22 and 33% in SBx/PR, respectively; p < 0.001); 29% of the sample endorsed None (38 and 21% in SBx/PR, respectively.) Compared to None, identifying as Catholic was associated with reduced risk of illicit SUD (OR = 0.51, p = 0.02), and identifying as Non-Catholic Christian with reduced risk for any SUD (OR = 0.68, p = 0.04). Additionally, in PR but not SBx, being Catholic or Non-Catholic Christian was protective for illicit SUD when compared to None (OR = 0.13 and 0.34, respectively). We found no evidence of an interaction between religious affiliation and gender.

Discussion

The percentage of PR TAY who endorse no affiliation is higher than the general PR population, reflective of increasing religious non-affiliation among TAY across cultures. Critically, TAY with no religious affiliation are twice as likely as Catholics to have illicit SUD, and 1.5 times as likely as Non-Catholic Christians to have any SUD. Endorsing no affiliation is more adverse for illicit SUD in PR than the SBx, underscoring the importance of social context.

Parental suicide attempts and offspring's risk of attempting or dying by suicide: does the timing of a parental suicide attempt matter?

BACKGROUND

Studies on the transmission of suicide risk have focused on parental history of suicide attempts (SAs), overlooking when the attempt happened. This study examined how the offspring's risk of attempting or dying by suicide varied by the timing of a first parental SA and the sex of the parent who attempted suicide.

METHODS

Participants were 59 469 members of the 1987 Finnish Birth Cohort. The Finnish Hospital Discharge and Cause of Death Registers were the sources for parental and offspring SAs and offspring suicide. Timing of parental SA was coded as before (pre-pregnancy and pregnancy) and after the child's birth [infant/toddler years (0-2 years), childhood (3-11 years), adolescence (12-17 years), and young adulthood (18-26 years)].

RESULTS

In the multivariate models, having a parent who attempted suicide increased the offspring's risk of attempting suicide (odds ratio (OR) = 1.77, 95% confidence interval (CI) 1.39-2.25), but not of dying by suicide. Compared to unexposed offspring, those exposed after child's birth were at higher risk of attempting suicide (OR = 1.90, 95% CI 1.46-2.47), specifically when the parent attempted during offspring's childhood, adolescence, and young adulthood. A first maternal SA increased offspring's risk of attempting suicide regardless of the timing.

CONCLUSIONS

The impact of a parental SA on offspring's risk of attempting suicide differed depending on the timing and sex of the parent who attempted suicide, suggesting that the transmission of suicide risk may occur through genetic as well as environmental factors. Our findings call for an intergenerational approach in suicide risk assessment.

A Multi-Site Study of Mental Disorders in the Mozambican Health Care System

In Mozambique, human and financial resources for public mental health services are extremely limited. Understanding the mental health needs of those seeking healthcare can inform efficient targeting of mental health services. We examined if the frequency of mental disorders in a health facility varied based on the level of specialization of such facility, from primary care without mental health specialists (PrCMH -), to those with mental health specialists (PrCMH +) and tertiary care (TerC), where both inpatient and outpatient mental health services are available. Participants were adults (convenience sample) seeking health or mental health services at six facilities (2 PrCMH + , 3 PrCMH -, and 1 TerC) in the cities of Maputo and Nampula in Mozambique. Mental disorders were assessed by the MINI International Neuropsychiatric Interview (MINI) 4.0.0. We compared the sociodemographic characteristics and MINI diagnoses across the three types of health facilities. Multiple logistic regression models determined the likelihood that a person seeking services at each type of facility would have any mental disorder, common mental disorders (CMD), severe mental disorders (SMD), substance use disorders (SUD), and moderate-to-high suicide risk, adjusting for sociodemographic factors. Of the 612 total participants, 52.6% (n = 322) were positive for at least one mental disorder: 37.1% were positive for CMD, 28.9% for SMD, 13.2% for SUD, and 10.5% had suicide risk. Presence of any mental disorder was highest in TerC (62.5%) and lowest in PrCMH - (48.4%). Adjusting for sociodemographic covariates, participants in PrCMH + were significantly more likely to have SMD (OR 1.85, 95%CI 1.10-3.11) and SUD (OR 2.79, 95%CI 1.31-5.94) than participants in PrCMH -; participants in TerC were more likely to have CMD (OR 1.70, 95%CI 1.01-2.87) and SUD (OR 2.57, 95%CI 1.14-5.79) than in PrCMH -. Suicide risk was the only condition that did not differ across facility types. As anticipated, people with mental disorders were more likely to be cared for at facilities with mental health specialists. However, our study detected in this convenience sample a remarkably high frequency of mental disorders across different types of facilities within the Mozambican healthcare system. These results, if confirmed in representative samples, suggest a need to increase mental health services at the primary care level.

Does Context and Adversity Shape Sexual Behavior in Youth? Findings from Two Representative Samples of Puerto Rican Youth

Sexual risk behaviors often co-occur. Understanding the heterogeneity in patterns of sexual behavior among youth and how context of majority and minoritized status may be related to these behaviors can inform targeted STIs/HIV interventions. Data are from the Boricua Youth Study, a longitudinal study of two probability samples of Puerto Rican youth recruited in the South Bronx (SBx) and the metropolitan area in Puerto Rico (PR). We identified patterns of sexual behaviors among young adults (ages 15-24) with sexual experience (N = 1,203) using latent class analysis. Analyses examined context differences and the prospective relationship between adverse childhood experiences (ACEs) (childhood maltreatment/violence, family/parental dysfunction) and patterns of sexual behaviors (age at first sex, number of sex partners, sex with a high-risk partner, condom use, sex while intoxicated, oral sex, anal sex). We identified five classes of sexual behaviors: (1) currently inactive (16.51%); (2) single partner, low activity (13.49%); (3) single partner, inconsistent condom use (32.19%); (4) single partner, sex without a condom (27.65%); and (5) multirisk (10.16%). Young adults from the SBx (minoritized context), those who identified as male, and those with higher child maltreatment/violence ACEs were more likely to be in the multi-risk class relative to the single partner, inconsistent condom use class. Those from the SBx were also more likely to be in the single partner, sex without condom class, relative to the single partner, inconsistent condom use class. Differences in young adults' patterns of sexual behaviors between the two contexts, one representing the minoritized context (SBx) contrasted to the majority context (PR), were not explained by ACEs. Findings highlight the heterogeneity in the patterns of sexual behaviors among Puerto Rican young adults as well as how such patterns vary based on sociocultural contexts. Exposure to child maltreatment/violence ACEs was related to the riskier patterns; however, they did not explain why riskier patterns of sexual behaviors were found in the SBx compared to PR. Results underscore the need for tailored interventions and more in-depth examination of differences across contexts.

Parental suicide attempts and offspring mental health problems in childhood and adolescence

BACKGROUND

The relationship between parental suicide attempts and offspring suicide risk has been established. However, the impact of parental suicide attempts on mental health problems in offspring as youth remains unexplored. This study examined the prospective association between parental suicide attempts and offspring internalizing, externalizing, and attention/hyperactivity problems in childhood and adolescence. We also examined how offspring mental health problems in childhood mediated the association between parental suicide attempts and offspring mental health problems in adolescence.

METHODS

A subsample of 6,381 (48.4% female) cohort members with complete data on mental health problems in childhood and adolescence was extracted from the Northern Finland Birth Cohort 1986 Study. Offspring mental health problems were assessed via teacher's Rutter B2 scale during the childhood assessment (child's age of 8) and the Youth Self-Report scale (child's age of 15/16). Information about first parental suicide attempts was collected using ICD codes from hospital discharge records.

RESULTS

Lifetime parental suicide attempts during the study period (N = 95) were associated with offspring internalizing, externalizing, and attention/hyperactivity problems in adolescence. Parental suicide attempts before the childhood assessment (N = 55) were associated with offspring behavioral problems in childhood [B (95% CI) = .64 (0.08-1.28)]. In the mediation models, parental suicide attempts before the childhood assessment had a significant indirect effect on offspring externalizing [B (95% CI) = .03 (0.01-0.05)] and attention/hyperactivity problems [B (95% CI) = .02 (0.01-0.04)] in adolescence via offspring behavioral problems in childhood.

CONCLUSIONS

Our findings highlight the importance of assessing and monitoring mental health problems in offspring whose parents have been hospitalized for attempting suicide. Among children with behavioral problems, clinicians should inquire about parental history of suicide attempts, as children with familial vulnerability to suicide may develop externalizing and attention/hyperactivity problems in adolescence.

Community Health Workers' Knowledge, Attitudes, and Practices towards Epilepsy in Sofala, Central Mozambique

BACKGROUND

Epilepsy is the most common neurological disease in the world, affecting 50 million people, with the majority living in low- and middle-income countries (LMICs). A major focus of epilepsy treatment in LMICs has been task-sharing the identification and care for epilepsy by community health workers (CHWs). The present study aimed to assess the knowledge, attitudes, and practices (KAPs) of CHWs towards epilepsy in Mozambique.

METHODS

One hundred and thirty-five CHWs completed a questionnaire that included socio-demographic characteristics and 44-items divided into six subscales pertaining to KAPs towards epilepsy (QKAP-EPI) across nine districts of Sofala, Mozambique. The internal consistency was examined to evaluate the reliability of the instrument (QKAP-EPI). The association between sociodemographic variables and QKAP-EPI subscales was examined using linear regression models.

RESULTS

The internal consistency was moderate for two subscales (causes of epilepsy, α = 0.65; medical treatment, α = 0.694), acceptable for cultural treatment (α = 0.797) and excellent for 2 subscales (safety and risks, α = 0.926; negative attitudes, α = 0.904). Overall, CHWs demonstrated accurate epilepsy knowledge (medical treatment: mean = 1.63, SD = 0.28; safety/risks: mean = 1.62, SD = 0.59). However, CHWs reported inaccurate epilepsy knowledge of the causes, negative attitudes, as well as culturally specific treatments for epilepsy, such as: "if a person with epilepsy burns when set on fire they cannot be treated". Knowledge about how to manage epileptic seizures varied across the different emergency care practices, from the accurate belief that it is not advisable to place objects in the individual's mouth during an epileptic seizure, to the wrong perception of the need to hold the person in seizures to control seizures. Heterogeneity in the level of epilepsy knowledge was observed among CHWs, when considering epilepsy according to the local names as treatable ("Dzumba") and other forms as untreatable ("Nzwiti").

CONCLUSION

CHWs knowledge of medical treatment and epilepsy safety/risks were adequate. However, information on the causes of epilepsy, stigmatizing attitudes, cultural treatment, and some knowledge of epileptic seizure management were low. These areas of poor knowledge should be the focus of educating CHWs in increasing their ability to provide quality care for patients with epilepsy in Mozambique.

Lay HIV counselors' knowledge and attitudes toward depression: A mixed-methods cross-sectional study at primary healthcare centers in Mozambique

Introduction

Depression is the most common mental disorder among people living with HIV/AIDS and has a negative impact on HIV treatment outcomes. Training lay HIV counselors to identify and manage depression may contribute to improved patient access and adherence to treatment, and reduce stigma and discrimination among lay health workers toward both HIV and depression. The purpose of this study was to assess the current knowledge and attitudes of lay HIV counselors toward managing depression in primary care in Mozambique.

Methods

We conducted a mixed-methods cross-sectional study to assess depression-related knowledge and attitudes among lay HIV counselors in 13 primary healthcare facilities in Mozambique. We used the quantitative Depression Attitude Questionnaire (DAQ) scale, followed by open-ended questions to further explore three key DAQ domains: the nature of depression, treatment preferences, and professional attitudes or reactions.

Results

The sample included 107 participants (77.6% female, mean age: 32.3 years, sd = 7.4). Most (82.2%) had less than a high/technical school education. Findings suggested that some HIV counselors had knowledge of depression and described it as a cluster of psychological symptoms (e.g., deep sadness, anguish, apathy, isolation, and low self-esteem) sometimes leading to suicidal thoughts, or as a consequence of life stressors such as loss of a loved one, abuse, unemployment or physical illness, including being diagnosed with HIV infection. HIV counselors identified talking to trusted people about their problems, including family and/or counseling with a psychotherapist, as the best way for patients to deal with depression. While acknowledging challenges, counselors found working with patients with depression to be rewarding.

Conclusion

Lay health counselors identified HIV and psychosocial issues as key risk factors for depression. They believed that the treatment approach should focus on social support and psychotherapy.

Adverse childhood experiences and perceived stress in early adulthood in the context of disadvantage

BACKGROUND

Adverse childhood experiences (ACEs) may sensitize individuals to view situations in adulthood as more stressful, which may contribute to poor health outcomes. In populations facing disadvantage, ACEs may lead to the accumulation of stressors (stress proliferation or mediation hypothesis) throughout the life course. ACEs could also heighten perceived stress later in life due to its enduring impact (stress sensitization or effect modification hypothesis).

OBJECTIVE

We examine the associations between ACEs and perceived stress in early adulthood, considering concurrent life stressors, in a longitudinal cohort of Puerto Rican youth exposed to a high degree of disadvantage.

PARTICIPANTS AND SETTING

A community-based sample of 1626 Puerto Rican children living in disadvantaged contexts was followed longitudinally in the Boricua Youth Study from 2000 to 2017.

METHODS

ACEs were measured prospectively during childhood (<18 yrs), and life stressors and past year perceived stress were measured in early adulthood (EA; mean age = 23.4, sd 2.22). Causal mediation analysis tested ACEs' effects on EA perceived stress indirectly through life stressors including potential effect modification.

RESULTS

ACEs influenced perceived stress in EA (standardized total effect = 0.13, p < .001) with 35% mediated by increased exposure to life stressors in EA due to ACEs. There was no evidence of increased sensitization to EA life stressors among those with higher ACEs exposure.

CONCLUSIONS

ACEs contribute to perceived stress in EA, albeit with small effect, partially through accumulating effects of ongoing stressors, supporting the stress proliferation hypothesis. Policies aimed at reducing exposure to adversity from childhood to EA are needed to reduce the experience of ACEs and negative sequelae.

Validation of brief screening instruments for internalizing and externalizing disorders in Mozambican adolescents

BACKGROUND

Mental disorders are the leading cause of disability for youth worldwide. However, there is a dearth of validated, brief instruments to assess mental health in low- and middle-income countries (LMIC). We aimed to facilitate identification of mental disorders in LMIC contexts by adapting and validating measures of internalizing and externalizing disorders for adolescents in Mozambique, an LMIC in southeastern Africa.

METHODS

We selected instruments with good support for validity in high-income and other LMIC settings: the Patient Health Questionnaire Adolescent (PHQ-A), Generalized Anxiety Disorders 7 (GAD-7), and Strengths and Difficulties Questionnaire (SDQ). Instruments were adapted by local and international mental health specialists followed by cognitive interviews (n = 48) with Mozambican adolescents. We administered the instruments along with the Miniature International Neuropsychiatric Interview for Children and Adolescents (MINI-KID)to 485 adolescents aged 12-19 years attending two secondary schools in Maputo City, Mozambique. One week later, we re-administered instruments to a randomly selected sample of 49 adolescents.

RESULTS

Participants were 66.2% (n = 321) female and the average age was 15.9 (S.D = 1.7).Internal consistency (alpha = 0.80, PHQ-A; 0.84, GAD-7; 0.80, SDQ) and test-retest reliabilty (ICC = 0.74, PHQ-A; 0.70, GAD-7; 0.77, SDQ) were acceptabe for the PHQ-A, GAD-7, and the full SDQ. The SDQ internalizing subscale showed poor test-retest reliability (ICC = 0.63) and the SDQ externalizing subscale showed poor internal consistency (alpha = 0.65). All instruments demonstrated good sensitivity and specificity (> 0.70). Youden's index identified optimal cutoff scores of 8 for the PHQ-A, 5 for the GAD-7, 10 for the SDQ internalizing and 9 for the SDQ externalizing subscales, though a range of scores provided acceptable sensitivity and specificity.

CONCLUSIONS

Our data supports reliability and validity of the PHQ-A, GAD-7, and SDQ instruments for rapidly assessing mental health problems in Mozambican adolescents. Use of these tools in other contexts with limited specialists may asist with expanding mental health assessment. Specific instrument and cutoff selection should be based on screening goals, treatment resources, and program objectives.

The positive impact of maternal depression intervention on children's emotional and behavioral symptoms in a low-resource setting

OBJECTIVE

Children of depressed mothers are at risk of developing mental health problems. We sought to determine whether treatment for maternal depression delivered by community health workers (CHW) would decrease behavioral/emotional symptoms in their child. An intervention treating maternal depressive symptoms in a low-middle-income country can have a high global impact.

METHODS

CHW were trained to deliver a psychosocial intervention for mothers with depression in a primary care setting. 49 mothers and 60 children were assessed pre-intervention, post-intervention, and at a 6-months follow-up. Child behavioral/emotional symptoms were evaluated by type of change in maternal depressive symptoms: remission and response.

RESULTS

An overall decrease in maternal depressive symptoms from baseline to post-intervention and 6-month follow-up were found. Remission and response of maternal depression was associated with better outcomes related to child´s behavioral/emotional symptoms at the 6-month follow-up (p = 0.0247, Cohen's d: 0.76; p = 0.0224, Cohen's f: 0.44) but not at post-intervention (p = 0.1636, Cohen's d: 0.48; p = 0.0720, Cohen's f: 0.33).

CONCLUSION

Maternal depression improvement was related to their child's decreased behavioral/emotional symptoms. Our results suggest that interventions addressing maternal depression in primary care is a viable strategy to prevent behavioral/emotional symptoms in the next generation.

Social and Psychiatric Factors of Suicidal Thoughts and Behaviors in Mozambican Adolescents

Globally, suicide is the second leading cause of death for youth ages 10-24 years, and more than 75% of all deaths by suicide occur in low- and middle-income countries (LMIC).1 Suicidal thoughts (ST) and suicidal behaviors (SB), valuable signals for early detection and prevention of suicide deaths, have been associated with a number of different factors in adolescents, including gender and age, socioeconomic status, exposure to childhood adversity, and psychopathology.2 However, research has largely focused on Western, White populations from high-income countries (HIC).2 To lessen the suicide burden among adolescents in LMIC, there is an urgent need to identify contextually relevant risk identification and treatment targets. In Mozambique, the country with the highest suicide rate in southern Africa, this need is particularly dire, as there are fewer than 2 mental health specialists per 100,000 inhabitants,3 and limited resources must be efficiently targeted in youth suicide prevention efforts. We conducted a cross-sectional study at 2 secondary schools in the Mozambican capital Maputo City to identify the social and psychiatric factors associated with ST and SB in Mozambican adolescents.

ID-Seg: an infant deep learning-based segmentation framework to improve limbic structure estimates

Infant brain magnetic resonance imaging (MRI) is a promising approach for studying early neurodevelopment. However, segmenting small regions such as limbic structures is challenging due to their low inter-regional contrast and high curvature. MRI studies of the adult brain have successfully applied deep learning techniques to segment limbic structures, and similar deep learning models are being leveraged for infant studies. However, these deep learning-based infant MRI segmentation models have generally been derived from small datasets, and may suffer from generalization problems. Moreover, the accuracy of segmentations derived from these deep learning models relative to more standard Expectation-Maximization approaches has not been characterized. To address these challenges, we leveraged a large, public infant MRI dataset (n = 473) and the transfer-learning technique to first pre-train a deep convolutional neural network model on two limbic structures: amygdala and hippocampus. Then we used a leave-one-out cross-validation strategy to fine-tune the pre-trained model and evaluated it separately on two independent datasets with manual labels. We term this new approach the Infant Deep learning SEGmentation Framework (ID-Seg). ID-Seg performed well on both datasets with a mean dice similarity score (DSC) of 0.87, a mean intra-class correlation (ICC) of 0.93, and a mean average surface distance (ASD) of 0.31 mm. Compared to the Developmental Human Connectome pipeline (dHCP) pipeline, ID-Seg significantly improved segmentation accuracy. In a third infant MRI dataset (n = 50), we used ID-Seg and dHCP separately to estimate amygdala and hippocampus volumes and shapes. The estimates derived from ID-seg, relative to those from the dHCP, showed stronger associations with behavioral problems assessed in these infants at age 2. In sum, ID-Seg consistently performed well on two different datasets with an 0.87 DSC, however, multi-site testing and extension for brain regions beyond the amygdala and hippocampus are still needed.

Leveraging Stakeholder Engagement and Virtual Environments to Develop a Strategy for Implementation of Adolescent Depression Services Integrated Within Primary Care Clinics of Mozambique

Psychiatric disorders are the number one cause of disability in adolescents worldwide. Yet, in low- and middle-income countries (LMIC), where 90% of adolescents reside, mental health services are extremely limited, and the majority do not have access to treatment. Integration of mental health services within primary care of LMICs has been proposed as an efficient and sustainable way to close the adolescent mental health treatment gap. However, there is limited research on how to effectively implement integrated mental health care in LMIC. In the present study, we employed Implementation Mapping to develop a multilevel strategy for integrating adolescent depression services within primary care clinics of Maputo, Mozambique. Both in-person and virtual approaches for Implementation Mapping activities were used to support an international implementation planning partnership and promote the engagement of multilevel stakeholders. We identified determinants to implementation of mental health services for adolescents in LMIC across all levels of the Consolidated Framework for Implementation Research, of which of 25% were unique to adolescent-specific services. Through a series of stakeholder workshops focused on implementation strategy selection, prioritization, and specification, we then developed an implementation plan comprising 33 unique strategies that target determinants at the intervention, patient, provider, policy, and community levels. The implementation plan developed in this study will be evaluated for delivering adolescent depression services in Mozambican primary care and may serve as a model for other low-resource settings.

Maternal tobacco smoking and offspring autism spectrum disorder or traits in ECHO cohorts

Given inconsistent evidence on preconception or prenatal tobacco use and offspring autism spectrum disorder (ASD), this study assessed associations of maternal smoking with ASD and ASD-related traits. Among 72 cohorts in the Environmental Influences on Child Health Outcomes consortium, 11 had ASD diagnosis and prenatal tobaccosmoking (n = 8648). and 7 had Social Responsiveness Scale (SRS) scores of ASD traits (n = 2399). Cohorts had diagnoses alone (6), traits alone (2), or both (5). Diagnoses drew from parent/caregiver report, review of records, or standardized instruments. Regression models estimated smoking-related odds ratios (ORs) for diagnoses and standardized mean differences for SRS scores. Cohort-specific ORs were meta-analyzed. Overall, maternal smoking was unassociated with child ASD (adjusted OR, 1.08; 95% confidence interval [CI], 0.72-1.61). However, heterogeneity across studies was strong: preterm cohorts showed reduced ASD risk for exposed children. After excluding preterm cohorts (biased by restrictions on causal intermediate and exposure opportunity) and small cohorts (very few ASD cases in either smoking category), the adjusted OR for ASD from maternal smoking was 1.44 (95% CI, 1.02-2.03). Children of smoking (versus non-smoking) mothers had more ASD traits (SRS T-score + 2.37 points, 95% CI, 0.73-4.01 points), with results homogeneous across cohorts. Maternal preconception/prenatal smoking was consistently associated with quantitative ASD traits and modestly associated with ASD diagnosis among sufficiently powered United States cohorts of non-preterm children. Limitations resulting from self-reported smoking and unmeasured confounders preclude definitive conclusions. Nevertheless, counseling on potential and known risks to the child from maternal smoking is warranted for pregnant women and pregnancy planners. LAY SUMMARY: Evidence on the association between maternal prenatal smoking and the child's risk for autism spectrum disorder has been conflicting, with some studies reporting harmful effects, and others finding reduced risks. Our analysis of children in the ECHO consortium found that maternal prenatal tobacco smoking is consistently associated with an increase in autism-related symptoms in the general population and modestly associated with elevated risk for a diagnosis of autism spectrum disorder when looking at a combined analysis from multiple studies that each included both pre- and full-term births. However, this study is not proof of a causal connection. Future studies to clarify the role of smoking in autism-like behaviors or autism diagnoses should collect more reliable data on smoking and measure other exposures or lifestyle factors that might have confounded our results.

Do Trajectories of Sensation Seeking Vary by Sex and Child Maltreatment Subtypes?

Child maltreatment and elevated sensation seeking are associated with a wide range of negative outcomes. Longitudinal data from a study of Puerto Ricans living in two sociocultural contexts were used to determine whether child maltreatment subtypes, sex, or sociocultural context relate to trajectories of sensation seeking. Participants were 2,489 individuals from the Boricua Youth Study (48.5% girls) living in New York and in Puerto Rico (PR; 5-15 years old at Wave 1). Subtypes of child maltreatment were measured using child report on the Parent-Child Conflict Tactics Scale and the Sexual Victimization Scale at Wave 1. The association between child maltreatment subtypes, sex, sociocultural context, and previously established sensation-seeking trajectories across three waves of data collection was probed using multinomial logistic regression. Girls, but not boys, who experienced neglect (adjusted odds ratio; AOR; 95% confidence interval [95% CI] = 5.33 [1.35, 21.03]), or physical abuse (AOR [95% CI] = 3.66 [1.07, 12.54]), were more likely to have an elevated sensation-seeking trajectory than a normative trajectory. For boys, none of the maltreatment subtypes were linked to the elevated sensation-seeking class. Girls exposed to verbal abuse (AOR [95% CI] = 0.33 [0.15, 0.75]) and boys exposed to physical abuse (AOR [95% CI] = 0.39 [0.16, 0.97]) were less likely to belong to the low sensation-seeking class. No significant interactions between sociocultural context (i.e., PR vs. New York) and maltreatment subtype on the development of sensation seeking were found. This research suggests sensation-seeking levels vary by experiences of childhood maltreatment, and that sex moderates the relationship between child maltreatment experiences and sensation seeking, with an association between some maltreatment subtypes and elevated sensation-seeking trajectories found in girls, but not boys. These results underline the importance of considering sex when examining how child maltreatment relates to outcomes.

Women's mental health in Mozambique: is maternity a protective factor?

Backgroud

Globally, women have been shown to have high rates of common mental disorders (CMDs). In low and middle-income countries (LMICs), women face significant challenges related to maternity. However, no study has compared mental health problems among pregnant/post-partum women, childless women of childbearing age, and women with children in a low-income country. We sought to compare the frequency of CMD and suicide risk in a sample of women presenting or accompanying patients in primary care in two Mozambican semi-urban settings.

Methods

We administered the MINI International Neuropsychiatric Interview to 853 women, of whom 220 (25.8%) were pregnant/post-partum, 177 (20.8%) were non-pregnant and childless, and 456 (53.5%) were non-pregnant and with children more than 1-year-old. Logistic regression models compared the likelihood of a psychiatric disorder across groups, adjusting for sociodemographic and chronic-illness covariates.

Results

We found a high frequency of CMD and suicide risk among all women in this low-income context sample. In adjusted models, no differences in rates of depression, anxiety, or panic disorder were observed among groups. However, suicide risk was higher in women without children than pregnant/post-partum women.

Conclusion

The frequency of CMD among women of childbearing age in our study was higher than documented rates in high-income countries and other LMIC. Additionally, we found that motherhood was not protective and that pregnancy and the postpartum period were not stages of increased risk for most disorders. This highlights the need to expand mental health services not only for perinatal women but all women of childbearing age in this and possibly similar settings.

Espiritismo and Santeria: a gateway to child mental health services among Puerto Rican families?

BACKGROUND

Barriers to mental health care access among Latinx children contribute to mental health disparities. It is unclear whether traditional spiritual guides in Latinx communities may function more as gateway providers or in some instances as deterrents to mental health treatment. This study assesses whether family involvement in Espiritismo and/or Santeria, two forefront non-Christian spiritual traditions among Latinx families, is associated with mental health care utilization among Puerto Rican children in two contexts.

METHODS

Data are from Waves 1-3 (2000-2004) of the Boricua Youth Study, a population-based longitudinal cohort study of Puerto Rican children from San Juan and Caguas, Puerto Rico (PR), and the South Bronx, New York (SBx), 5 to 17 years of age (N = 2491).

RESULTS

At baseline, 5.02% (n = 58) of the families reported involvement with Espiritismo and/or Santeria in the SBx and 3.64% (n = 52) in PR. Logistic regression models predicting mental health service use found, after adjusting for multiple risk and protective factors, that families involved with Espiritismo and/or Santeria were 2.41 times more likely (p = 0.0034) to use mental health services over the course of 3 years than children with no family involvement in these practices in the SBx. The same association was not found in PR.

CONCLUSIONS

The findings among PR families in the SBx lend support to the gateway provider model in which spiritual guides open doors to mental health treatment. Forming community connections between mental health providers and traditional spiritual groups may be a culturally considerate, fruitful approach to reducing barriers to mental health treatment among Latinx families.

The Child Mental Health Treatment Gap in an Urban Low-Income Setting: Multisectoral Service Use and Correlates

OBJECTIVE

To efficiently target capacity-building efforts for child mental health services in low- and middle-income countries (LMICs), it is critical to define how care is structured across sectors and individual-level factors.

METHODS

In a community-based sample of 1,408 children and adolescents (ages 6-15 years) from Itaboraí, Brazil, the authors assessed need and service use across four care systems (mental health specialty, health, welfare, and informal). Individual-level factors included child gender and age, maternal perception of child mental health need, paternal absence, maternal education, and maternal anxiety and depression.

RESULTS

The mental health treatment gap was 88%, with only 12% of children with psychiatric problems using mental health services. Children with mental health problems were more likely than those without these problems to use health and other sectors of care and to use services in more than one sector of care. Overall, 46% of the children with any clinical mental health problems and 31% of those with only internalizing problems were identified by their mothers as having a mental health need. Among those with clinical mental health problems, factors associated with mental health service use were being a boy and paternal absence but not mental health problem type or maternal awareness.

CONCLUSIONS

Closing the child mental health treatment gap in urban settings in LMICs where resources are scarce will likely require system-level changes, such as engagement of diverse service sectors of care. Interventions need to target increased maternal awareness about mental health problems and encourage provision of mental health services to girls.

Home, school, and community violence exposure and emotional and conduct problems among low-income adolescents: the moderating role of age and sex

PURPOSE

The purpose of this study is to assess whether violence exposure is associated with emotional/conduct problems, when adjusting for confounders/covariates and controlling for comorbidity, and to investigate interactions between violence exposure and sex and/or age.

METHODS

This cross-sectional study evaluated a community-based sample of 669 in-school 11-15-year-olds. A three-stage probabilistic sampling plan included a random selection of census units, eligible households, and target child. Multivariable logistic regression investigated the effect of severe physical punishment by parents, peer victimization at school, and community violence on the study outcomes (adolescent-reported emotional/conduct problems identified by the Strengths and Difficulties Questionnaire/SDQ) when controlling for confounders (resilience, parental emotional warmth, maternal education/unemployment/anxiety/depression) and covariates (age, sex, stressful life events, parental rejection).

RESULTS

Considering interactions, emotional problems were associated with community violence victimization among girls, while conduct problems were associated with severe physical punishment among the younger, suffering peer aggression among the oldest, bullying victimization among girls, and witnessing community violence among boys. Desensitization (less emotional problems with greater violence exposure) was noted among the youngest exposed to severe physical punishment and the oldest who witnessed community violence.

CONCLUSION

Age and sex are moderators of the association between violence exposure and emotional/conduct problems. Interventions at local health units, schools, and communities could reduce the use of harsh physical punishment as a parental educational method, help adolescents deal with peer aggression at school and keep them out of the streets by increasing the usual five hours in school per day and making free sports and cultural/leisure activities available near their homes.

Regional and sociodemographic differences in average BMI among US children in the ECHO program

OBJECTIVE

The aim of this study was to describe the association of individual-level characteristics (sex, race/ethnicity, birth weight, maternal education) with child BMI within each US Census region and variation in child BMI by region.

METHODS

This study used pooled data from 25 prospective cohort studies. Region of residence (Northeast, Midwest, South, West) was based on residential zip codes. Age- and sex-specific BMI z scores were the outcome.

RESULTS

The final sample included 14,313 children with 85,428 BMI measurements, 49% female and 51% non-Hispanic White. Males had a lower average BMI z score compared with females in the Midwest (β = -0.12, 95% CI: -0.19 to -0.05) and West (β = -0.12, 95% CI: -0.20 to -0.04). Compared with non-Hispanic White children, BMI z score was generally higher among children who were Hispanic and Black but not across all regions. Compared with the Northeast, average BMI z score was significantly higher in the Midwest (β = 0.09, 95% CI: 0.05 to 0.14) and lower in the South (β = -0.12, 95% CI: -0.16 to -0.08) and West (β = -0.14, 95% CI: -0.19 to -0.09) after adjustment for age, sex, race/ethnicity, and birth weight.

CONCLUSIONS

Region of residence was associated with child BMI z scores, even after adjustment for sociodemographic characteristics. Understanding regional influences can inform targeted efforts to mitigate BMI-related disparities among children.

Brief Screening Tool for Stepped-Care Management of Mental and Substance Use Disorders

OBJECTIVE

Stepped mental health care requires a rapid method for nonspecialists to detect illness. This study aimed to develop and validate a brief instrument, the Mental Wellness Tool (mwTool), for identification and classification.

METHODS

Cross-sectional development and validation samples included adults at six health facilities in Mozambique. Mini International Neuropsychiatric Interview diagnoses were the criterion standard. Candidate items were from nine mental disorder and functioning assessments. Regression modeling and expert consultation determined best items for identifying any mental disorder and classifying positives into disorder categories (severe mental disorder, common mental disorder, substance use disorder, and suicide risk). For validation, sensitivity and specificity were calculated for any mental disorder (index and proxy respondents) and disorder categories (index).

RESULTS

From the development sample (911 participants, mean±SD age=32.0±11 years, 63% female), 13 items were selected-three with 0.83 sensitivity (95% confidence interval [CI]=0.79-0.86) for any mental disorder and 10 additional items classifying participants with a specificity that ranged from 0.72 (severe mental disorder) to 0.90 (suicide risk). For validation (453 participants, age 31±11 years, 65% female), sensitivity for any mental disorder was 0.94 (95% CI=0.89-0.97) with index responses and 0.73 (95% CI=0.58-0.85) with family proxy responses. Specificity for categories ranged from 0.47 (severe mental disorder) to 0.93 (suicide risk). Removing one item increased severe mental disorder specificity to 0.63 (95% CI=0.58-0.68).

CONCLUSIONS

The mwTool performed well for identification of any mental disorder with index and proxy responses to three items and for classification into treatment categories with index responses to nine additional items.

ADHD and risk for subsequent adverse childhood experiences: understanding the cycle of adversity

BACKGROUND

Children with adverse childhood experiences (ACEs) are more likely to develop Attention-Deficit/Hyperactivity Disorder (ADHD). The reverse relationship - ADHD predicting subsequent ACEs - is vastly understudied, although it may be of great relevance to underserved populations highly exposed to ACEs.

METHODS

Participants were 5- to 15-year-olds (48% females) with (9.9%) and without ADHD (DSM-IV criteria except age of onset) in a longitudinal population-based study of Puerto Rican youth. In each wave (3 yearly assessments, W1-3), ten ACEs (covering parental loss and maladjustment and child maltreatment) were examined, plus exposure to violence. Logistic regression models examined ADHD (including subtypes) and subsequent risk for ACEs. Also considered were interactions by age, sex, number of W1 ACEs, and recruitment site.

RESULTS

Children with W1 ADHD were more likely to experience subsequent adversity (OR: 1.63; 95% CI: 1.12-2.37) accounting for child age, sex, public assistance, maternal education, site, disruptive behavior disorders, and W1 ACEs. Inattentive (OR: 2.00; 95% CI: 1.09-3.66), but not hyperactive/impulsive or combined ADHD, predicted future ACEs.

CONCLUSIONS

ADHD predicts subsequent risk for ACEs, and the inattentive presentation may confer the most risk. Inattentive presentations could pose a bigger risk given differences in symptom persistence, latency to access to treatment, and treatment duration. The present study suggests a pathway for the perpetuation of adversity, where bidirectional relationships between ADHD and ACEs may ensnare children in developmental pathways predictive of poor outcomes. Understanding the mechanism underlying this association can help the development of interventions that interrupt the cycle of adversity exposure and improve the lives of children with ADHD.