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While there is a strong link between caregiver mental health, caregiver engagement, and child development, limited research has examined the underlying mechanisms of these associations in Africa. We examined the mediating role of dimensions of caregiver engagement in the association of caregiver psychological distress with children's academic and socioemotional outcomes in Ghana. Data came from 4,714 children (aged 5-17 years) and their caregivers in five regions of northern Ghana. Caregiver psychological distress and engagement (i.e., engagement in education, emotional supportiveness, and parenting self-efficacy) were self-reported by children's primary caregiver. Children's academic (literacy and numeracy) and socioemotional (prosocial skills and socioemotional difficulties) outcomes were directly assessed using validated measures. Structural equation modelling was used to estimate mediation models. We tested moderation by caregiver exposure to formal education, child's age, and child's sex. Fourteen percent of caregivers experienced elevated psychological distress. Higher levels of psychological distress were associated with children's poorer literacy and numeracy skills, and higher socioemotional difficulties, but not prosocial skills. The mediating role of caregiver engagement varied by caregiver exposure to formal education but not child's age or sex. Caregiver engagement in education explained the association between psychological distress and children's literacy skills (but not numeracy or socioemotional) in families where the caregiver had no formal education (indirect effect: ß = 0.007 [95% CI: 0.000, 0.016]), explaining 23% of the association. No mediator explained the association of psychological distress with child outcomes among families where the caregiver had some formal education. The mechanisms through which caregiver psychological distress is associated with child outcomes in rural Ghana differ as a function of caregivers' exposure to formal education. These results highlight the importance of developing multi-component and culturally-sensitive programs to improve child outcomes. Further research in similar contexts is needed to advance scientific understanding on how to effectively promote child and family wellbeing.

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BACKGROUND: Maternal postpartum depression is an important risk factor for internalizing and externalizing problems in children. The role of concurrent paternal depression remains unclear, especially by socioeconomic status. This study examined independent and interactive associations of postpartum maternal and paternal depression with children's internalizing/externalizing symptoms throughout childhood and adolescence (ages 3.5-17 years). METHODS: We used data from the Québec Longitudinal Study of Child Development, a representative birth cohort (1997-1998) in Canada. Data included self-reported maternal and paternal depressive symptoms at 5 months' postpartum using the Center for Epidemiologic Studies Depression Scale. Internalizing and externalizing symptoms in children were reported by parents, teachers and children/adolescents using the Social Behaviour Questionnaire (ages 3.5-13 years) and the Mental Health and Social Inadaptation Assessment for Adolescents (ages 15-17 years). We used three-level mixed effects modelling to test associations after adjusting for confounding factors. RESULTS: With 168 single-parent families excluded, our sample consisted of 1,700 families with useable data. Of these, 275 (16.2%) families reported maternal depression (clinically elevated symptoms), 135 (7.9%) paternal depression and 39 (2.3%) both. In families with high socioeconomic status, maternal depression was associated with greater child internalizing (ß = .34; p < .001) and externalizing symptoms (ß = .22; p = .002), regardless of the presence/absence of paternal depression. In families with low socioeconomic status, associations with symptoms were stronger with concurrent paternal depression (internalizing, ß = .84, p < .001; externalizing, ß = .71, p = .003) than without (internalizing, ß = .30, p < .001; externalizing, ß = .24, p = .002). CONCLUSIONS: Maternal depression increases the risk for children's internalizing/externalizing problems in all socioeconomic contexts. In families with low socioeconomic status, risks were exacerbated by concurrent paternal depression. Postpartum depression, especially in low socioeconomic environments, should be a primary focus to optimize mental health across generations.

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Importance: Depression is a leading cause of disability. The timing and persistence of depression may be differentially associated with long-term mental health and psychosocial outcomes. Objective: To examine if depression symptoms during early and middle childhood and adolescence and persistent depression symptoms are associated with impaired young adult outcomes independent of early risk factors. Design, Setting, and Participants: Data for this prospective, longitudinal cohort study were from the Québec Longitudinal Study of Child Development, a representative population-based Canadian birth cohort. The cohort consists of infants born from October 1, 1997, to July 31, 1998. This is an ongoing study; data are collected annually or every 2 years and include those ages 5 months to 21 years. The end date for the data in this study was June 30, 2019, and data analyses were performed from October 4, 2022, to January 3, 2024. Exposures: Depression symptoms were assessed using maternal reports in early childhood (ages 1.5 to 6 years) from 1999 to 2004, teacher reports in middle childhood (ages 7 to 12 years) from 2005 to 2010, and self-reports in adolescence (ages 13 to 17 years) from 2011 to 2015. Main Outcomes and Measures: The primary outcome was depression symptoms at age 20 years, and secondary outcomes were indicators of psychosocial functioning (binge drinking; perceived stress; not being in education, employment, or training; social support; and experiencing online harrasment) at age 21 years. All outcomes were self-reported. Adult outcomes were reported by participants at ages 20 and 21 years from 2017 to 2019. Risk factors assessed when children were aged 5 months old were considered as covariates to assess the independent associations of childhood and adolescent depression symptoms with adult outcomes. Results: The cohort consisted of 2120 infants. The analytic sample size varied from 1118 to 1254 participants across outcomes (56.85% to 57.96% female). Concerning the primary outcome, adjusting for early risk factors and multiple testing, depression symptoms during adolescence were associated with higher levels of depression symptoms (ß, 1.08 [95% CI, 0.84-1.32]; P < .001 unadjusted and Bonferroni adjusted) in young adulthood. Concerning the secondary outcomes, depression symptoms in adolescence were only associated with perceived stress (ß, 3.63 [95% CI, 2.66-4.60]; P < .001 unadjusted and Bonferroni adjusted), while both middle-childhood (ß, -1.58 [95% CI, -2.65 to -0.51]; P = .003 unadjusted and P < .001 Bonferroni adjusted) and adolescent (ß, -1.97 [95% CI, -2.53 to -1.41]; P < .001 unadjusted and Bonferroni adjusted) depression symptoms were associated with lower levels of social support. There were no associations for binge drinking; not being in education, employment, or training; or experiencing online harrasment. Conclusions and Relevance: In this cohort study of Canadian children and adolescents, childhood and adolescent depression symptoms were associated with impaired adult psychosocial functioning. Interventions should aim to screen and monitor children and adolescents for depression to inform policymaking regarding young adult mental health and psychosocial outcomes.

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BACKGROUND: Interventions supporting parents of young children often target parenting or parental mental health separately. Multi-component parenting and parental mental health interventions have the potential to improve parenting practices, mental health, and early childhood development. We aimed to examine their impact on child and parent outcomes. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science Core Collection, APA PsycINFO, CINAHL Complete, the Cochrane Central Register of Controlled Trials, and the Global Health Database from inception to Jan 23, 2024. Eligible studies were randomised controlled trials of interventions explicitly targeting parenting behaviours and parental mental health antenatally or in children's first 3 years of life. Screening, extraction, and quality assessment were done independently by two authors. Primary outcomes were cognitive and social-emotional functioning in children and depressive symptoms in parents, meta-analysed as standardised mean differences (SMDs), relative to control. This study is registered with PROSPERO, CRD42022302848. FINDINGS: We found 5843 records. After screening 2636 (45·1%) titles and abstracts, we manually identified and screened three additional articles and excluded 2177 records. After screening 462 full-length articles, 25 articles, representing a sample size of 8520 children and caregivers, were included. At baseline, mean caregiver age was 27·7 years (SD 5·9) and mean child age (excluding those enrolled during pregnancy) was 14·4 months (8·0). Interventions lasted a mean of 14 months (SD 11) and used a mean of 3·7 behaviour change techniques (2·0). Most interventions dedicated more time to parenting behaviours than to parental mental health. We found significant intervention effects on children's cognitive (SMD 0·19 [95% CI 0·04 to 0·34]; I2=69%) and social-emotional (0·26 [0·17 to 0·34]; I2=47%) outcomes but not on depressive symptoms in female caregivers (-0·18 [-0·36 to 0·002]; I2=86%) relative to control conditions. Risk of bias across studies was moderate, and we found heterogeneity across results. INTERPRETATION: Multi-component parenting and mental health interventions had a positive effect on child cognitive and social-emotional outcomes, but not on depressive symptoms in parents, suggesting that other factors might contribute to positive ECD outcomes. Interventions might lack adequate focus on mental health to make a discernible impact, highlighting a need for future studies to differentiate and assess contributions of parenting and mental health components to understand independent and collective effects on family outcomes. FUNDING: Canadian Institutes of Health Research.

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This study examined modifiable caregiver factors influencing child development in Malawi using baseline data from 1,021 mothers and their children <2 years of age participating in a cluster-randomized controlled trial implemented in rural Malawi (2022-2025). We fit an evidence-based theoretical model using structural equation modelling examining four caregiver factors: (1) diet diversity (sum of food groups consumed in the past 24 h), (2) empowerment (assessed using the project-level Women's Empowerment in Agriculture Index), (3) mental health (assessed using the Self-Reported Questionnaire, SRQ-20), and (4) stimulation (number of stimulation activities the mother engaged in the past 3 days). Child development was assessed using the Malawi Development Assessment Tool (norm-referenced aggregate Z-score). The model controlled for child, caregiver, and household socioeconomic characteristics. Results showed that caregiver dietary diversity was directly associated with higher child development scores (standardized coefficient 0.091 [95% CI 0.027, 0.153]) and lower SRQ-20 scores -0.058 (-0.111, -0.006). Empowerment was directly associated with higher child development scores (0.071 [0.007, 0.133]), higher stimulation score (0.074 [0.013, 0.140]), higher dietary diversity (0.085 [0.016, 0.145]), and lower SRQ-20 scores (-0.068 [-0.137, -0.002]). Further, higher empowerment was indirectly associated with improved child development through enhancement of caregiver dietary diversity, with an indirect effect of 0.008 (0.002, 0.018). These findings highlight the important role that caregiver diet and empowerment play in directly influencing child development and other aspects of caregiver well-being. Interventions aimed at enhancing child development should consider these factors as potential targets to improve outcomes for children and caregivers.

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BACKGROUND: Providing nurturing care for young children is essential for promoting early child development (ECD). However, there is limited knowledge about how mothers and fathers across diverse contexts in sub-Saharan Africa care for their children and from whom they receive guidance and support in their caregiving roles. We aimed to examine caregivers' nurturing care practices and sources of parenting knowledge in rural Mozambique. METHODS: This is a secondary analysis using data from a qualitative evaluation of a pilot intervention to improve nurturing care for early child health and development within existing health systems. The evaluation was conducted across three primary care health facilities and their catchment areas in Nampula province, Mozambique. For this study, we analyzed data from in-depth interviews conducted with 36 caregivers (32 mothers and 4 fathers) to investigate mothers' and fathers' daily caregiving experiences. Data were analyzed using thematic content analysis. RESULTS: Caregivers described various caregiving roles relating to general caregiving of young children (e.g., feeding, bathing, caring for child's health) and stimulation (e.g., play and communication) activities. Mothers more commonly engaged in general caregiving activities than fathers, whereas both mothers and fathers engaged in stimulation activities. Other family members, including siblings, grandparents, and aunts/uncles, were also actively engaged in general caregiving activities. With respect to sources of parenting knowledge, caregivers received parenting guidance and support primarily from their own mothers/parents and facility-based health providers. CONCLUSIONS: These findings highlight the importance of adopting a holistic approach involving caregivers and their context and reveal potential strategies to promote caregiving and ECD in rural Mozambique and similar contexts.

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This review summarizes the implementation characteristics of parenting interventions to promote early child development (ECD) outcomes from birth to 3 years. We included 134 articles representing 123 parenting trials (PROSPERO record CRD42022285998). Studies were conducted across high-income (62%) and low-and-middle-income (38%) countries. The most frequently used interventions were Reach Up and Learn, Nurse Family Partnership, and Head Start. Half of the interventions were delivered as home visits. The other half used mixed settings and modalities (27%), clinic visits (12%), and community-based group sessions (11%). Due to the lack of data, we were only able to test the moderating role of a few implementation characteristics in intervention impacts on parenting and cognitive outcomes (by country income level) in the meta-analysis. None of the implementation characteristics moderated intervention impacts on cognitive or parenting outcomes in low- and middle-income or high-income countries. There is a significant need in the field of parenting interventions for ECD to consistently collect and report data on key implementation characteristics. These data are needed to advance our understanding of how parenting interventions are implemented and how implementation factors impact outcomes to help inform the scale-up of effective interventions to improve child development.

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OBJECTIVES: To investigate the nature of paternal mental health problems, their causes and the coping strategies used by fathers of young children under the age of 2 years. DESIGN AND SETTING: We conducted in-depth interviews with fathers, mothers, community leaders and community health workers as well as focus group discussions with fathers-only, mothers-only and mixed groups of fathers and mothers. Respondents provided their perspectives on the psychosocial challenges affecting fathers and how fathers responded to their mental health problems. Data were triangulated across stakeholders and analysed using thematic content analysis. SETTING: The study was conducted in four communities in Mwanza, Tanzania. PARTICIPANTS: The total sample included 56 fathers, 56 mothers and 8 community stakeholders that were equally distributed across the four communities. RESULTS: Respondents highlighted a spectrum of mental health concerns affecting fathers, including elevated parenting stress, depressive symptoms, and anxiety. Causes of paternal mental health problems included poverty, child-related concerns, marital problems and family illness. When asked about paternal coping strategies, both fathers and mothers shared that fathers mostly turned to negative coping strategies to manage their distress, such as paternal alcohol use and poor conflict resolution strategies. However, respondents also shared how some fathers used positive coping strategies, such as seeking out social support from their family and friends, engaging in exercise and leisure activities and relying on their faith. CONCLUSIONS: Overall, this study highlights the importance of supporting positive mental health among fathers. Our findings can inform the design of psychosocial programme components that can be integrated within parenting interventions to promote the well-being of specifically fathers and ultimately improve the family caregiving environment.

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BACKGROUND: Multicomponent interventions are needed to address the various co-occurring risks that compromise early child nutrition and development. We compared the independent and combined effects of engaging fathers and bundling parenting components into a nutrition intervention on early child development (ECD) and parenting outcomes. METHODS: We conducted a 2×2 factorial cluster-randomized controlled trial across 80 villages in Mara Region, Tanzania, also known as EFFECTS (Engaging Fathers for Effective Child Nutrition and Development in Tanzania; ClinicalTrials.gov, NCT03759821). Households with children under 18 months of age residing with their mother and father were enrolled. Villages were randomly assigned to one of five groups: a nutrition intervention for mothers, a nutrition intervention for couples, a bundled nutrition and parenting intervention for mothers, a bundled intervention for couples, and a standard-of-care control. Interventions were delivered by trained community health workers through peer groups and home visits over 12 months. Mothers, fathers, and children were assessed at baseline, midline, and endline or postintervention. We used a difference-in-difference approach with intention-to-treat analysis to estimate intervention effects on ECD (Bayley Scales of Infant and Toddler Development, third edition) and maternal and paternal parenting and psychosocial well-being. RESULTS: Between October 29, 2018, and May 24, 2019, 960 households were enrolled (n = 192 per arm). Compared to nutrition interventions, bundled interventions improved children's cognitive (ß = .18 [95% CI: 0.01, 0.36]) and receptive language development (ß = .23 [0.04, 0.41]). There were no differences between interventions for other ECD domains. Compared to nutrition interventions, bundled interventions achieved additional benefits on maternal stimulation (ß = .21 [0.04, 0.38]) and availability of home learning materials (ß = .25 [0.07-0.43]) and reduced paternal parenting distress (ß = -.34 [-0.55, -0.12]). Compared to interventions with mothers only, interventions that engaged fathers improved paternal stimulation (ß = .45 [0.27, 0.63]). CONCLUSIONS: Jointly bundling parenting components into nutrition interventions while also engaging both mothers and fathers is most effective for improving maternal and paternal parenting and ECD outcomes.

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Fathers can influence child development through various pathways, such as via their caregiving behaviors, marital relationships, and their psychosocial wellbeing. However, few parenting interventions have been designed to target these multiple dimensions among fathers with young children in low- and middle-income countries. In June 2022, we conducted qualitative formative research to explore the perceptions surrounding fatherhood and the underlying barriers and enablers to engaged fathering in Mwanza, Tanzania. We completed individual in-depth interviews with 29 fathers and 23 mothers of children under aged 2 years along with 5 community leaders and 3 community health workers. We also completed 10 focus group discussions: 4 with fathers, 2 with mothers, and 4 mixed groups that combined both fathers and mothers. In total, the sample included 120 respondents stratified from across 4 study communities. Data were analyzed using thematic content analysis. Respondents highlighted that poor couples' relationships (e.g., limited male partner support, male dominance in decision-making) and fathers' mental health problems (e.g., parenting stress) were major priorities affecting fathers. Father involvement in parenting, childcare, and household activities were generally low. These dimensions of fatherhood were interlinked (e.g., poor paternal mental health constrained marital relationships and parenting). A constellation of determinants impacted engaged fathering. Common barriers included poverty, restrictive gender attitudes and norms, men's limited time at home, and inadequate knowledge about caregiving. Key enablers included mutual respect in marital relationships and men's desires to show their love for their families. Our results highlight the cultural relevance and the need for multicomponent strategies that jointly target fathers' caregiving, marital relationships, and psychosocial wellbeing for enhancing nurturing care and promoting early child development in Tanzania. Study findings can be used to inform the design of a future father-inclusive, gender-transformative parenting intervention for engaging and supporting fathers with young children in the local cultural context.

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Introduction: In the last decade, there has been increased global policy and program momentum to promote early childhood development. The Care for Child Development (CCD) package, developed by UNICEF and the WHO, is a key tool responding to the global demand. The CCD package comprises two age-specific evidence-based recommendations for caregivers to 1) play and communicate and 2) responsively interact with their children (0-5 years) and was designed to be integrated within existing services to strengthen nurturing care for child development. The aim of this report was to provide an up-to-date global review of the implementation and evaluation of the CCD package. Methods: In addition to a systematic review of 55 reports, we interviewed 23 key informants (including UNICEF and WHO personnel) to better understand the implementation of CCD. Results: The CCD package has been or is being implemented in 54 low- and middle-income countries and territories, and it has been integrated into government services across the health, social, and education sectors in 26 countries. Across these contexts, CCD has been adapted in three primary ways: 1) translations of CCD materials (mostly counseling cards) into local language(s), 2) adaptations of CCD materials for the local context, vulnerable children, or a humanitarian/emergency setting (e.g., including local play activities, using activities that are better suited to children with visual impairments), and 3) substantive modifications to the content of CCD materials (e.g., expansion of play and communication activities, addition of new themes, creation of a structured curriculum). While there is promising evidence and examples of good implementation practice, there has been mixed experience about implementation of CCD with respect to adaptation, training, supervision, integration into existing services, and monitoring implementation fidelity and quality. For example, many users of CCD found difficulties with training the workforce, garnering buy-in from governments, and ensuring benefits for families, among others. Discussion: Additional knowledge on how to improve the effectiveness, implementation fidelity and quality, and acceptance of CCD is needed. Based on the findings of the review we make recommendations for future efforts to implement CCD at-scale.

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The aim of this longitudinal study was to examine bidirectional associations of adolescents' internalizing symptoms with dating violence victimization and perpetration. We conducted secondary analyses of the Québec Longitudinal Study of Child Development data (n = 974). Each adolescent completed items from the Conflict Tactics Scale (at ages 15 and 17 years) to assess psychological, physical, and sexual dating violence victimization and perpetration in the past 12 months. Adolescents' symptoms of depression and general anxiety in the past 12 months were self-reported (at ages 15 and 17 years) using The Mental Health and Social Inadaptation Assessment for Adolescents. There were concurrent associations of adolescents' internalizing symptoms with dating violence victimization and perpetration. Internalizing symptoms at age 15 years were positively associated with dating violence victimization and perpetration 2 years later in both males and females, even after adjusting for baseline characteristics. However, neither dating violence victimization nor perpetration at age 15 years was associated with internalizing symptoms 2 years later. For males and females, internalizing symptoms put adolescents at risk for future dating violence victimization and perpetration. Interventions that target internalizing symptoms may have the potential to decrease subsequent dating violence.

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Maternal self-efficacy (MSE) is associated with healthy functioning in mothers and children globally. Maternal exposure to adverse childhood experiences (ACEs) and intimate partner violence (IPV) is known to negatively impact MSE in high-income countries; however, the association has not been examined in low-and-middle-income countries, such as India, which face socioeconomic risks including poverty, illiteracy, and discrimination based on caste membership. The present study examines the mediating role of IPV in the association between ACEs (specifically-emotional, physical, and sexual abuse, neglect, household dysfunction, and discrimination) and MSE and tests caste membership as a moderator. A community-based, cross-sectional survey was performed with 316 mothers with at least one child between 0 and 24 months in a rural area in the North Indian state of Uttar Pradesh. A structural equation framework was used to test the moderated-mediation model. Results from the moderated-mediation model indicate that greater ACEs exposure was associated with lower MSE and this association was mediated by IPV exposure for low-caste but not high-caste mothers, even after controlling for wealth and literacy. These findings add to existing evidence on ACEs exposure as a significant burden for rural Indian mothers, negatively impacting parenting outcomes such as MSE. The critical role of caste membership is also highlighted, providing implications for future research.

La autoeficacia materna (MSE) se asocia con el saludable funcionamiento en las madres y niños globalmente. Se conoce que el hecho de que la madre haya estado expuesta a experiencias adversas en la niñez (ACE) y a la violencia de la pareja íntima (IPV) tiene un negativo impacto en MSE en países de altas entradas económicas; sin embargo, esta asociación no se ha examinado en países donde las entradas económicas son bajas o medias, como India, que enfrenta riesgos socioeconómicos entre los que se incluyen la pobreza, el analfabetismo, así como la discriminación basada en la pertenencia a una casta. El presente estudio examina el papel mediador de IPV en la asociación entre ACE (específicamente - el abuso emocional, físico y sexual, negligencia, disfuncionalidad en el hogar y discriminación) y MSE, y pone a prueba la pertenencia a una casta como aspecto moderador. Se llevó a cabo una encuesta de base comunitaria e inter-seccional con 316 madres con por lo menos un niño entre 0 y 24 meses de edad en un área rural en el estado de Uttar Pradesh en el norte de India. Se usó un marco de trabajo de ecuación estructural para examinar el modelo de moderación y mediación. Los resultados del modelo de moderación y mediación indican que una mayor exposición a ACE estaba asociada con una más baja MSE y que la exposición a IPV mediaba esa asociación para madres de castas bajas, pero no para madres de castas altas, aun después del factor control de recursos económicos y alfabetismo. Estos resultados contribuyen a la existente evidencia de que el haber estado expuesta a ACE es una carga significativa para las madres en la India rural, la cual tiene un impacto negativo en los resultados de crianza tales como MSE. También se subraya el papel esencial de la pertenencia a una casta, lo cual aporta implicaciones para la investigación futura.

L'auto-efficacité maternelle (MSE en anglais) est globalement liée à un fonctionnement sain chez les mères et les enfants. L'exposition maternelle à des expériences de l'enfance adverses (ACE en anglais) et à la violence intime ou conjugale (IPV) est connue comme impactant de manière négative l'auto-efficacité maternelle dans les pays à revenus élevés. Cependant ce lien n'a pas toujours été examiné dans les pays à faibles ou moyens revenus, tels que l'Inde qui fait face à des risques socioéconomiques qui comportent la pauvreté, l'illettrisme, la discrimination en fonction de l'appartenance à une caste. Cette étude examine le rôle médiateur de la violence conjugale (ou violence entre partenaires intimes) dans le lien entre les ACE (plus spécifiquement l'abus émotionnel, physiques, sexuel, la négligence, la dysfonction au sein du foyer et la discrimination) et l'auto-efficacité maternelle et les tests d'appartenance à une caste en tant que modérateurs. Un questionnaire communautaire, en coupe transversale, a été présenté à 116 mères ayant au moins un enfant entre l'âge de 0-24 mois dans une région rurale de l'état du nord de l'Inde, Uttar Pradesh. Un cadre d'équation structurelle a été utilisé pour tester le modèle de modération-médiation. Les résultats de ce modèle de modération-médiation indiquent que plus l'exposition aux ACE est grande, plus l'auto-efficacité maternelle est basse et cette association est affectée par l'exposition à la violence conjugale pour les castes moins élevées mais pas pour les mères des castes plus élevées, même en effectuant un contrôle pour la richesse et l'alphabétisation. Ces résultats s'ajoutent aux preuves existantes sur l'exposition aux ACE en tant que poids important pour les mères indienne de milieux ruraux, ce qui impacte de manière négative les résultats de parentage telles que l'auto-efficacité maternelle. Le rôle critique de l'appartenance à une caste est également mis en lumière, offrant des implications pour les recherches à venir.

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Maternal depressive symptoms are a robust risk factor for poor cognitive outcomes in children, yet the role of gene-environment interplay in this association is not well understood. The objective of this study was to evaluate gene-environment interaction in the association between maternal depressive symptoms and children's cognitive school readiness. Data come from a population-based birth cohort of 538 twin pairs. Maternal depressive symptoms were self-reported (Centre for Epidemiologic Studies Depression Scale) when children were aged 6 and 18 months (a mean score was used). Children's cognitive school readiness was assessed using the Lollipop Test when children were aged 5 years. Analyses were conducted with structural equation modeling. Maternal depressive symptoms were correlated with children's cognitive school readiness (r = -0.10). Shared environmental factors explained most of the variance in children's cognitive school readiness (52%). The remaining variance was accounted for by genetic (30%) and nonshared environmental factors (18%). As the level of maternal depressive symptoms increased, the relative contribution of nonshared environmental factors to the variance in children's cognitive school readiness increased (0.14 [95% CI: 0.04 to 0.24]), whereas the relative contribution of genetic factors decreased (-0.28 [-0.64 to 0.08]). In contexts of elevated maternal depressive symptoms, environmental - and potentially modifiable - factors may be especially important for shaping children's cognitive outcomes. This suggests that interventions to improve the early childhood environment of children exposed to maternal depressive symptoms may improve their cognitive outcomes.

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BACKGROUND: Although early life factors are associated with increased suicide risk in youth, there is a dearth of research on these associations for individuals growing up in disadvantaged socioeconomic contexts, particularly in low- and middle-income countries (LMICs). We documented the association between individual, familial, and environmental factors in childhood with suicidal ideation among South African youth. METHODS AND FINDINGS: We used data from 2,020 participants in the Birth to Twenty Plus (Bt20+) study, a South African cohort following children born in Soweto, Johannesburg from birth (1990) to age 28 years (2018). Suicidal ideation was self-reported at ages 14, 17, 22, and 28 years, and the primary outcome of interest was suicidal ideation reported at any age. We assessed individual, familial, and socioeconomic characteristics at childbirth and during infancy, adverse childhood experiences (ACEs) between ages 5 and 13 years, and externalizing and internalizing problems between 5 and 10 years. We estimated odds ratios (ORs) of suicidal ideation for individuals exposed to selected childhood factors using logistic regression. Lifetime suicidal ideation was reported by 469 (23.2%) participants, with a 1.7:1 female/male ratio. Suicidal ideation rates peaked at age 17 and decreased thereafter. Socioeconomic adversity, low birth weight, higher birth order (i.e., increase in the order of birth in the family: first, second, third, fourth, or later born child), ACEs, and childhood externalizing problems were associated with suicidal ideation, differently patterned among males and females. Socioeconomic adversity (OR 1.13, CI 1.01 to 1.27, P = 0.031) was significantly associated with suicidal ideation among males only, while birth weight (OR 1.20, CI 1.02 to 1.41, P = 0.03), ACEs (OR 1.11, CI 1.01 to 1.21, P = 0.030), and higher birth order (OR 1.15, CI 1.07 to 1.243, P < 0.001) were significantly associated with suicidal ideation among females only. Externalizing problems in childhood were significantly associated with suicidal ideation among both males (OR 1.23, 1.08 to 1.40, P = 0.002) and females (OR 1.16, CI 1.03 to 1.30, P = 0.011). Main limitations of the study are the high attrition rate (62% of the original sample was included in this analysis) and the heterogeneity in the measurements of suicidal ideation. CONCLUSIONS: In this study from South Africa, we observed that early life social and environmental adversities as well as childhood externalizing problems are associated with increased risk of suicidal ideation during adolescence and early adulthood.

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Human capital-that is the cumulative abilities, education, social skills, and mental and physical health one possesses-is increasingly recognized as key to the reduction of inequality in societies. Adverse childhood experiences have been linked to a range of human capital indicators, with the majority of research in high-income, western settings. This study aims to examine the link between adverse childhood experiences and adult human capital in a South African birth cohort and to test whether associations differ by measurement of adversity. Secondary analysis of data from the Birth to Thirty study was undertaken. Exposure data on adversity was collected prospectively throughout childhood and retrospectively at age 22. Human capital outcomes were collected at age 28. Adversity was measured as single adverse experiences, cumulative adversity, and clustered adversity. All three measurements of adversity were linked to poor human capital outcomes, with risk for poor human capital increasing with the accumulation of adversity. Adversity was clustered by quantity (low versus high) and type (household dysfunction versus abuse). Adversity in childhood was linked to a broad range of negative outcomes in young adulthood regardless of how it was measured. Nevertheless, issues of measurement are important to understand the risk mechanisms that underlie the association between adversity and poor human capital.

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Little is known about the COVID-19 pandemic-related disruptions in health services and the resilience of the health system response in rural low-resource settings. We conducted a phenomenological qualitative study (October-November 2020) to understand COVID-19-related influences on the utilization and delivery of child health services in Monapo district, rural Mozambique. We interviewed 36 caregivers with children <2.5 years, 21 health providers and 4 district health services staff using in-person in-depth interviews. Data were analysed using inductive thematic content analysis. Our findings showed that caregivers, providers and district health services staff unanimously reported a decrease in child consultations at the start of the pandemic. Administrative data from health facilities confirmed persisting declines in monthly consultations. Respondents explained reductions due to miscommunication about health facility operations, fear of COVID-19, reduced consultation schedules and reduced household incomes. Providers reported several challenges in delivering services including lack of caregiver compliance with risk mitigation measures, caregivers' fear of risk mitigation measures, perceived lack of caregiver knowledge about COVID-19 and lack of supplies and protective equipment. All respondents described how COVID-19 had increased food insecurity and food prices and reduced incomes and livelihoods. These negative economic consequences were perceived as the main reason for reported increases in cases of child malnutrition. Despite reductions, child health service utilization and delivery have largely continued throughout the COVID-19 pandemic, indicating an adaptive and resilient primary health system response in Monapo district. Our findings highlighted the persistent difficulties providers and caregivers face adhering to COVID-19 prevention and risk mitigation measures. A coordinated multi-sectoral response is needed to address the persistent negative economic impacts of the pandemic for young children and their families in rural areas.

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BACKGROUND: Maternal depressive symptoms (MDSs) are negatively associated with children's academic performance, with stronger effects sometimes reported in boys. However, few studies have tested the mechanisms of this association. We examined the mediating role of school engagement and peer victimization in this association and tested for sex differences. METHODS: Participants were 1173 families from a population-based longitudinal Canadian study. MDSs were self-reported annually using the Centre for Epidemiologic Studies Depression Scale (child's age: 5 months to 5 years). Data on mediators (peer victimization, cognitive, behavioral, and emotional school engagement) were reported annually from ages 6-10 by multiple informants including children, parents, and teachers using items from validated scales. Mathematics, reading, and writing exam scores at age 12 were obtained from standardized exams administered by Québec's Ministry of Education and Teaching. Structural equation modeling was used to test mediation by school experiences in boys and girls. RESULTS: Exposure to MDSs was negatively associated with mathematics, reading, and writing scores in girls and with mathematics only in boys. Cognitive and behavioral engagement significantly mediated the association between MDSs and mathematics, reading, and writing scores in girls. There were no significant mediators for boys. CONCLUSIONS: Prevention and intervention strategies aiming to improve school engagement might be beneficial for daughters of mothers experiencing depressive symptoms. Further research is needed to replicate these findings and to identify the mechanisms explaining this association in boys.

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Health systems offer unique opportunities for integrating services to promote early child development (ECD). However, there is limited knowledge about the implementation experiences of using health services to target nurturing care and ECD, especially in sub-Saharan Africa. We conducted a qualitative implementation evaluation to assess the delivery, acceptability, perceived changes, and barriers and facilitators associated with a pilot strategy that integrated developmental monitoring, nutritional screening, and early learning and nutrition counseling into the existing health facility, and community-based services for young children in rural Mozambique. We completed individual interviews with caregivers (N = 36), providers (N = 27), and district stakeholders (N = 10), and nine facility observational visits at three primary health facilities in October-November 2020. We analyzed data using thematic content analysis. Results supported fidelity to the intended pilot model and acceptability of nurturing care services. Respondents expressed various program benefits, including strengthened health system capacity and improved knowledge, attitudes, and practices regarding nurturing care and ECD. Government leadership and supportive supervision were key facilitators, whereas health system resource constraints were key barriers. We conclude that health systems are promising platforms for supporting ECD and discuss several programmatic recommendations for enhancing service delivery and maximizing potential impacts on nurturing care and ECD outcomes.

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