Understanding priorities and needs for child and adolescent mental health in Greece from multiple informants: an open resource dataset.

The Child and Adolescent Mental Health Initiative (CAMHI) aims to enhance mental health care capacity for children and adolescents across Greece. Considering the need for evidence-based policy, the program developed an open-resource dataset for researching the field within the country. A comprehensive, mixed-method, community-based research was conducted in 2022/2023 assessing the current state, needs, barriers, and opportunities according to multiple viewpoints. We surveyed geographically distributed samples of 1,756 caregivers, 1,201 children/adolescents, 404 schoolteachers, and 475 health professionals using validated instruments to assess mental health symptoms, mental health needs, literacy and stigma, service use and access, professional practices, training background, and training needs and preferences. Fourteen focus groups were conducted with informants from diverse populations (including underrepresented minorities) to reach an in-depth understanding of those topics. A dataset with quantitative and qualitative findings is now available for researchers, policymakers, and society [ https://osf.io/crz6h/ and https://rpubs.com/camhi/sdashboard ]. This resource offers valuable data for assessing the needs and priorities for child and adolescent mental health care in Greece. It is now freely available to consult, and is expected to inform upcoming research and evidence-based professional training. This initiative may inspire similar ones in other countries, informing methodological strategies for researching mental health needs.

Translation and cross-cultural adaptation of seventeen widely-used assessment instruments for child and adolescent mental health in Greece.

BACKGROUND: In the context of Greece, many instruments measuring constructs pertinent to child and adolescent mental health lacked a locally-validated, freely-available version. As part of a nationwide survey, we translated and cross-culturally adapted a collection of seventeen brief, largely-employed assessment tools that can be used at scale. METHODS: This study is part of the Child and Adolescent Mental Health Initiative in Greece (CAMHI), a capacity-building program focusing on enhancing mental health care for children and adolescents living in Greece. We conducted a nationwide survey assessing mental health symptoms, parenting practices, service availability and quality, mental health literacy and stigma, and professional practices within the country. As part of this process, we selected outcomes and instruments after consulting the International Consortium for Health Outcomes Measurement (ICHOM) and the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). From our selection, we identified 17 instruments that did not have a Greek-validated version available for use. These instruments were translated and cross-culturally adapted following a structured procedure, including independent back-and-forth translations, synthesis of versions, expert revision, and pilot testing. Some instruments were slightly modified to meet CAMHI survey purposes. RESULTS: A cross-culturally adapted version in Greek was made available for the following instruments: Pediatric Symptoms Checklist (PSC); Deliberate Self Harm Inventory (DSH) (modified); Child and Adolescent Trauma Screen-2 (CATS-2); ABCD Screen Use (modified); Swanson, Nolan, and Pelham-IV (SNAP-IV); Parent Behavior Inventory (PBI); Mental Health Literacy Scale (MHLS)-(modified); Australian Mental Health Vignettes; Reported and Intended Behavior Scale (RIBS); Barriers to Access to Care (BACE) (modified); Experience of Service Questionnaire (ESQ) (modified); and Multitheoretical List of Therapeutic Interventions (MULTI-30) (modified). CONCLUSION: A collection of these widely-used assessment tools is now adapted for the local context and freely accessible at [ https://osf.io/crz6h/ ]. Researchers and health professionals in Greece can utilize this resource to screen, evaluate, and monitor various constructs related to mental health in accordance with the most effective practices.

Worldwide Prevalence and Disability From Mental Disorders Across Childhood and Adolescence: Evidence From the Global Burden of Disease Study.

Importance: The period from childhood to early adulthood involves increased susceptibility to the onset of mental disorders, with implications for policy making that may be better appreciated by disaggregated analyses of narrow age groups. Objective: To estimate the global prevalence and years lived with disability (YLDs) associated with mental disorders and substance use disorders (SUDs) across 4 age groups using data from the 2019 Global Burden of Disease (GBD) study. Design, Setting, and Participants: Data from the 2019 GBD study were used for analysis of mental disorders and SUDs. Results were stratified by age group (age 5 to 9, 10 to 14, 15 to 19, and 20 to 24 years) and sex. Data for the 2019 GBD study were collected up to 2018, and data were analyzed for this article from April 2022 to September 2023. Exposure: Age 5 to 9 years, 10 to 14 years, 15 to 19 years, and 20 to 24 years. Main Outcomes and Measures: Prevalence rates with 95% uncertainty intervals (95% UIs) and number of YLDs. Results: Globally in 2019, 293 million of 2516 million individuals aged 5 to 24 years had at least 1 mental disorder, and 31 million had an SUD. The mean prevalence was 11.63% for mental disorders and 1.22% for SUDs. For the narrower age groups, the prevalence of mental disorders was 6.80% (95% UI, 5.58-8.03) for those aged 5 to 9 years, 12.40% (95% UI, 10.62-14.59) for those aged 10 to 14 years, 13.96% (95% UI, 12.36-15.78) for those aged 15 to 19 years, and 13.63% (95% UI, 11.90-15.53) for those aged 20 to 24 years. The prevalence of each individual disorder also varied by age groups; sex-specific patterns varied to some extent by age. Mental disorders accounted for 31.14 million of 153.59 million YLDs (20.27% of YLDs from all causes). SUDs accounted for 4.30 million YLDs (2.80% of YLDs from all causes). Over the entire life course, 24.85% of all YLDs attributable to mental disorders were recorded before age 25 years. Conclusions and Relevance: An analytical framework that relies on stratified age groups should be adopted for examination of mental disorders and SUDs from childhood to early adulthood. Given the implications of the early onset and lifetime burden of mental disorders and SUDs, age-disaggregated data are essential for the understanding of vulnerability and effective prevention and intervention initiatives.

Reimagining mental health care for newcomer children and families: a qualitative framework analysis of service provider perspectives.

BACKGROUND: Persistent disparities in access to mental health care for refugee and immigrant children and their families pose unique challenges to policy and practice. This study examined service provider perspectives on the barriers and opportunities for improving mental health supports for newcomer children and families in Canada. METHODS: Semi-structured individual and group interviews were conducted with 33 leadership and frontline staff from 14 organizations in the health, education, settlement, and social service sectors in Hamilton, Ontario. Interview data were analyzed using the framework method. RESULTS: Participants described barriers at the systems, provider, and individual and family levels that prevented newcomer families from accessing and benefiting from mental health supports. Structural barriers included inadequate services and funding, complexity of systems, cultural tensions, and, lack of prevention and early identification. Provider-level barriers included lack of representation, mental health knowledge and cultural competency, and staff shortages and burnout. Individual and family-level barriers included lack of mental health literacy, primacy of settlement needs, stigma, fear, and the high threshold for help-seeking. Participants' recommendations for "reimagining care" related to newcomer engagement, person- and family-centered care, cultural responsiveness, mental health promotion and prevention, workforce diversity and development, collaborative and integrated care, and knowledge generation and uptake. CONCLUSIONS: The intersection of structural, provider, and individual/family-level barriers reduce newcomer families' access to and effectiveness of mental health supports. Reducing disparities in mental health and access to care will require a paradigm shift in the way that mental health care is conceptualized and delivered to newcomer children and families.

A protocol for a scoping review of equity measurement in mental health care for children and youth.

BACKGROUND: Mental health (MH) problems are among the most important causes of morbidity and mortality for children and youth. Problems of lack of equity in child and youth MH services (CYMHS)-including, but not limited to, problems in inaccessibility and quality of services-are widespread. Characterizing the nature of equity in CYMHS is an ongoing challenge because the field lacks a consistent approach to conceptualizing equity. We will conduct a scoping review of how equity in MH services for children and youth has been defined, operationalized, and measured. Our objectives are to discover: (1) What conceptual definitions of equity are used by observational studies of CYMHS?; (2) What service characteristics of CYMHS care do indices of equity cover?; (3) What population dimensions have been used to operationalize equity?; (4) What statistical constructs have been used in indices that measure CYMHS equity?; and (5) What were the numerical values of those indices? METHODS: The following databases will be searched: Medline, Embase, PsycINFO, Cochrane Controlled Register of Trials, CINAHL, EconLit, and Sociological Abstracts. Searches will be conducted from the date of inception to the end of the last full calendar year (December 2019). Studies will be included if they include an evaluation of a mental health service for children or youth (defined as those under 19 years of age) and which quantify variation in some aspect of child or youth mental health services (e.g., accessibility, volume, duration, or quality) as a function of socio-demographic and/or geographic variables. Study selection will occur over two stages. Stage one will select articles based on title and abstract using the liberal-accelerated method. Stage two will review the full texts of selected titles. Two reviewers will work independently on full-text reviewing, with each study screened twice using pre-specified eligibility criteria. One reviewer will chart study characteristics and indices to be verified by a second reviewer. Reviewers will resolve full-text screening and data extraction disagreements through discussion. Synthesis of the collected data will focus on compiling and mapping the types and characteristics of the indices used to evaluate MH services equity. DISCUSSION: The planned, systematic scoping review will survey the literature regarding how equity in MH services for children and youth has been operationalized and help inform future studies of equity in CYMHS. SYSTEMATIC REVIEW REGISTRATION: Open Science Foundation ID SYSR-D-19-00371, https://osf.io/58srv/ .

Social assistance and trajectories of child mental health problems in Canada: evidence from the National Longitudinal Survey of Children and Youth.

OBJECTIVES: To examine the link between stability and change in social assistance (SA) use and children's mental health trajectories to better understand whether social policies targeted at low-income families might be an effective population-based mechanism for preventing mental health problems among children at risk. METHODS: The National Longitudinal Survey of Children and Youth (N = 8981) is used to classify children into 5 categories based on their family's pattern of SA use from age 4-5 to 10-11: always or never on SA, a single transition on or off SA, or fluctuations on and off SA. Latent growth modelling is used to compare trajectories of emotional and behavioural problems among children with different patterns of SA exposure to their counterparts never on SA over this same time period. RESULTS: Child emotional and behavioural problems are exacerbated over time in accordance with patterns of SA use: chronic SA use (behavioural) and moving onto SA (emotional and behavioural). These differential rates of change result in mental health disparities at age 10-11 that were not present at age 4-5. Children exposed to SA when they were age 4-5 but subsequently moved off continue to demonstrate elevated levels of emotional and behavioural problems at age 10-11. CONCLUSIONS: Successful social policies and interventions will require understanding the specific mechanisms through which SA undermines child mental health and how programs can be modified to reduce its negative consequences.

Area-Level Variation in Children's Unmet Need for Community-Based Mental Health Services: Findings from the 2014 Ontario Child Health Study.

There is limited empirical evidence documenting the magnitude and correlates of area-level variability in unmet need for children's mental health services. Research is needed that identifies area-level characteristics that can inform strategies for reducing unmet need in the population. The study purpose is to: (1) estimate area-level variation in children's unmet need for mental health services (using Service Areas as defined by the Ontario Ministry of Children and Youth Services), and (2) identify area-level service arrangements, and geographic and population characteristics associated with unmet need. Using individual-level general population data, area-level government administrative data and Census data from Ontario, Canada, we use multilevel regression models to analyze unmet need for mental health services among children (level 1) nested within Service Areas (level 2). The study finds that 1.64% of the reliable variance in unmet need for mental health services is attributable to between-area differences. Across areas, we find that Service Areas with more agencies had a lower likelihood of unmet need for mental health services. Compared to other Service Areas, Toronto had much lower likelihood of unmet need compared to the rest of Ontario. Rural areas, areas with unsatisfactory public transport, and areas with higher levels of socio-economic disadvantage had a higher likelihood of unmet need for mental health services. These findings identify challenges in service provision that researchers, policymakers and administrators in children's mental health services need to better understand. Policy implications and potential Service Area strategies that could address equitable access to mental health services are discussed.

Examining the relationships between parent experiences and youth self-reports of slapping/spanking: a population-based cross-sectional study.

BACKGROUND: Slapping/spanking is related to a number of poor health outcomes. Understanding what factors are related to the increased or decreased use of spanking/slapping is necessary to inform prevention. This study used a population-based sample to determine the prevalence of slapping/spanking reported by youth; the relationship between sociodemographic factors and slapping/spanking; and the extent to which parental exposures to victimization and maltreatment in childhood and current parental mental health, substance use and family circumstances, are associated with youth reports of slapping/spanking. METHODS: Data were from the 2014 Ontario Child Health Study, a provincially representative sample of households with children and youth aged 4-17 years. Self-reported lifetime slapping/spanking prevalence was determined using a sub-sample of youth aged 14-17 years (n = 1883). Parents/primary caregivers (i.e., person most knowledgeable (PMK) of the youth) self-reported their own childhood experiences including bullying victimization, slapping/spanking and child maltreatment, and current mental health, substance use and family circumstances including mental health functioning and emotional well-being, alcohol use, smoking, marital conflict and family functioning. Analyses were conducted in 2018. RESULTS: Living in urban compared to rural residence and family poverty were associated with decreased odds of slapping/spanking. PMK childhood experiences of physical and verbal bullying victimization, spanking, sexual abuse, emotional abuse, and exposure to physical intimate partner violence were associated with increased odds of youth reported slapping/spanking (adjusted odds ratio [AOR] ranged from 1.33-1.77). PMK experiences of physical abuse and exposure to emotional/verbal intimate partner violence in childhood was associated with decreased odds of youth reported slapping/spanking (AOR = 0.72 and 0.88, respectively). PMK's higher levels of marital conflict, languishing to moderate mental health functioning and emotional well-being, and moderate or greater alcohol use were associated with increased odds of youth reported slapping/spanking (AOR ranged from 1.36-1.61). CONCLUSIONS: It may be important to consider parent/primary caregiver's childhood experiences with victimization and maltreatment along with their current parental mental health, substance use and family circumstances when developing and testing strategies to prevent slapping/spanking.

Children's Mental Health Need and Expenditures in Ontario: Findings from the 2014 Ontario Child Health Study.

OBJECTIVE: To estimate the alignment between the Ontario Ministry of Children and Youth Services (MCYS) expenditures for children's mental health services and population need, and to quantify the value of adjusting for need in addition to population size in formula-based expenditure allocations. Two need definitions are used: "assessed need," as the presence of a mental disorder, and "perceived need," as the subjective perception of a mental health problem. METHODS: Children's mental health need and service contact estimates (from the 2014 Ontario Child Health Study), expenditure data (from government administrative data), and population counts (from the 2011 Canadian Census) were combined to generate formula-based expenditure allocations based on 1) population size and 2) need (population size adjusted for levels of need). Allocations were compared at the service area and region level and for the 2 need definitions (assessed and perceived). RESULTS: Comparisons were made for 13 of 33 MCYS service areas and all 5 regions. The percentage of MCYS expenditure reallocation needed to achieve an allocation based on assessed need was 25.5% at the service area level and 25.6% at the region level. Based on perceived need, these amounts were 19.4% and 27.2%, respectively. The value of needs-adjustment ranged from 8.0% to 22.7% of total expenditures, depending on the definition of need. CONCLUSION: Making needs adjustments to population counts using population estimates of children's mental health need (assessed or perceived) provides additional value for informing and evaluating allocation decisions. This study provides much-needed and current information about the match between expenditures and children's mental health need.

Association of immigrant generational status with asthma.

OBJECTIVE: We sought to examine whether asthma risk is lower in second-generation immigrants (i.e., Canadian-born children with at least one foreign-born parent) and first-generation immigrants (i.e., foreign-born children) compared with non-immigrants (i.e., Canadian-born children to Canadian-born parents). METHODS: Data were obtained from the Canadian National Longitudinal Survey of Children and Youth from 1994 to 2008, which measured child health and developmental factors from birth to early adulthood. The sample included 15,799 participants aged 2-26 years. Asthma was defined as diagnosis by a health professional as having asthma, having wheezing or whistling in the chest, or use of medication for asthma. RESULTS: Prevalence of asthma (defined as a combination of any three factors) was lower in first-generation (32%) and second-generation (34%) immigrants compared with non-immigrants (46%). After controlling for covariates, first- and second-generation immigrants had 0.21 (AOR = 0.21; 95% CI = 0.07-0.67) and 0.19 (AOR = 0.19; 95% CI = 0.09-0.39) lower odds of reporting asthma compared with non-immigrants, respectively. For every year the parent(s) of second-generation immigrants resided in Canada, the odds for asthma increased by 5% (AOR = 1.05; 95% CI = 1.02-1.06). CONCLUSION: Immigrant children and youth in Canada, regardless of whether they are first- or second-generation, have lower odds for asthma compared with non-immigrants.

Community- and individual-level factors associated with smoking and heavy drinking among Aboriginal people in Canada.

OBJECTIVES: 1) To examine the association between place of residence (i.e., on- versus off-communities and between provinces) and daily smoking and heavy drinking among Aboriginal people in Canada; and 2) to identify community- and individual-level factors that may account for these associations. METHODS: Data were from the Aboriginal Peoples Survey (2001). The sample included 52,110 Aboriginal people (≥ 15 years of age). Community-level variables included: place of residence, community socio-economic status (SES) and perceived community social problems. Individual-level variables included: age, sex, education, income, employment status, marital status, Aboriginal heritage and social support. Multilevel logistic regressions were conducted to analyze the data. RESULTS: Living in First Nations communities (compared with living off-communities) was associated with daily smoking, and this association was accounted for by perceived community social problems. However, the association between Inuit communities and daily smoking remained after controlling for all covariates (odds ratio (OR) = 1.97, 95% confidence intervals (CI) = 1.44-2.70). Residence in First Nations communities was associated with heavy drinking (OR = 1.54, 95% CI = 1.17-2.04), however this risk became evident only after controlling for community SES, which was also positively associated with heavy drinking (OR = 1.46, 95% CI = 1.26-1.69). Compared with Saskatchewan, Aboriginal people in Atlantic Provinces (OR = 2.80, 95% CI = 2.08-3.78) or Territories (OR = 1.39, 95% CI = 1.01-1.92) were more likely to engage in heavy drinking. CONCLUSION: Studies are needed to better understand the increased risk for smoking in Inuit communities and heavy drinking in First Nations communities, Atlantic Provinces and Territories, and to identify possible reasons for the positive association between community SES and heavy drinking among Aboriginal people.

Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born?

We conducted a systematic review to examine first generation immigrant adolescents' likelihood of experiencing bullying, violence, and suicidal behaviours compared to their later-generation and native born counterparts, and to identify factors that may underlie these risks. Eighteen studies met full inclusion criteria. First generation immigrant adolescents experience higher rate of bullying and peer aggression compared to third generation and native counterparts. Refugee status and advanced parental age were associated with increased parent to child aggression among South East Asians. Family cohesion was associated with lower rates of violence. Suicidal ideation was lower across most immigrant adolescents' ethnicities, with the exception of Turkish and South Asian Surinamese female adolescents in the Netherlands. Bullying and peer aggression of immigrant children and adolescents and potential mitigating factors such as family cohesion warrant research and program attention by policymakers, teachers and parents.

Caesarean delivery and neonatal mortality rates in 46 low- and middle-income countries: a propensity-score matching and meta-analysis of Demographic and Health Survey data.

BACKGROUND: Previous research on the association between caesarean delivery (CD) and neonatal mortality has had methodological limitations and given conflicting results. We conducted a study to: (i) estimate the association between CD at the individual level and neonatal mortality rates (NMR) in 46 countries; and (ii) examine whether this association varies among countries according to country-level rates of CD or gross domestic product (GDP). METHODS: We obtained data from nationally representative Demographic and Health Surveys of women aged 15-49 years and their children aged 0-59 months (N = 392 883). Propensity-score matching, meta-analysis, and meta-regression were used to address the study objectives. RESULTS: The pooled odds ratio (OR) for the association between individual level CD and NMR in 46 countries was 1.67 (95% confidence interval (CI) 1.48-1.89), with moderate heterogeneity (I(2) = 39%). A meta-analysis of subgroups indicated that CD at the individual level was positively associated with NMR in countries with low (OR = 1.99, 95% CI 1.71-2.33, I(2) = 8.5%) and medium (OR = 1.53, 95% CI 1.29-1.82, I(2) = 24%) rates of CD. There was substantial heterogeneity of the effects of CD among countries with high rates of CD (I(2) = 63%). Results of meta-regression showed that the association of individual-level CD with NMR depended upon country-level rates of CD. Compared with countries with high rates of CD, the OR of the NMR associated with individual-level CD in countries with low rates of CD was estimated to increased by a factor of 1.48 (95% CI 1.09-1.97). CONCLUSIONS: Studies are needed to better understand the risks posed by CD in countries with low and medium rates of CD and to identify possible reasons for the heterogeneity in effects of CD among countries with high rates of CD.

Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A).

OBJECTIVE: Mental health policy for youth has been constrained by a paucity of nationally representative data concerning patterns and correlates of mental health service utilization in this segment of the population. The objectives of this investigation were to examine the rates and sociodemographic correlates of lifetime mental health service use by severity, type, and number of DSM-IV disorders in the National Comorbidity Survey-Adolescent Supplement. METHOD: Face-to-face survey of mental disorders from 2002 to 2004 using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview in a nationally representative sample of 6,483 adolescents 13 to 18 years old for whom information on service use was available from an adolescent and a parent report. Total and sector-specific mental health service use was also assessed. RESULTS: Approximately one third of adolescents with mental disorders received services for their illness (36.2%). Although disorder severity was significantly associated with an increased likelihood of receiving treatment, half of adolescents with severely impairing mental disorders had never received mental health treatment for their symptoms. Service rates were highest in those with attention-deficit/hyperactivity disorder (59.8%) and behavior disorders (45.4%), but fewer than one in five affected adolescents received services for anxiety, eating, or substance use disorders. Comorbidity and severe impairment were strongly associated with service utilization, particularly in youth with behavior disorders. Hispanic and non-Hispanic Black adolescents were less likely than their White counterparts to receive services for mood and anxiety disorders, even when such disorders were associated with severe impairment. CONCLUSIONS: Despite advances in public awareness of mental disorders in youth, a substantial proportion of young people with severe mental disorders have never received specialty mental health care. Marked racial disparities in lifetime rates of mental health treatment highlight the urgent need to identify and combat barriers to the recognition and treatment of these conditions.

Regional and individual influences on use of mental health services in Canada.

OBJECTIVE: Knowledge is lacking on the extent to which area-level characteristics contribute to variations observed in the use of mental health services. This study examined the influence of area- and individual-level characteristics on the use of mental health services. METHODS: Data from a nationally representative, population-based, cross-sectional survey, the Canadian Community Health Survey-Mental Health and Well-Being, consisting of adults aged 15 years or older (n = 36 984), were linked to Canadian 2001 Census profiles according to health region boundaries (n = 97). Multilevel multivariable logistic regression modelling was used to: estimate variation in 12-month self-reported use of health services for mental health reasons between health regions; and, estimate the effects of individual- and area-level need, health resources, and sociodemographic factors on self-reported 12-month use of medical services for mental health reasons. RESULTS: There was a 2.1% and 3.5% regional variation for general practitioner-family physician (GP-FP) and psychiatric health service use during 12 months, respectively. Most of the regional variation observed was explained by number of physicians per health region and regional and individual need factors. Adults who were middle-aged, had a post-secondary education, low-income, were separated, widowed, or divorced, and Canadian-born were significantly more likely to use GP-FP and psychiatry services for mental health reasons at the individual level, even after adjusting for area- and individual-level need factors. CONCLUSIONS: Most area-level variation was explained by the availability of health region resources and individual-level need factors. After accounting for need, numerous sociodemographic factors retained their association with use of mental health services. Additional efforts are needed at the area and individual level to reduce inequities through appropriate targeted care.

Stability of resting frontal electroencephalogram (EEG) asymmetry and cardiac vagal tone in adolescent females exposed to child maltreatment.

The experience of child maltreatment is a known risk factor for the development of psychopathology. Structural and functional modifications of neural systems implicated in stress and emotion regulation may provide one mechanism linking early adversity with later outcome. The authors examined two well-documented biological markers of stress vulnerability [resting frontal electroencephalogram (EEG) asymmetry and cardiac vagal tone] in a group of adolescent females exposed to child maltreatment (n = 38; M age = 14.47) and their age-matched non-maltreated (n = 25; M age = 14.00) peers. Maltreated females exhibited greater relative right frontal EEG activity and lower cardiac vagal tone than controls over a 6-month period. In addition, frontal EEG asymmetry and cardiac vagal tone remained stable in the maltreated group across the 6 months, suggesting that the neurobiological correlates of maltreatment may not simply reflect dynamic, short-term changes but more long lasting alterations. The present findings appear to be the first to demonstrate stability of two biologically based stress-vulnerability measures in a maltreated population. Findings are discussed in terms of plasticity within the neural circuits of emotion regulation during the early childhood period and alternative causal models of developmental psychopathology.

Community influences on intimate partner violence in India: Women's education, attitudes towards mistreatment and standards of living.

Intimate partner violence (IPV) directed towards women is a serious public health problem. Women's education may offer protection against IPV, but uncertainty exists over how it might reduce risk for IPV at the community and individual levels. The objectives of this study are to: (1) disentangle community from individual-level influences of women's education on risk for IPV; (2) quantify the moderating influence of communities on individual-level associations between women's education and IPV; (3) determine if women's attitudes towards mistreatment and living standards at the community and individual levels account for the protective influence of women's education; and (4) determine if the protective influence of education against IPV is muted among women living in communities exhibiting attitudes more accepting of mistreatment. Study information came from 68,466 married female participants in the National Family Health Survey conducted throughout India in 1998-1999. Multilevel logistic regression was used to address the study objectives. IPV showed substantial clustering at both the state (10.2%) and community levels (11.5%). At the individual level, there was a strong non-linear association between women's education and IPV, partially accounted for by household living standards. The strength of association between women's education and IPV varied from one community to the next with evidence that the acceptance of mistreatment at the community level mutes the protective influence of higher education. Furthermore, women's attitudes towards mistreatment and their standards of living accounted for community-level associations between women's education and IPV. Place of residence accounted for substantial variation in risk of IPV and also modified individual-level associations between IPV and women's education. At the community level, women's education appeared to exert much of its protective influence by altering population attitudes towards the acceptability of mistreatment. However, there was no residual association between women's education and IPV at the community level once living standards are taken into account. While women's education provides strong, independent leverage for reducing the risk of IPV, planners must keep in mind important community factors that modify its protective influence.

A multilevel analysis of whole family functioning using the McMaster Family Assessment Device.

This study demonstrates the use of multilevel modeling to examine influences on ratings of whole family functioning collected from multiple family members (N=26,614) living in 11,023 families with 1 or more dependent children aged 0 to 24 years. Results indicate that 45.7% of the variance in ratings of whole family functioning was shared among family members, whereas 54.3% was nonshared. Family-level characteristics, such as socioeconomic status (SES), family structure and composition, and family well-being, accounted for 30.6% of between-family variation (i.e., shared perceptions). Individual-level characteristics, such as sex, age, dependent child status, education, and well-being, accounted for 5.6% of within-family variance (i.e., unique perceptions). There was significant between-family variation in the relationship between dependent child status and ratings of family functioning, and increased rating discrepancies among members of the same family were linked with higher levels of family SES. The findings attest to the validity of measuring whole family functioning directly from self-report ratings provided from multiple family members. However, caution is warranted when assessments are available only from single respondents.

HIV/AIDS knowledge, women's education, epidemic severity and protective sexual behaviour in low- and middle-income countries.

A fundamental public health strategy to reduce the risk of HIV/AIDS is to increase levels of awareness and knowledge about the disease. Although knowledge about HIV/AIDS and protective sexual behaviour are linked theoretically, relatively little is known about their empirical relationship. Using Demographic and Health Survey data from 23 low- and middle-income countries, this study used multilevel logistic regression models: to examine cross-national variability in the relationship between HIV/AIDS knowledge and protective behaviour (condom use and restricted sex); to investigate the moderating influences of women's educational attainment on this relationship; and to test the extent to which severity of the HIV/AIDS epidemic accounts for cross-national variability in the association between HIV/AIDS knowledge and protective behaviour. There was an association between increased knowledge of HIV/AIDS and condom use that varied in strength and form cross-nationally. This cross-national variation was accounted for partially by the socioeconomic characteristics of women resident in the study countries and between-country differences in the severity of the HIV epidemic. While education modified the association between HIV/AIDS knowledge and protective behaviour--stronger associations at lower levels of education--epidemic severity exerted a stronger influence on behaviour than any other characteristic. Finally, this study indicates that protective sexual practices are disturbingly low. In eight of 23 countries, overall levels of condom use to prevent STDs and HIV/AIDS were less than 5.0%. Waiting for the spread of HIV/AIDS infection to change sexual practices in low- and middle-income countries will result in dramatic unnecessary suffering.

The influence of economic development level, household wealth and maternal education on child health in the developing world.

This study estimates the relative importance to child health (indicated by weight and height for age) of economic development level [gross domestic product (GDP) converted to international dollars using purchasing power parity (PPP) rates: GDP-PPP], household wealth and maternal education and examines the modifying influence of national contexts on these estimates. It uses information collected from mothers aged 15-49-years participating in Demographic Health Surveys (DHS) conducted in 42 developing countries. In multilevel regression models, the three study variables exhibited strong independent associations with child health: GDP-PPP accounted for the largest amount of unique variation, followed by maternal education and household wealth. There was also substantial overlap (shared variance) between maternal education and the other two study variables. The regressions of child health on household wealth and maternal education exhibited substantial cross-national variation in both strength and form of association. Although higher education levels were associated with disproportionately greater returns to child health, the pattern for household wealth was erratic: in many countries there were diminishing returns to child health at higher levels of household wealth. We conclude that there are inextricable links among different strategies for improving child health and that policy planners, associating benefits with these strategies, must take into account the strong moderating impact of national context.