Development and evaluation of a predictive algorithm and telehealth intervention to reduce suicidal behavior among university students

BACKGROUND

Suicidal behaviors are prevalent among college students; however, students remain reluctant to seek support. We developed a predictive algorithm to identify students at risk of suicidal behavior and used telehealth to reduce subsequent risk.

METHODS

Data come from several waves of a prospective cohort study (2016-2022) of college students (n = 5454). All first-year students were invited to participate as volunteers. (Response rates range: 16.00-19.93%). A stepped-care approach was implemented: (i) all students received a comprehensive list of services; (ii) those reporting past 12-month suicidal ideation were directed to a safety planning application; (iii) those identified as high risk of suicidal behavior by the algorithm or reporting 12-month suicide attempt were contacted via telephone within 24-h of survey completion. Intervention focused on support/safety-planning, and referral to services for this high-risk group.

RESULTS

5454 students ranging in age from 17-36 (s.d. = 5.346) participated; 65% female. The algorithm identified 77% of students reporting subsequent suicidal behavior in the top 15% of predicted probabilities (Sensitivity = 26.26 [95% CI 17.93-36.07]; Specificity = 97.46 [95% CI 96.21-98.38], PPV = 53.06 [95% CI 40.16-65.56]; AUC range: 0.895 [95% CIs 0.872-0.917] to 0.966 [95% CIs 0.939-0.994]). High-risk students in the Intervention Cohort showed a 41.7% reduction in probability of suicidal behavior at 12-month follow-up compared to high-risk students in the Control Cohort.

CONCLUSIONS

Predictive risk algorithms embedded into universal screening, coupled with telehealth intervention, offer significant potential as a suicide prevention approach for students.

Does reading anxiety impact on academic achievement in higher education students?

Poor readers have lower academic achievement and increased anxiety, including reading anxiety, which may perpetuate lower academic achievement. We explored reading anxiety in university students, investigating whether the association between reading ability and academic achievement is mediated by reading anxiety (independent of general anxiety). Participants were students (n = 169, 69% female, age = 20.70) at an Australian university who completed an online reading assessment (decoding skills, phonological awareness, orthographical knowledge and comprehension), and a survey examining reading anxiety, trait anxiety and self-reported reading history. Academic achievement was based on university grades. Two reading anxiety factors (social and non-social) were identified; both factors were distinct from trait anxiety. Reading ability was negatively correlated with reading anxiety and positively correlated with academic achievement. Reading anxiety was not correlated with academic achievement and it did not mediate the relationship between reading ability and academic achievement as expected. As this was the first study to explore reading anxiety in adults, further research is required to determine the impact reading anxiety may have on university students beyond academic achievement.

Associations between non-suicidal self-injury and experiential avoidance: A systematic review and Robust Bayesian Meta-analysis

OBJECTIVES

Non-suicidal self-injury (NSSI) is the intentional and deliberate damage to an individual's own body tissue without the intent to suicide. Individuals who have higher self-reported levels of experiential avoidance are more likely to report a history of NSSI. The current study systematically reviewed the literature and meta-analysed studies assessing associations between experiential avoidance and self-injury.

METHOD

An extensive review was conducted of several databases (including ProQuest, Joanna Briggs, Web of Science, PsychArticles, PubMed, Scopus, and Ovid). Nineteen articles (two dissertations) met the inclusion criteria for the systematic review and 14 were analysed in a Robust Bayesian Meta-analysis. This review was registered through PROSPERO (CRD42020198041).

RESULTS

There was a small to medium, pooled effect size (d = 0.48, 95 % Credibility Interval 0.00-0.85). There was strong evidence for this effect size (Bayes Factor = 12.16), although there was considerable heterogeneity between studies (τ =0.68, 95 % CI [0.44, 0.1.05]). The analysis testing whether these findings may be due to publication bias was inconclusive (Bayes Factor = 2.45).

LIMITATIONS

The majority of studies included were cross-sectional, in English, and most studies were of university students. While some studies reported on recency/frequency of NSSI there was not enough data to conduct meta-analysis.

CONCLUSION

These results suggest there is a robust association between history of NSSI and experiential avoidance. However, as most studies operationalise avoidance as a unidimensional construct, it is not clear which aspects of avoidance differentiate individuals with and without a history of NSSI.

Emotional responding to overt and subtle social exclusion among young women who engage in non-suicidal self-injury

People who engage in non-suicidal self-injury (NSSI) consistently report greater emotion reactivity and dysregulation than their peers. However, evidence that these self-reports reflect an amplified emotional response under controlled conditions is limited. Here we test the effects of both subtle and overt social exclusion, to determine whether self-reported emotion dysregulation reflects responses to real-time emotional challenge for people who self-injure. We recruited 100 young women with past-year NSSI and 100 without NSSI to an online experiment. Participants took part in a baseline social inclusion ball-tossing game, followed by either an overt or subtle social exclusion ball-tossing game, while we measured negative mood and belongingness. Despite reporting greater emotion reactivity (d = 1.40) and dysregulation (d = 1.63) than controls, women with past-year NSSI showed no differences in negative mood or belongingness ratings in response to either overt or subtle social exclusion. Within the NSSI group, exploratory analyses found greater endorsement of intrapersonal functions predicted greater negative mood following social exclusion (β = 0.19). Given that amplified emotional responding is central to prominent theoretical models of NSSI, findings highlight the need to better understand the divergence in findings between self-reported emotion dysregulation and real-time emotional responding among people who self-injure.

Is ceasing self-injury enough? Differences in psychological health between people reporting behavioral cessation of non-suicidal self-injury and those who consider themselves to have stopped self-injuring

OBJECTIVE

This study examined the overlap between considering oneself to have stopped nonsuicidal self-injury (NSSI) and the actual cessation of the behavior in terms of days self-injured in the last month and last year, and how these operationalizations are associated with constructs related to NSSI recovery.

METHODS

A cross-sectional survey including measures of coping, emotion dysregulation, psychological distress, general self-efficacy, and self-efficacy in resisting NSSI was answered by 144 adults aged 17-81 years (Mage [SD] = 21.43 [7.32]).

RESULTS

Having self-injured for ≥5 days in the last year was overly inclusive of individuals who currently considered themselves as having stopped NSSI (39.02%). Considering oneself to have stopped NSSI was associated with better emotion regulation (Cohen's d = 0.45), and higher general self-efficacy and higher self-efficacy to resist NSSI (d = 0.59-0.64) than behavioral cessation. Not actually engaging in NSSI was only associated with self-efficacy to resist NSSI in risk contexts, such that fewer days self-injured in the last year increased confidence (partial η2  = 0.085).

CONCLUSION

Accounting for whether an individual considers themselves as having stopped NSSI or not may complement estimates of behavioral cessation, and strengthen outcomes associated with NSSI recovery.

Applying social cognitive theory to nonsuicidal self-injury: Interactions between expectancy beliefs

ObjectiveA measure was recently developed which assesses self-efficacy to resist NSSI across differing contexts. The aim of this study was to examine how self-efficacy to resist NSSI across contexts interacts with NSSI-related outcome expectancies when differentiating NSSI history. Participant: 501 Australian college students aged 17-40 years (M = 21.21, SD = 2.36). Method: Participants completed online questionnaires. Results: Self-efficacy to resist NSSI when in contexts considered to be protective or of high risk moderated the relationships between NSSI-related outcome expectancies and recent engagement in NSSI. Participants who expected NSSI to result in communication were more likely to have recently engaged in NSSI if they held weak self-efficacy to resist NSSI in protective contexts. Expecting NSSI to result in diminished self-worth was protective against weak self-efficacy to resist NSSI. Conclusion: Results support the application of Social Cognitive Theory to NSSI and provide future avenues for exploring NSSI-specific cognitions.

Correlates of disclosure of non-suicidal self-injury amongst Australian university students

Purpose

Non-suicidal self-injury (NSSI) is associated with psychological disorders and suicidal thoughts and behaviours; disclosure of NSSI can serve as a catalyst for help-seeking and self-advocacy amongst people who have self-injured. This study aims to identify the socio-demographic, NSSI-related, socio-cognitive and socio-emotional correlates of NSSI disclosure. Given elevated rates of NSSI amongst university students, this study aimed to investigate these factors amongst this population.

Design/methodology/approach

Australian university students (n = 573) completed online surveys; 80.2% had previously disclosed self-injury.

Findings

NSSI disclosure was associated with having a mental illness diagnosis, intrapersonal NSSI functions, specifically marking distress and anti-dissociation, having physical scars from NSSI, greater perceived impact of NSSI, less expectation that NSSI would result in communication and greater social support from friends and significant others.

Originality/value

Expanding on previous works in the area, this study incorporated cognitions about NSSI. The ways in which individuals think about the noticeability and impact of their NSSI, and the potential to gain support, are associated with the decision to disclose self-injury. Addressing the way individuals with lived experience consolidate these considerations could facilitate their agency in whether to disclose their NSSI and highlight considerations for health-care professionals working with clients who have lived experience of NSSI.

Thoughts and beliefs about nonsuicidal self-injury: An application of social cognitive theory

According to Social Cognitive Theory, the anticipated consequences of a behavior (outcome expectancies), coupled with our belief in our ability to successfully perform the behavior (self-efficacy), determine the likelihood of engagement in a behavior. We explored whether the relationship between nonsuicidal self-injury outcome expectancies and self-injury was moderated by self-efficacy to resist nonsuicidal self-injury. Participants: Five hundred and sixteen college students aged 18-26 years (M = 20.60, SD = 1.86). Methods: Self-report measures were completed online. Results: The relationship between expecting self-injury would result in pain or emotion regulation and engaging in self-injury was moderated by a belief in the ability to resist self-injury. People who had never self-injured were more likely to believe that self-injury would cause physical pain and believe they could resist self-injury. A belief in the ability to resist self-injury countered expectations that self-injury would result in emotion regulation. Conclusion: Results may inform college-based prevention and intervention efforts.

The Language of Self-Injury: A Data-Informed Commentary

ABSTRACT

Nonsuicidal self-injury (NSSI) is a behavior that can be perplexing to many people. Usually engaged as a means of regulating intense or unwanted emotions, it seems to counter the human instinct to avoid pain and harm to the self. The language people use to talk about NSSI, and individuals who engage in the behavior, can contribute to the significant stigma that is associated with NSSI. In this data-driven commentary, we report on the language clinicians and researchers typically use when talking about NSSI, and the language they consider appropriate to use. We observed some disparity in the language people use and what they deemed appropriate. Notably, researchers and clinicians report underusing terms that people with lived experience find most appropriate (someone with a history of self-injury; someone with lived experience of self-injury). We call on all researchers and clinicians to be mindful of the language they use to discuss NSSI and adopt person-centered and respectful language at all times.

The impact of ambivalence on recovery from non-suicidal self-injury: considerations for health professionals

Purpose

Non-suicidal self-injury (NSSI) is a growing public health concern. Continued NSSI is often associated with negative outcomes, yet the behaviour usually serves a purpose for individuals who self-injure (e.g. emotional relief). As such, individuals who self-injure often experience ambivalence about the behaviour. The purpose of this paper is to highlight the importance of recognising ambivalence as a natural and expected part of the recovery process.

Design/methodology/approach

This paper draws on literature regarding NSSI recovery, ambivalence towards stopping the behaviour and challenges for both clients and health professionals.

Findings

This paper argues that ambivalence towards self-injury can be challenging for both clients and health professionals. Clients may feel shame and sense of failure if they experience a setback; health professionals may experience frustration towards clients who continue to self-injure despite treatment.

Originality/value

Validation of the clients’ experience can have significant positive outcomes in treatment and help-seeking behaviours. Acknowledgement of client ambivalence during the recovery process will serve to validate clients’ experience and facilitate rapport. Health professionals who accept ambivalence as a natural part of the recovery process may experience less frustration with clients who continue to self-injure.

Piloting 'Clever Kids': A randomized-controlled trial assessing feasibility, efficacy, and acceptability of a socioemotional well-being programme for children with dyslexia

Children with dyslexia are at elevated risk of internalizing (emotional) and externalizing (behavioural) problems. Clever Kids is a nine-week socioemotional well-being programme developed specifically for upper primary school children with dyslexia. In a small randomized-controlled trial, we tested the feasibility, efficacy, and acceptability of the Clever Kids programme. 'Forty children (M_age  = 10.45 years, 65% male) with clinically diagnosed dyslexia too part in the study. Children were randomized to either attend Clever Kids (n = 20) or to a wait-list control condition (n = 20). Coping skills, self-esteem, resilience, emotion regulation, and internalizing and externalizing symptoms were measured at pre-programme, post-programme, and at three-month follow-up. Recruitment and retention rates indicate high feasibility for further evaluation of the programme. There was a significant interaction between intervention condition and time for non-productive coping [F(2, 76) = 4.29, p = 0.017, f²  = 0.11]. Children who attended Clever Kids significantly reduced their use of non-productive coping strategies, and this was maintained at three-month follow-up assessment. For all other outcomes, the interactions between intervention condition and time were non-significant. The programme appears acceptable to children with dyslexia and their families, but may be improved by further reducing the number of activities involving reading and writing. Clever Kids improved the coping skills of children with dyslexia; however, a larger trial is needed to replicate this finding and investigate whether programme attendance is associated with additional improvements in children's socioemotional well-being.

Prospective associations between bullying victimisation, internalised stigma, and mental health in South African adolescents living with HIV

BACKGROUND

Adolescents living with HIV may be at elevated risk of psychological problems, which are correlated with negative health outcomes. In cross-sectional research with HIV-affected adolescents, bullying victimisation and internalised HIV stigma have been associated with poorer psychological health. We extended these findings and tested longitudinal associations between bullying victimisation, internalised stigma, and mental health among adolescents living with HIV. We also tested whether relationships between bullying victimisation and psychological symptoms were mediated by internalised stigma.

METHOD

Adolescents living with HIV (n = 1060, 10-19 years, 55% female), who had ever initiated HIV treatment in 53 public health facilities in the Eastern Cape, South Africa, were interviewed and followed up 18 months later (n = 995, 94% retention). Participants completed well-validated measures of depression, anxiety, posttraumatic stress, bullying victimisation, and internalised stigma.

RESULTS

After adjusting for baseline mental health and sociodemographic characteristics, baseline internalised stigma prospectively predicted poorer outcomes on all psychological measures. Bullying victimisation at baseline was not directly associated with any psychological measures at follow up; however, it was indirectly associated with all psychological measures via internalised stigma.

LIMITATIONS

Reliance on self-report measures and poor reliability of the depression scale.

CONCLUSIONS

Bullying victimisation is associated with internalised stigma, which in turn predicts psychological symptoms over time. Interventions reducing internalised stigma and associated psychological distress are needed, and these should be integrated into HIV care to ensure optimal HIV management. The implementation of bullying prevention programs may reduce internalised stigma and promote mental health among adolescents living with HIV.

Guided Internet-delivered cognitive behaviour therapy for perfectionism in a non-clinical sample of adolescents: A study protocol for a randomised controlled trial

BACKGROUND

Perfectionism is elevated across a range of psychopathologies and has been shown to impede treatment outcomes. There is also evidence suggesting elevated perfectionism may contribute to the onset and maintenance of non-suicidal self-injury. There is a growing body of evidence suggesting that Internet-delivered cognitive-behavioural therapy for perfectionism reduces perfectionism and symptoms of psychological disorders and that reductions are maintained at 3-month and 6-month follow-up. There may also be reductions in non-suicidal self-injury, although no study has investigated this potential benefit. Given that associations between perfectionism and psychopathology are observed across both adults and adolescents, the need for the development of interventions targeting adolescents is essential for early intervention and prevention.

METHODS

The present study will employ a randomised controlled trial to examine the efficacy of 8-week guided Internet-delivered cognitive-behavioural therapy for perfectionism in adolescents compared to a waitlist control group. The primary outcome is perfectionism, and secondary outcomes include symptoms of psychological disorders, well-being, and non-suicidal self-injury. Outcomes will be assessed at pre-intervention, post-intervention, 1-month follow-up, 3-month follow-up, and 6-month follow-up. A minimum of 240 participants will be recruited online through social media, Australian universities, and schools across Australia. Generalised linear mixed models will be used to test for changes in outcomes between the intervention group and the waitlist control.

DISCUSSION

The outcomes of this trial will contribute to the literature on perfectionism and psychopathology in adolescents, as well as the efficacy of guided Internet-delivered interventions for adolescents.

TRIAL REGISTRATION

The trial was registered on the 20th of June 2019 at the Australia New Zealand Clinical Trials Registry (ACTRN12619000881134).

TRIAL STATUS

This is protocol version 1.0. Participant recruitment began on 31 July 2019 and is still actively running with an anticipated completion date in the fourth quarter of 2020.

Nonsuicidal Self-Injury-Related Differences in the Experience of Negative and Positive Emotion

OBJECTIVE

Emotional experience is argued to contribute to the initiation and maintenance of nonsuicidal self-injury (NSSI). We investigated whether individuals with/without a history of NSSI differed in their dispositional experience of negative and positive emotion, as well as their state responses to negatively and positively valenced movie clips.

METHOD

Undergraduates (n = 214, M_age  = 21.33, 73.8% female, 35.5% reporting NSSI) completed measures of NSSI and dispositional emotional experience. Participants also viewed a sad and amusing movie clip and provided sadness/amusement ratings at seven time-points.

RESULTS

Relative to participants with no history of self-injury, participants reporting NSSI indicated more reactivity, intensity, and perseveration of dispositional negative emotion; however, differences were negated after adjusting for mental illness. Unexpectedly, individuals with a history of NSSI responded less intensely to the sad clip, although they demonstrated perseveration of sadness over time. Participants reporting NSSI also indicated less reactivity, intensity, and perseveration of dispositional positive emotion and, in response to the amusing film, reported less amusement at all time-points.

CONCLUSIONS

Considering different dimensions of negative and positive emotion may enhance understanding of NSSI. Future research should disentangle which dimensions of emotional experience are unique to NSSI and which are shared with mental illness more generally.

Self-concept in poor readers: a systematic review and meta-analysis

BACKGROUND

The aims of this systematic review and meta-analyses were to determine if there is a statistically reliable association between poor reading and poor self-concept, and if such an association is moderated by domain of self-concept, type of reading impairment, or contextual factors including age, gender, reading instruction, and school environment.

METHODOLOGY

We searched 10 key databases for published and unpublished studies, as well as reference lists of included studies, and studies that cited included studies. We calculated standardised mean differences (SMDs) and 95% confidence intervals for one primary outcome (average self-concept) and 10 secondary outcomes (10 domains of self-concept). We assessed the data for risk of bias, heterogeneity, sensitivity, reporting bias, and quality of evidence.

RESULTS

Thirteen studies with 3,348 participants met our selection criteria. Meta-analyses revealed statistically significant SMDs for average self-concept (-0.57) and five domains of self-concept (reading/writing/spelling: -1.03; academic: -0.67; math: -0.64; behaviour: -0.32; physical appearance: -0.28). The quality of evidence for the primary outcome was moderate, and for secondary outcomes was low, due to lack of data.

CONCLUSIONS

These outcomes suggest a probable moderate association between poor reading and average self-concept; a possible strong association between poor reading and reading-writing-spelling self-concept; and possible moderate associations between poor reading and self-concept in the self-concept domains of academia, mathematics, behaviour, and physical appearance.

Attention biases in perfectionism: Biased disengagement of attention from emotionally negative stimuli

BACKGROUND AND OBJECTIVES

Perfectionism is associated with the development and maintenance of several psychological disorders. Consequently, efforts to better understand perfectionism have potential transdiagnostic impact. One mechanism proposed to underlie perfectionism is an attention bias towards information signalling threats to perfectionism whereby people with elevated perfectionism selectively attend to threatening stimuli.

METHOD

The present study assessed whether two core dimensions of perfectionism, perfectionistic strivings and perfectionistic concerns, are characterised by a threat-related attention bias, and whether this bias was characterised by attention being more rapidly captured by the stimuli (engagement bias), or of greater difficulty to disengage attention (disengagement bias). Participants (N = 108) completed measures of perfectionistic strivings and concerns, and symptoms of psychological distress before completing a modified dot-probe task to measure attention biases. Attention bias index scores were calculated across three factors: engagement bias vs disengagement bias, perfectionism relevant vs irrelevant stimuli, and negative vs positive emotional stimuli.

RESULTS

Overall, perfectionistic concerns were associated with a disengagement bias for negative stimuli, regardless of whether stimuli were perfectionism relevant or not. No other significant main or interaction effects were observed.

LIMITATIONS

The study was cross-sectional in design, and no temporal or causal inferences could be made. Additionally, participants were from a community sample and therefore replication is required in clinical populations.

CONCLUSION

These findings demonstrate that individuals higher in perfectionistic concerns experience difficulty withdrawing their attention from emotionally negative stimuli. These findings contribute new information to our theoretical understandings of perfectionism and provide support for the cognitive-behavioural model of perfectionism.

When language is maladaptive: recommendations for discussing self-injury

Purpose

The purpose of this paper is to call on researchers and clinicians to carefully consider the terminology used when discussing non-suicidal self-injury (NSSI), and specifically the use of the term “maladaptive” coping.

Design/methodology/approach

Drawing on literature regarding stigma, language and self-injury to support the argument that the term maladaptive is inappropriate to describe self-injury.

Findings

Use of the term maladaptive conflates short-term effectiveness with long-term outcomes and ignores context in which the behaviour occurs.

Social implications

Use of the term maladaptive to describe self-injury can invalidate the person with a history of NSSI, impacting stigma and potentially help-seeking. An alternate framing focussed on specific coping strategies is offered.

Originality/value

Language is a powerful medium of communication that has significant influence in how society shapes ideas around mental health. In proposing a change in the way the authors’ talk about self-injury there is potential to significantly improve the wellbeing of people with lived experience of self-injury.

Common Pathways to NSSI and Suicide Ideation: The Roles of Rumination and Self-Compassion

We investigated whether rumination and self-compassion moderate and/or mediate the relationships between negative affect and both non-suicidal self-injury (NSSI) and suicide ideation. Undergraduate university students (n = 415) completed well-validated measures of negative affect, rumination, self-compassion, NSSI, and suicide ideation. Neither rumination nor self-compassion moderated associations between negative affect and NSSI and suicide ideation. However, both rumination and self-compassion mediated associations between negative affect and lifetime history of NSSI and suicide ideation. Self-compassion additionally mediated the association between negative affect and both 12-month NSSI and suicide ideation. The salience of self-compassion, particularly in predicting recent NSSI and suicide ideation, offers promise for early intervention initiatives focusing on less judgmental or self-critical means of self-relation.

Applying a cognitive-emotional model to nonsuicidal self-injury

The recently proposed cognitive-emotional model of nonsuicidal self-injury (NSSI) draws on emotion regulation models and social cognitive theory to understand the onset, maintenance, and cessation of NSSI. We tested the prediction of the model that the relationship between emotional reactivity and NSSI is moderated by specific cognitions about self-injury (i.e., self-efficacy to resist NSSI, NSSI outcome expectancies), emotion regulation, and rumination. A sample of 647 university students aged 17-25 years (M = 19.92, SD = 1.78) completed self-report measures of the constructs of interest. As expected, we found that emotional reactivity was positively related to NSSI, particularly for people who had weak self-efficacy to resist NSSI. However, emotional reactivity was negatively related to NSSI for people who were more likely to use expressive suppression to regulate emotion. Implications for the theoretical understanding of NSSI are discussed.

The effect of psychological distress on self-care intention and behaviour in young adults with type 1 diabetes

An extended theory of planned behaviour including psychological distress was used to predict blood glucose monitoring in young adults with type 1 diabetes. Participants completed two surveys, a week apart (n = 167). Attitudes and perceived behavioural control were significantly associated with intention but subjective norm was not. Intention predicted blood glucose monitoring at T2. Higher scores in psychological distress significantly predicted poorer blood glucose monitoring at T2 but did not moderate the intention-behaviour relationship. Findings demonstrate some concerns with the theory of planned behaviour to predict self-care behaviour, yet highlight the importance of addressing psychological distress in diabetes self-management.

Mental health in South African adolescents living with HIV: correlates of internalising and externalising symptoms

Although declining in all other age groups, AIDS-related deaths among adolescents are increasing. In the context of HIV, mental health problems are associated with negative health outcomes, including non-adherence to life-saving ART. For effective programming it is essential to identify factors associated with psychological outcomes in this population. Adopting a socioecological perspective, we aimed to identify correlates of internalising and externalising symptoms in a large, representative sample of South African adolescents living with HIV. HIV-positive adolescents (n = 1060), who received care in public health facilities in South Africa's Eastern Cape, completed measures of internalising and externalising symptoms. Hypothesised correlates included HIV and health-related factors (physical health, mode of infection, medication side-effects, disclosure, stigma), health-service related factors (negative interactions with clinic staff, clinic support group), interpersonal factors (abuse, bullying victimisation, social support), parenting-related factors (orphanhood, positive parenting, parental monitoring, parent communication), as well as individual and demographic-related factors (self-efficacy, age, gender, urban/rural location, poverty). Correlates operating across a variety of contexts were identified. Bullying victimisation, self-efficacy, and positive parenting may be particularly salient intervention targets as they were associated with better outcomes on most or all mental health measures, can be addressed without directly targeting adolescents living with HIV (reducing the chances of accidental exposure and stigma), and are associated with better adolescent mental health in South Africa more generally.

Adaptation and psychometric properties of the ISPCAN Child Abuse Screening Tool for use in trials (ICAST-Trial) among South African adolescents and their primary caregivers

Child abuse prevention research has been hampered by a lack of validated multi-dimensional non-proprietary instruments, sensitive enough to measure change in abuse victimization or behavior. This study aimed to adapt the ICAST child abuse self-report measure (parent and child) for use in intervention studies and to investigate the psychometric properties of this substantially modified tool in a South African sample. First, cross-cultural and sensitivity adaptation of the original ICAST tools resulted in two preliminary measures (ICAST-Trial adolescents: 27 items, ICAST-Trial caregivers: 19 items). Second, ICAST-Trial data from a cluster randomized trial of a parenting intervention for families with adolescents (N = 1104, 552 caregiver-adolescent dyads) was analyzed. Confirmatory factor analysis established the hypothesized 6-factor (adolescents) and 4-factor (caregivers) structure. Removal of two items for adolescents and five for caregivers resulted in adequate model fit. Concurrent criterion validity analysis confirmed hypothesized relationships between child abuse and adolescent and caregiver mental health, adolescent behavior, discipline techniques and caregiver childhood abuse history. The resulting ICAST-Trial measures have 25 (adolescent) and 14 (caregiver) items respectively and measure physical, emotional and contact sexual abuse, neglect (both versions), and witnessing intimate partner violence and sexual harassment (adolescent version). The study established that both tools are sensitive to measuring change over time in response to a parenting intervention. The ICAST-Trial should have utility for evaluating the effectiveness of child abuse prevention efforts in similar socioeconomic contexts. Further research is needed to replicate these findings and examine cultural appropriateness, barriers for disclosure, and willingness to engage in child abuse research.

Parenting for Lifelong Health: a pragmatic cluster randomised controlled trial of a non-commercialised parenting programme for adolescents and their families in South Africa

OBJECTIVE

To assess the impact of 'Parenting for Lifelong Health: Sinovuyo Teen', a parenting programme for adolescents in low-income and middle-income countries, on abuse and parenting practices.

DESIGN

Pragmatic cluster randomised controlled trial.

SETTING

40 villages/urban sites (clusters) in the Eastern Cape province, South Africa.

PARTICIPANTS

552 families reporting conflict with their adolescents (aged 10-18).

INTERVENTION

Intervention clusters (n=20) received a 14-session parent and adolescent programme delivered by trained community members. Control clusters (n=20) received a hygiene and hand-washing promotion programme.

MAIN OUTCOME MEASURES

Primary outcomes: abuse and parenting practices at 1 and 5-9 months postintervention. Secondary outcomes: caregiver and adolescent mental health and substance use, adolescent behavioural problems, social support, exposure to community violence and family financial well-being at 5-9 months postintervention. Blinding was not possible.

RESULTS

At 5-9 months postintervention, the intervention was associated with lower abuse (caregiver report incidence rate ratio (IRR) 0.55 (95% CI 0.40 to 0.75, P<0.001); corporal punishment (caregiver report IRR=0.55 (95% CI 0.37 to 0.83, P=0.004)); improved positive parenting (caregiver report d=0.25 (95% CI 0.03 to 0.47, P=0.024)), involved parenting (caregiver report d=0.86 (95% CI 0.64 to 1.08, P<0.001); adolescent report d=0.28 (95% CI 0.08 to 0.48, P=0.006)) and less poor supervision (caregiver report d=-0.50 (95% CI -0.70 to -0.29, P<0.001); adolescent report d=-0.34 (95% CI -0.55 to -0.12, P=0.002)), but not decreased neglect (caregiver report IRR 0.31 (95% CI 0.09 to 1.08, P=0.066); adolescent report IRR 1.46 (95% CI 0.75 to 2.85, P=0.264)), inconsistent discipline (caregiver report d=-0.14 (95% CI -0.36 to 0.09, P=0.229); adolescent report d=0.03 (95% CI -0.20 to 0.26, P=0.804)), or adolescent report of abuse IRR=0.90 (95% CI 0.66 to 1.24, P=0.508) and corporal punishment IRR=1.05 (95% CI 0.70 to 1.57, P=0.819). Secondary outcomes showed reductions in caregiver corporal punishment endorsement, mental health problems, parenting stress, substance use and increased social support (all caregiver report). Intervention adolescents reported no differences in mental health, behaviour or community violence, but had lower substance use (all adolescent report). Intervention families had improved economic welfare, financial management and more violence avoidance planning (in caregiver and adolescent report). No adverse effects were detected.

CONCLUSIONS

This parenting programme shows promise for reducing violence, improving parenting and family functioning in low-resource settings.

TRIAL REGISTRATION NUMBER

Pan-African Clinical Trials Registry PACTR201507001119966.

School, Supervision and Adolescent-Sensitive Clinic Care: Combination Social Protection and Reduced Unprotected Sex Among HIV-Positive Adolescents in South Africa

Social protection can reduce HIV-risk behavior in general adolescent populations, but evidence among HIV-positive adolescents is limited. This study quantitatively tests whether social protection is associated with reduced unprotected sex among 1060 ART-eligible adolescents from 53 government facilities in South Africa. Potential social protection included nine 'cash/cash-in-kind' and 'care' provisions. Analyses tested interactive/additive effects using logistic regressions and marginal effects models, controlling for covariates. 18 % of all HIV-positive adolescents and 28 % of girls reported unprotected sex. Lower rates of unprotected sex were associated with access to school (OR 0.52 95 % CI 0.33-0.82 p = 0.005), parental supervision (OR 0.54 95 % CI 0.33-0.90 p = 0.019), and adolescent-sensitive clinic care (OR 0.43 95 % CI 0.25-0.73 p = 0.002). Gender moderated the effect of adolescent-sensitive clinic care. Combination social protection had additive effects amongst girls: without any provisions 49 % reported unprotected sex; with 1-2 provisions 13-38 %; and with all provisions 9 %. Combination social protection has the potential to promote safer sex among HIV-positive adolescents, particularly girls.

Exploring the impact of living with dyslexia: The perspectives of children and their parents

PURPOSE

A small but growing body of literature indicates that children with dyslexia are at elevated risk of internalising and externalising mental health problems. However, little research addresses why this might be the case, particularly from the point of view of the children or their parents. This study therefore aimed to explore the lived experiences of children with dyslexia, and their parents.

METHOD

Drawing on a phenomenological approach, 13 children with dyslexia and 21 parents were interviewed. The semi-structured interviews were analysed thematically.

RESULT

Dyslexia was seen to impact at the individual, family and community level. Children's accounts of their experiences were ecologically situated at both the micro and mesosystem levels of Bronfenbrenner's ecological model, while parent's accounts extended to include the exosystem. Both also reflected on "difference", a theme related to cultural and attitudinal views at the level of the macrosystem.

CONCLUSION

Presentation of the themes contrasts the experiences of children and parents, illustrating that the experience of dyslexia is indicative of broader challenges associated with societal values and attitudes that privilege perceived ability and shame difference. This study provides information that could be used to inform and educate families and teachers about the impact of living with dyslexia.

The dyadic effects of HIV stigma on the mental health of children and their parents in South Africa

HIV stigma - both 'self-stigma' towards positive individuals and 'stigma by association' towards their families - is linked with adverse mental health. This study examined how stigma was associated with the mental health of parents and children in South Africa. Parent-child dyads (n=2477 dyads) in South Africa participated in a cross-sectional survey. For both parents and children, greater stigma was associated with their own reports of greater anxious and depressive symptoms. Parents reports of stigma was associated with children's greater anxious and depressive symptoms. Children's reports of stigma was related to parents greater anxious and depressive symptoms. There was a significant interaction, such that the association between parent stigma and depression was stronger when children also reported high levels of stigma. Findings provide support the effect of HIV stigma on the mental health of families and illustrate the importance of taking a family-based approach to stigma-reduction interventions to alleviate mental health problems.

Adverse Life Experience and Psychological Distress in Adolescence: Moderating and Mediating Effects of Emotion Regulation and Rumination

The current study tested whether emotion regulation and rumination moderated and/or mediated the relationship between accumulated adverse life experience and psychological distress in adolescence. In class, Australian high school students (n = 2637, 12-18 years, 68% female) from 41 schools completed well-validated measures of adverse life experience, emotion regulation, rumination and psychological distress, and were followed up 1 year later (n = 1973, 75% retention rate). Adjusting for age, gender and baseline psychological distress, adverse life experience predicted psychological distress 1 year later. Expressive suppression and rumination were positively associated with psychological distress. Cognitive reappraisal was negatively associated with psychological distress and moderated the relationship between adverse life experience and psychological distress. This relationship was also partially mediated by cognitive reappraisal, expressive suppression and rumination. Promoting cognitive reappraisal and minimizing expressive suppression and rumination may be useful strategies to improve mental health for adolescents who have experienced adverse life events. Future research should examine whether adolescents who have experienced adverse life events can be trained in effective emotion regulation strategies and whether this training can prevent development of psychological maladjustment. Copyright © 2015 John Wiley & Sons, Ltd.

Physical, emotional and sexual adolescent abuse victimisation in South Africa: prevalence, incidence, perpetrators and locations

BACKGROUND

Physical, emotional and sexual abuse of children is a major problem in South Africa, with severe negative outcomes for survivors. To date, no known studies have used data directly obtained from community-based samples of children to investigate prevalence, incidence, locations and perpetrators of child abuse victimisation. This study aims to investigate prevalence and incidence, perpetrators, and locations of child abuse victimisation in South Africa using a multicommunity sample.

METHODS

3515 children aged 10-17 years (56.6% female) were interviewed from all households in randomly selected census enumeration areas in two South African provinces. Child self-report questionnaires were completed at baseline and at 1-year follow-up (96.7% retention).

RESULTS

Prevalence was 56.3% for lifetime physical abuse (18.2% past-year incidence), 35.5% for lifetime emotional abuse (12.1% incidence) and 9% for lifetime sexual abuse (5.3% incidence). 68.9% of children reported any type of lifetime victimisation and 27.1% reported lifetime multiple abuse victimisation. Main perpetrators of abuse were reported: for physical abuse, primary caregivers and teachers; for emotional abuse, primary caregivers and relatives; and for sexual abuse, girlfriend/boyfriends or other peers.

CONCLUSIONS

This is the first study assessing current self-reported child abuse through a large, community-based sample in South Africa. Findings of high rates of physical, emotional and sexual abuse demonstrate the need for targeted and effective interventions to prevent incidence and re-victimisation.

Why Are Reading Difficulties Associated with Mental Health Problems?

A growing literature indicates that children with reading difficulties are at elevated risk for mental health problems; however, little attention has been given to why this might be the case. Associations between reading difficulties and mental health differ substantially across studies, raising the possibility that these relationships may be ameliorated or exacerbated by risk or resilience-promoting factors. Using socio-ecological theory as a conceptual framework, we outline four potential lines of research that could shed light on why children with reading difficulties are at risk of mental health problems and identify potential targets for intervention. Copyright © 2016 John Wiley & Sons, Ltd.

Child and Adolescent Suicide Attempts, Suicidal Behavior, and Adverse Childhood Experiences in South Africa: A Prospective Study

PURPOSE

This is the first known prospective study of child suicidal behavior in sub-Saharan Africa. Aims were to determine whether (1) cumulative exposure to adverse childhood experiences (ACEs) predicts later suicidality and (2) heightened risks are mediated by mental health disorder and drug/alcohol misuse.

METHODS

Longitudinal repeated interviews were conducted 1 year apart (97% retention) with 3,515 adolescents aged 10-18 years in South Africa (56% female; <2.5% refusal). Random selection of census enumeration areas from urban/rural sites within two provinces and door-to-door sampling included all homes with a resident adolescent. Measures included past-month suicide attempts, planning, and ideation, mental health disorders, drug/alcohol use, and ACE, for example, parental death by AIDS or homicide, abuse, and exposure to community violence. Analyses included multivariate logistic regression and multiple mediation tests.

RESULTS

Past-month suicidality rates were 3.2% of adolescents attempting, 5.8% planning, and 7.2% reporting ideation. After controlling for baseline suicidality and sociodemographics, a strong, graded relationship was shown between cumulative ACE and all suicide behaviors 1 year later. Baseline mental health, but not drug/alcohol misuse, mediated relationships between ACE and subsequent suicidality. Suicide attempts rose from 1.9% among adolescents with no ACE to 6.3% among adolescents with >5 ACEs (cumulative odds ratio [OR], 2.46; confidence interval [CI], 1.00-6.05); for suicide planning, from 2.4% to 12.5% (cumulative OR, 4.40; CI, 2.08-9.29); and for suicide ideation, from 4.2% to 15.6% (cumulative OR, 2.99; CI, 1.68-5.53).

CONCLUSIONS

Preventing and mitigating childhood adversities have the potential to reduce suicidality. Among adolescents already exposed to adversities, effective mental health services may buffer against future suicidality.

Bullying victimisation, internalising symptoms, and conduct problems in South African children and adolescents: a longitudinal investigation

Bullying victimisation has been prospectively linked with mental health problems among children and adolescents in longitudinal studies in the developed world. However, research from the developing world, where adolescents face multiple risks to social and emotional development, has been limited by cross-sectional designs. This is the first longitudinal study of the psychological impacts of bullying victimisation in South Africa. The primary aim was to examine prospective relationships between bullying victimisation and internalising and externalising symptoms in South African youth. Secondary aims were to examine gender and age-related differences in experiences of bullying victimisation. Children and adolescents (10-17 years, 57 % female, n = 3,515) from high HIV-prevalent (>30 %) communities in South Africa were interviewed and followed-up 1 year later (97 % retention). Census enumeration areas were randomly selected from urban and rural sites in two provinces and door-to-door sampling included all households with a resident child/adolescent. Exposure to multiple experiences of bullying victimisation at baseline predicted internalising symptoms and conduct problems 1 year later. Additionally, baseline mental health scores predicted later bullying victimisation, demonstrating bi-directionality of relationships between bullying victimisation and mental health outcomes in this sample. Expected gender differences in physical, verbal, and relational bullying victimisation were evident and predicted declines in bullying victimisation over time were observed. In the developed world, school-based anti-bullying programmes have been shown to be effective in reducing bullying and victimisation. Anti-bullying programmes should be implemented and rigorously evaluated in South Africa, as this may promote improved mental health among South African children and adolescents.

Household illness, poverty and physical and emotional child abuse victimisation: findings from South Africa's first prospective cohort study

Background

Physical and emotional abuse of children is a large scale problem in South Africa, with severe negative outcomes for survivors. Although chronic household illness has shown to be a predictor for physical and emotional abuse, no research has thus far investigated the different pathways from household chronic illness to child abuse victimisation in South Africa.

Methods

Confidential self-report questionnaires using internationally utilised measures were completed by children aged 10-17 (n = 3515, 56.7% female) using door-to-door sampling in randomly selected areas in rural and urban locations of South Africa. Follow-up surveys were conducted a year later (96.7% retention rate). Using multiple mediation analyses, this study investigated direct and indirect effects of chronic household illness (AIDS or other illness) on frequent (monthly) physical and emotional abuse victimisation with poverty and extent of the ill person’s disability as hypothesised mediators.

Results

For children in AIDS-ill families, a positive direct effect on physical abuse was obtained. In addition, positive indirect effects through poverty and disability were established. For boys, a positive direct and indirect effect of AIDS-illness on emotional abuse through poverty were detected. For girls, a positive indirect effect through poverty was observed. For children in households with other chronic illness, a negative indirect effect on physical abuse was obtained. In addition, a negative indirect effect through poverty and positive indirect effect through disability was established. For boys, positive and negative indirect effects through poverty and disability were found respectively. For girls, a negative indirect effect through poverty was observed.

Conclusions

These results indicate that children in families affected by AIDS-illness are at higher risk of child abuse victimisation, and this risk is mediated by higher levels of poverty and disability. Children affected by other chronic illness are at lower risk for abuse victimisation unless they are subject to higher levels of household disability. Interventions aiming to reduce poverty and increase family support may help prevent child abuse in families experiencing illness in South Africa.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1792-4) contains supplementary material, which is available to authorized users.

Risk and protective factors for physical and sexual abuse of children and adolescents in Africa: a review and implications for practice

There is now conclusive evidence of the major and long-lasting negative effects of physical and sexual abuse on children. Within Africa, studies consistently report high rates of child abuse, with prevalence as high as 64%. However, to date, there has been no review of factors associated with physical and sexual child abuse and polyvictimization in Africa. This review identified 23 quantitative studies, all of which showed high levels of child abuse in varying samples of children and adults. Although studies were very heterogeneous, a range of correlates of abuse at different levels of the Model of Ecologic Development were identified. These included community-level factors (exposure to bullying, sexual violence, and rural/urban location), household-level factors (poverty, household violence, and non-nuclear family), caregiver-level factors (caregiver illness in particular AIDS and mental health problems, caregiver changes, family functioning, parenting, caregiver-child relationship, and substance abuse), and child-level factors (age, disability, physical health, behavior, and gender). These findings identify key associated factors that are potential foci of child abuse prevention interventions. In addition, there is a clear need for further rigorous longitudinal research into predictive factors and culturally relevant interventions.

Relationships between familial HIV/AIDS and symptoms of anxiety and depression: the mediating effect of bullying victimization in a prospective sample of South African children and adolescents

South African children and adolescents living in HIV/AIDS-affected families are at elevated risk of both symptoms of anxiety and depressive symptoms. Poverty and HIV/AIDS-related stigma are additional risk factors for these negative mental health outcomes. Community level factors, such as poverty and stigma, are difficult to change in the short term and identifying additional potentially malleable mechanisms linking familial HIV/AIDS with mental health is important from an intervention perspective. HIV/AIDS-affected children are also at increased risk of bullying victimization. This longitudinal study aimed to determine whether prospective relationships between familial HIV/AIDS and both anxiety symptoms and depressive symptoms operate indirectly via bullying victimization. Adolescents (M = 13.45 years, 56.67 % female, n = 3,515) from high HIV-prevalent (>30 %) communities in South Africa were interviewed and followed-up one year later (n = 3,401, 96.70 % retention). Census enumeration areas were randomly selected from urban and rural sites in two provinces, and door-to-door sampling included all households with a resident child/adolescent. Familial HIV/AIDS at baseline assessment was not directly associated with mental health outcomes 1 year later. However, significant indirect effects operating via bullying victimization were obtained for both anxiety and depression scores. Importantly, these effects were independent of poverty, HIV/AIDS-related stigma, and baseline mental health, which highlight bullying victimization as a potential target for future intervention efforts. The implementation and rigorous evaluation of bullying prevention programs in South African communities may improve mental health outcomes for HIV/AIDS-affected children and adolescents and this should be a focus of future research and intervention.

Pathways to poor educational outcomes for HIV/AIDS-affected youth in South Africa

A recent systematic review of studies in the developing world has critically examined linkages from familial HIV/AIDS and associated factors such as poverty and child mental health to negative child educational outcomes. In line with several recommendations in the review, the current study modelled relationships between familial HIV/AIDS, poverty, child internalising problems, gender and four educational outcomes: non-enrolment at school, non-attendance, deficits in grade progression and concentration problems. Path analyses reveal no direct associations between familial HIV/AIDS and any of the educational outcomes. Instead, HIV/AIDS-orphanhood or caregiver HIV/AIDS-sickness impacted indirectly on educational outcomes via the poverty and internalising problems that they occasioned. This has implications for evidence-based policy inferences. For instance, by addressing such intervening variables generally, rather than by seeking to target families affected by HIV/AIDS, interventions could avoid exacerbating stigmatisation, while having a more direct and stronger impact on children's educational outcomes. This analytic approach also suggests that future research should seek to identify causal paths, and may include other intervening variables related to poverty (such as child housework and caring responsibilities) or to child mental health (such as stigma and abuse), that are linked to both familial HIV/AIDS and educational outcomes.

Positive parenting for positive parents: HIV/AIDS, poverty, caregiver depression, child behavior, and parenting in South Africa

Families affected by HIV/AIDS in the developing world experience higher risks of psychosocial problems than nonaffected families. Positive parenting behavior may buffer against the negative impact of child AIDS-orphanhood and caregiver AIDS-sickness on child well-being. Although there is substantial literature regarding the predictors of parenting behavior in Western populations, there is insufficient evidence on HIV/AIDS as a risk factor for poor parenting in low- and middle-income countries. This paper examines the relationship between HIV/AIDS and positive parenting by comparing HIV/AIDS-affected and nonaffected caregiver-child dyads (n=2477) from a cross-sectional survey in KwaZulu-Natal, South Africa (27.7% AIDS-ill caregivers; 7.4% child AIDS-orphanhood). Multiple mediation analyses tested an ecological model with poverty, caregiver depression, perceived social support, and child behavior problems as potential mediators of the association of HIV/AIDS with positive parenting. Results indicate that familial HIV/AIDS's association to reduced positive parenting was consistent with mediation by poverty, caregiver depression, and child behavior problems. Parenting interventions that situate positive parenting within a wider ecological framework by improving child behavior problems and caregiver depression may buffer against risks for poor child mental and physical health outcomes in families affected by HIV/AIDS and poverty.

Performance of the Revised Children’s Manifest Anxiety Scale in a Sample of Children and Adolescents from Poor Urban Communities in Cape Town

The Revised Children’s Manifest Anxiety Scale (RCMAS) is regularly used with South African children, although its performance in this context has yet to be empirically evaluated. This study assessed the basic psychometric properties of the RCMAS using data collected in a large study examining the mental health of children and adolescents living in poor urban communities around Cape Town. Reliability of the full-scale was good, and the predicted relationships between anxiety, depression, PTSD, delinquency, age, sex, and somaticism scores offered evidence of construct validity. However, the reliabilities for the physiological, worry/oversensitivity, and concentration subscales were low, and confirmatory factor analysis revealed the hypothesized three-factor model did not adequately fit the data. Exploratory analyses suggested a four-factor solution consisting of social evaluation, worry, affective responses, and physiological symptoms/sleep disturbance factors. Further confirmatory research examining this four-factor structure is needed. Given the continued use of the RCMAS in South Africa, these findings provide an important first step in establishing its reliability and validity for use with South African youth; however, scores obtained on the three subscales should be interpreted with caution and further detailed psychometric evaluation of the RCMAS in South African samples is clearly required.

Pathways from parental AIDS to child psychological, educational and sexual risk: developing an empirically-based interactive theoretical model

Increasing evidence demonstrates negative psychological, health, and developmental outcomes for children associated with parental HIV/AIDS illness and death. However, little is known about how parental AIDS leads to negative child outcomes. This study used a structural equation modelling approach to develop an empirically-based theoretical model of interactive relationships between parental or primary caregiver AIDS-illness, AIDS-orphanhood and predicted intervening factors associated with children's psychological distress, educational access and sexual health. Cross-sectional data were collected in 2009-2011, from 6002 children aged 10-17 years in three provinces of South Africa using stratified random sampling. Comparison groups included children orphaned by AIDS, orphaned by other causes and non-orphans, and children whose parents or primary caregivers were unwell with AIDS, unwell with other causes or healthy. Participants reported on psychological symptoms, educational access, and sexual health risks, as well as hypothesized sociodemographic and intervening factors. In order to build an interactive theoretical model of multiple child outcomes, multivariate regression and structural equation models were developed for each individual outcome, and then combined into an overall model. Neither AIDS-orphanhood nor parental AIDS-illness were directly associated with psychological distress, educational access, or sexual health. Instead, significant indirect effects of AIDS-orphanhood and parental AIDS-illness were obtained on all measured outcomes. Child psychological, educational and sexual health risks share a common set of intervening variables including parental disability, poverty, community violence, stigma, and child abuse that together comprise chain effects. In all models, parental AIDS-illness had stronger effects and more risk pathways than AIDS-orphanhood, especially via poverty and parental disability. AIDS-orphanhood and parental AIDS-illness impact child outcomes through multiple, interlinked pathways. The interactive model developed in this study suggests key areas of focus for interventions with AIDS-affected children.

Psychometric properties of the child PTSD checklist in a community sample of South African children and adolescents

OBJECTIVE

The current study assessed the basic psychometric properties of the Child PTSD Checklist and examined the structure of symptoms of posttraumatic stress disorder (PTSD) in a large sample of South African youth.

METHODOLOGY

The checklist was completed by 1025 (540 male; 485 female) South African youth (aged between 10 and 19 years). The factor structure of the scale was assessed with a combination of confirmatory and exploratory techniques. Internal consistencies for the full scale and all subscales were evaluated with Cronbach's alpha and McDonald's omega. Validity was assessed by comparing PTSD scores obtained by children who had and had not experienced a traumatic event, and by examining associations between total PTSD scores and known correlates of PTSD.

RESULTS

Scores on the Child PTSD Checklist clearly discriminated between youth who had experienced a traumatic event and those who had not. Internal consistencies for the full scale (and all subscales) were acceptable to good and hypothesized correlations between PTSD, depression, anxiety, somatic symptoms, and age were observed. Two of the reported fit statistics for the tripartite DSM-IV-TR model of PTSD did not meet traditional criteria and further exploratory analyses revealed a four-factor structure (broadly consistent with Simms and colleagues' Dysphoria Model of PTSD symptoms) which provided a better fit to the observed data.

CONCLUSION

Given the continued use of the Child PTSD Checklist in South Africa, findings offer an important first step in establishing the reliability and validity of the checklist for use with South African youth. However, further evaluation of the checklist in South African samples is clearly required before conclusions regarding its use as diagnostic tool in this context can be made.

Persisting mental health problems among AIDS-orphaned children in South Africa

BACKGROUND

  By 2008, 12 million children in sub-Saharan Africa were orphaned by AIDS. Cross-sectional studies show psychological problems for AIDS-orphaned children, but until now no longitudinal study has explored enduring psychological effects of AIDS-orphanhood in the developing world.

METHODS

  A 4-year longitudinal follow-up of AIDS-orphaned children with control groups of other-orphans and non-orphans. 1021 children (M = 13.4 years, 50% female, 98% isiXhosa-speaking) were interviewed in 2005 and followed up in 2009 with 71% retention (49% female, M = 16.9 years), in poor urban South African settlements. Children were interviewed using sociodemographic questionnaires and well-validated standardised scales for assessing depression, anxiety, and post-traumatic stress. Data were analysed using mixed-design ANOVA and backward-stepping regression.

RESULTS

  AIDS-orphaned children showed higher depression, anxiety, and post-traumatic stress disorder (PTSD) scores in both 2005 and 2009 when compared with other-orphans and non-orphans. Backward-stepping regression, controlling for baseline mental health, and sociodemographic cofactors such as age, gender, and type of bereavement, revealed that being AIDS-orphaned in 2005 was associated with depression, anxiety, and PTSD scores in 2009. This was not the case for other-orphaned or non-orphaned children. Age interacted with orphan status, such that there was a steep rise in psychological distress in the AIDS-orphaned group, but no rise with age amongst other-orphans and non-orphans.

CONCLUSIONS

  Negative mental health outcomes amongst AIDS-orphaned children are maintained and worsen over a 4-year period. It is important that psychosocial support programmes are sustained, and focus on youth as well as young children.