Kirsty Donald

Investigating the psychosocial determinants of child health in Africa: the Drakenstein Child Health Study

BACKGROUND Early life psychobiological and psychosocial factors play a key role in influencing child health outcomes. Longitudinal studies may help elucidate the relevant risk and resilience profiles, and the underlying mechanisms that impact on child health, but there is a paucity of birth cohort data from low and middle-income countries (LMIC). We describe the rationale for and present baseline findings from the psychosocial component of the Drakenstein Child Health Study (DCHS). METHODS We review the psychosocial measures used in the DCHS, a multidisciplinary birth cohort study in a peri-urban area in South Africa, and provide initial data on psychological distress, depression, substance use, and exposure to traumatic stressors and intimate partner violence (IPV). These and other measures will be assessed longitudinally in mothers in order to investigate associations with child neurodevelopmental and health outcomes. RESULTS Baseline psychosocial data is presented for mothers (n=634) and fathers (n=75) who have completed antenatal assessments to date. The sample of pregnant mothers is characterized by multiple psychosocial risk factors, including a high prevalence of psychological distress and depression, high levels of substance use, and high exposure to traumatic stressors and IPV. DISCUSSION These data are consistent with prior South African studies which have documented a high prevalence of a multitude of risk factors during pregnancy. Further longitudinal assessment of mothers and children may clarify the underlying psychobiological and psychosocial mechanisms which impact on child health, and so inform clinical and public health interventions appropriate to the South African and other LMIC contexts.

Autism and the Grand Challenges in Global Mental Health

There is increasing recognition of the global burden related to mental and neurological conditions greatly surpassing many health conditions such as cardiovascular disease and cancer. Recently, partnership among leading funders and academics has given rise to the grand challenges in global mental health initiative, aiming to reduce the global burden associated with mental and neurological conditions [Collins et al., 2011]. Among the actions of this initiative was a priority-setting exercise to articulate the most pressing challenges research in this area needs to address. Representing a diverse group of researchers and practitioners, we collectively considered progress and barriers in these priorities as they apply to autism research. In this editorial, we describe, based on our knowledge of and direct experience with autism in lowand middle-income countries (LMICs), the state of the science corresponding to the grand challenges and offer suggestions for how a truly global approach to autism research can bridge knowledge gaps leading to substantive improvements in quality of life for those affected wherever they may be.

White matter integrity and cognitive performance in children with prenatal methamphetamine exposure

There is emerging evidence on the harmful effects of prenatal methamphetamine (MA) exposure on the structure and function of the developing brain. However, few studies have assessed white matter structural integrity in the presence of prenatal MA exposure, and results are inconsistent. This investigation thus used diffusion tensor imaging (DTI) to investigate white matter microstructure and cognitive performance in a group of prenatal MA exposed (or MA) children and controls of similar age. Seventeen MA children and 15 healthy controls (aged 6-7 years) underwent DTI and assessment of motor function and general cognitive ability. Whole brain analyses of white matter structure were performed using FSLs tract-based spatial statistics comparing fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD) and axial diffusivity (AD). Mean diffusion values were extracted from white matter regions shown to differ across groups to determine whether variations in FA predicted cognitive performance. Analyses were controlled for maternal nicotine use. MA children showed significantly lower FA as well as higher MD, RD and AD in tracts that traverse striatal, limbic and frontal regions. Abnormal FA levels in MA children were significantly associated with poorer motor coordination and general cognitive ability sub-items that relate to aspects of executive function. Our findings suggest that, consistent with previous studies in older children, there are disruptions of white matter microstructural integrity in striatal, limbic and frontal regions of young MA exposed children, with prominent cognitive implications. Future longitudinal studies may clarify how prenatal MA exposure affects white matter structural connectivity at different stages of brain maturation.

Clinical characteristics and neurodevelopmental outcomes of children with tuberculous meningitis and hydrocephalus

Tuberculous meningitis (TBM) is a lethal and commonly occurring form of extra‐pulmonary tuberculosis in children, often complicated by hydrocephalus which worsens outcome. Despite high mortality and morbidity, little data on the impact on neurodevelopment exists. We examined the clinical characteristics, and clinical and neurodevelopmental outcomes of TBM and hydrocephalus.

Preliminary Validation of a New Developmental Screening Tool for Neurodevelopmental Delay in HIV-Infected South African Children

Screening for developmental delays among HIV-infected children is not routine in most pediatric HIV clinics in Africa because of the lack of locally adaptable, simple, sensitive and rapid screening tools. The Division of Developmental Pediatrics of the Red Cross War Memorial Children’s Hospital developed a tool for rapid screening of moderate to severe global developmental delays among HIV-infected children aged 9 to 36 months. The diagnostic accuracy of the novel screening tool was evaluated. Forty-seven HIV-infected children aged 9 to 36 months were screened using the Red Cross War Memorial Children’s Hospital developmental screening tool. Full developmental assessments of same children were performed using the Bayley Scales of Infant and Toddler Development, Third Edition. The Red Cross War Memorial Children’s Hospital tool’s sensitivity was 78.5%, specificity 54.6%, positive predictive value was 42.6%, and negative predictive value was 85.4%. The Red Cross War Memorial Children’s Hospital screening tool was adequately sensitive and therefore recommended for screening of moderate to severe developmental delays among HIV-infected children.

Spina bifida: a multidisciplinary perspective on a many-faceted condition.

Open spina bifida or myelomeningocele (SBM) is the most common birth defect involving the central nervous system, second only in incidence to congenital cardiac disease. Outcomes in this disorder were poor until the mid-20th century, when modern neurosurgical techniques (closing the lesion and treating hydrocephalus) and treatment for the neuropathic bladder addressed the major causes of mortality, although SBM may still be poorly treated in the developing world. Initial management - or mismanagement - has a profound impact on survival and long-term quality of life.

An approach to the developmental and cognitive profile of the child with spina bifida

Myelomeningocele, or open spina bifida (SBM), is the most common congenital defect of the central nervous system. The brain anomalies described in SBM are varied and contribute to the complex phenotypic outcomes in neurocognition and behaviour. Several factors have an impact on the severity and type of cognitive outcome. The strongest association with cognitive dysfunction is the presence of hydrocephalus and its complications. Hydrocephalus occurs in 80 - 95% of cases and typically results in attenuation of cerebral white matter, particularly in the posterior aspects of the brain, which is important in the development of spatial skills.

Maltreatment in childhood and intimate partner violence: A latent class growth analysis in a South African pregnancy cohort

Intimate partner violence (IPV) is a significant global problem, prevalent in low and middle-income countries (LMICs). IPV is particularly problematic during the perinatal and early postnatal period, where it is linked with negative maternal and child health outcomes. There has been little examination of profiles of IPV and early life adversity in LMIC contexts. We aimed to characterize longitudinal IPV and to investigate maternal maltreatment in childhood as a predictor of IPV exposure during pregnancy and postnatally in a low resource setting. This study was nested in the Drakenstein Child Health Study, a longitudinal birth cohort. Maternal IPV (emotional, physical and sexual) was measured at six timepoints from pregnancy to two years postpartum (n = 832); sociodemographic variables and maternal maltreatment in childhood were measured antenatally at 28–32 weeks’ gestation. Associations between maternal maltreatment in childhood and IPV latent class membership (to identify patterns of maternal IPV exposure) were estimated using multinomial and logistic regression. We observed high levels of maternal maltreatment during childhood (34%) and IPV during pregnancy (33%). In latent class analysis separating by IPV sub-type, two latent classes of no/low and moderate sexual IPV and three classes of low, moderate, and high emotional and physical IPV (separately) were detected. In combined latent class analysis, including all IPV sub-types together, a low, moderate and high exposure class emerged as well as a high antenatal/decreasing postnatal class. Moderate and high classes for all IPV sub-types and combined analysis showed stable intensity profiles. Maternal childhood sexual abuse, physical abuse and neglect, and emotional abuse predicted membership in high IPV classes, across all domains of IPV (aORs between 1.99 and 5.86). Maternal maltreatment in childhood was associated with increased probability of experiencing high or moderate intensity IPV during and around pregnancy; emotional neglect was associated with decreasing IPV class for combined model. Intervening early to disrupt this cycle of abuse is critical to two generations.

Prevalence of early childhood disability in a rural district of Sind, Pakistan

Worldwide, estimates are that approximately a third of the 200 million children under 5 years old living in resourcepoor countries are failing to reach their potential because of the effects of multiple risk factors (including poverty, malnutrition/stunting, poor health, and psychosocial deprivation). However, what remains poorly defined is what proportion of these children has developmental disability. Prevalence estimates for disability in lowand middleincome countries (LMIC) range from 0.09 to 18.3%. Data from these countries are often poor, with the studies small or restricted, and methodology variable. National or published statistics on young children’s cognitive or socialemotional development are not available for most LMICs and this gap contributes to the under-recognition of developmental delay and disability in these environments. What is known is that disability is shared unequally. According to the 2011 UNICEF world report on disability, 80% of people with disabilities live in LMICs, where the increasing burden of non-communicable diseases accounts for two-thirds of disabilities. Ibrahim and Bhutta attempt to address this data gap in a vulnerable, largely impoverished population in rural Pakistan. This is a large population-based study which looked at an under-represented population in the literature on disability prevalence. Rural areas are less accessible than semiurban or urban populations, and therefore are more expensive and logistically complicated to study. The authors also chose to include children under 2 years old which is a far more specialized, but important group to assess. The rather surprising prevalence of 5.5 per 1000 in the 0 to 2-year age bracket, and 5.4 per 1000 in the 2to 5-year age bracket respectively, may well be a reflection of the lack of parental insight into expected developmental milestones and potential disabilities in their children, rather than representing this lower than expected prevalence. Though widely validated as a tool across cultures and continents for the screening of childhood disability, the Ten Questions screen is likely to be less reliable in populations such as this where there is less than 50% literacy and of the group of parents who were reported as literate, less than 50% had completed primary school education. Future studies may want to look at using a second stage assessment with a more in-depth developmental assessment tool. Repeating the screening tool, which even if administered by trained medical personnel still only reflects parental insight, is unlikely to pick up the false negatives in the group. Although these data are important to report, they are likely to be an under-representation of disability in this population. This reflects the reality for the vast majority of the population in LMICs. The recognition of an infant or young child with a disability relies on the parents or caregivers identifying a problem and presenting to medical facilities. In countries where levels of parental education are low, access to even the most basic health services is poor, and the burden of acute diseases high, many children with special needs remain unrecognized and hence without appropriate intervention. Initiatives which show promise include targeted programmes aimed at particularly vulnerable groups of children with ongoing medical needs (such as HIVpositive children). Harnessing a model of linking developmental followup and stimulation to medical care visits integrated with nutritional and social support seems to be achieving anecdotal success in some communities. As a global strategy, targeting families and/or communities solely on the basis of psychosocial or biomedical risk is not justified from a scientific or ethical standpoint. A universal or whole-population programme must be the core of any reliable and effective early intervention strategy. The targeting of risk is most effective when it is done from a strong base of universal services that is not only accessible but is actually accessed by all children and families. Programmes such as the one described above can provide a model for multi-sector collaboration which must be the future strategy. In resource-poor countries across the globe where significant proportions of young children are challenged by impoverished environments, risks to health, under-nutrition, and compromised care and stimulation, programmes should attend to children’s physical, social, and emotional needs, as well as providing developmental support and screening. Successful management of children’s physical health and developmental trajectory in LMICs will continue to require firm political and financial commitment across many sectors.