Family Strengthening in the Context of COVID-19: Adapting a Community-Based Intervention from Kenya to the United States.

COVID-19 led to widespread disruption of services that promote family well-being. Families impacted most were those already experiencing disparities due to structural and systemic barriers. Existing support systems faded into the background as families became more isolated. New approaches were needed to deliver evidence-based, low-cost interventions to reach families within communities. We adapted a family strengthening intervention developed in Kenya ("Tuko Pamoja") for the United States. We tested a three-phase participatory adaptation process. In phase 1, we conducted community focus groups including 11 organizations to identify needs and a community partner. In phase 2, the academic-community partner team collaboratively adapted the intervention. We held a development workshop and trained community health workers to deliver the program using an accelerated process combining training, feedback, and iterative revisions. In phase 3, we piloted Coping Together with 18 families, collecting feedback through session-specific surveys and participant focus groups. Community focus groups confirmed that concepts from Tuko Pamoja were relevant, and adaptation resulted in a contextualized intervention-"Coping Together"-an 8-session virtual program for multiple families. As in Tuko Pamoja, communication skills are central and applied for developing family values, visions, and goals. Problem-solving and coping skills then equip families to reach goals, while positive emotion-focused activities promote openness to change. Sessions are interactive, emphasizing skills practice. Participants reported high acceptability and appropriateness, and focus groups suggested that most content was understood and applied in ways consistent with the theory of change. The accelerated reciprocal adaptation process and intervention could apply across resource-constrained settings.

Impact of maternal adverse childhood experiences on child socioemotional function in rural Kenya: Mediating role of maternal mental health.

Mothers in low- and middle-income countries (LMIC) suffer heightened vulnerability for adverse childhood experiences (ACEs), which is exacerbated by the multitude of risk factors associated with poverty and may lead to increased risk of psychiatric disorder. The constellation of complex, co-occurring biological, environmental, social, economic and psychological risk factors are in turn transmitted to her child, conferring vulnerability for adverse development. This study examines the association between maternal intra- and extra-familial ACEs, maternal education and the mental health of her child, mediated by maternal mental health. Mother-child dyads (n = 121) in Machakos, Kenya were examined cross-sectionally using self-report measures of ACEs, maternal mental health and child internalizing and externalizing mental health problems. The four models proposed to examine the relationship between intra- and extra-familial maternal ACEs and child internalizing and externalizing problems demonstrated indirect pathways through maternal mental health. These effects were found to be conditional on levels of maternal education, which served as a protective factor at lower levels of maternal ACEs. These models demonstrate how the impact of ACEs persists across the lifespan resulting in a negative impact on maternal mental health and conferring further risk to subsequent generations. Elucidating the association between ACEs and subsequent intergenerational sequelae, especially in LMIC where risk is heightened, may improve targeted caregiver mental health programs for prevention and intervention.

A Pilot Study of the Coping Together Virtual Family Intervention: Exploring Changes in Family Functioning and Individual Well-Being.

In this pilot study, we tested a virtual family strengthening and mental health promotion intervention, Coping Together (CT), during the COVID-19 pandemic. We explored changes at the family and individual levels, as well as mechanisms of change. Participants included 18 families (24 caregivers, 24 youth) with children aged 7 to 18 years. Community health workers delivered the 8-session CT intervention using videoconferencing software. We used qualitative semi-structured interviews with 14 of the families to explore changes and mechanisms of change using a thematic content analysis approach. We also administered pre-post surveys with the 18 families to explore the direction of changes, using only descriptive statistics in this small sample. Qualitative findings supported positive changes across family and individual level outcomes including family functioning, relationship quality, and individual psychosocial well-being. Results also confirmed several hypothesized mechanisms of change with improved communication providing the foundation for increased hope and improved problem solving and coping. Pre-post survey results were mixed, showing positive, but very small, changes in family closeness, caregiver-child communication, and levels of hope; almost no change was observed on measures of caregiver and child mental health. Families reported few problems at baseline quantitatively despite qualitative descriptions of pre-intervention difficulties. Results provide preliminary support for benefits of CT with the most consistent improvements seen across family relationships. Findings were mixed related to individual-level mental health benefits. Results have implications for revising content on mental health coping strategies and suggest the need to revise the quantitative measurement strategy for this non-clinical sample.

Prediction of autism in infants: progress and challenges.

Autism spectrum disorder (henceforth autism) is a neurodevelopmental condition that can be reliably diagnosed in children by age 18-24 months. Prospective longitudinal studies of infants aged 1 year and younger who are later diagnosed with autism are elucidating the early developmental course of autism and identifying ways of predicting autism before diagnosis is possible. Studies that use MRI, EEG, and near-infrared spectroscopy have identified differences in brain development in infants later diagnosed with autism compared with infants without autism. Retrospective studies of infants younger than 1 year who received a later diagnosis of autism have also showed an increased prevalence of health conditions, such as sleep disorders, gastrointestinal disorders, and vision problems. Behavioural features of infants later diagnosed with autism include differences in attention, vocalisations, gestures, affect, temperament, social engagement, sensory processing, and motor abilities. Although research findings offer insight on promising screening approaches for predicting autism in infants, individual-level predictions remain a future goal. Multiple scientific challenges and ethical questions remain to be addressed to translate research on early brain-based and behavioural predictors of autism into feasible and reliable screening tools for clinical practice.

Improving access to early intervention for autism - findings from a proof-of-principle cascaded task-sharing naturalistic developmental behavioural intervention in South Africa.

Background Despite the high number of children living with neurodevelopmental disabilities in sub-Saharan Africa, access to early intervention is almost non-existent. It is therefore important to develop feasible, scalable early autism intervention that can be integrated into systems of care. While Naturalistic Developmental Behavioural Intervention (NDBI) has emerged as an evidence-based intervention approach, implementation gaps exist globally, and task-sharing approaches may address access gaps. In this South African proof-of-principle pilot study, we set out to answer two questions about a 12-session cascaded task-sharing NDBI - whether the approach could be delivered with fidelity, and whether we could identify signals of change in child and caregiver outcomes. Methods We utilized a single-arm pre-post design. Fidelity (non-specialists, caregivers), caregiver outcomes (stress, sense of competence), and child outcomes (developmental, adaptive) were measured at baseline (T1) and follow-up (T2). Ten caregiver-child dyads and four non-specialists participated. Pre-to-post summary statistics were presented alongside individual trajectories. Non-parametric Wilcoxon signed rank test for paired samples was used to compare group medians between T1 and T2. Results Caregiver implementation fidelity increased in 10/10 participants. Non-specialists demonstrated a significant increase in coaching fidelity (increases in 7/10 dyads). Significant gains were seen on two Griffiths-III subscales (Language/Communication - 9/10 improved, Foundations of Learning - 10/10 improved) and on the General Developmental Quotient (9/10 improved). Significant gains were also seen on two Vineland Adaptive Behaviour Scales (Third Edition) subscales (Communication - 9/10 improved, Socialization - 6/10 improved) and in the Adaptive Behaviour Standard Score (9/10 improved). Caregiver sense of competence improved in 7/10 caregivers and caregiver stress in 6/10 caregivers. Conclusions This proof-of-principle pilot study of the first cascaded task-sharing NDBI in Sub-Saharan Africa provided fidelity and intervention outcome data which supported the potential of such approaches in low-resource contexts. Larger studies are needed to expand on the evidence-base and answer questions on intervention effectiveness and implementation outcomes.

Social Vulnerability, COVID-19, Racial Violence, and Depressive Symptoms: a Cross-sectional Study in the Southern United States.

BACKGROUND: In March 2020, the novel 2019 coronavirus disease (COVID-19) was declared a pandemic. In May 2020, George Floyd was murdered, catalyzing a national racial reckoning. In the Southern United States, these events occurred in the context of a history of racism and high rates of poverty and discrimination, especially among racially and ethnically minoritized populations. OBJECTIVES: In this study, we examine social vulnerabilities, the perceived impacts of COVID-19 and the national racial reckoning, and how these are associated with depression symptoms in the South. METHODS: Data were collected from 961 adults between June and November 2020 as part of an online survey study on family well-being during COVID-19. The sample was majority female (87.2%) and consisted of 661 White participants, 143 Black participants, and 157 other racial and ethnic minoritized participants. Existing social vulnerability, perceived impact of COVID-19 and racial violence and protests on families, and depressive symptoms were assessed. Hierarchical regression analysis was used to predict variance in depressive symptoms. RESULTS: Half of the sample (52%) reported a negative impact of COVID-19, and 66% reported a negative impact of national racial violence/protests. Depressive symptoms were common with 49.8% meeting the cutoff for significant depressive symptoms; Black participants had lower levels of depressive symptoms. Results from the hierarchical regression analysis indicate social vulnerabilities and the perceived negative impact of COVID-19 and racial violence/protests each contribute to variance in depressive symptoms. Race-specific sensitivity analysis clarified distinct patterns in predictors of depressive symptoms. CONCLUSION: People in the South report being negatively impacted by the confluence of the COVID-19 pandemic and the emergence of racial violence/protests in 2020, though patterns differ by racial group. These events, on top of pre-existing social vulnerabilities, help explain depressive symptoms in the South during 2020.

Improving access to early intervention for autism: findings from a proof-of-principle cascaded task-sharing naturalistic developmental behavioural intervention in South Africa.

BACKGROUND: Despite the high number of children living with neurodevelopmental disabilities in sub-Saharan Africa, access to early intervention is almost non-existent. It is therefore important to develop feasible, scalable early autism intervention that can be integrated into systems of care. While Naturalistic Developmental Behavioural Intervention (NDBI) has emerged as an evidence-based intervention approach, implementation gaps exist globally, and task-sharing approaches may address access gaps. In this South African proof-of-principle pilot study, we set out to answer two questions about a 12-session cascaded task-sharing NDBI-whether the approach could be delivered with fidelity, and whether we could identify signals of change in child and caregiver outcomes. METHODS: We utilized a single-arm pre-post design. Fidelity (non-specialists, caregivers), caregiver outcomes (stress, sense of competence), and child outcomes (developmental, adaptive) were measured at baseline (T1) and follow-up (T2). Ten caregiver-child dyads and four non-specialists participated. Pre-to-post summary statistics were presented alongside individual trajectories. Non-parametric Wilcoxon signed rank test for paired samples was used to compare group medians between T1 and T2. RESULTS: Caregiver implementation fidelity increased in 10/10 participants. Non-specialists demonstrated a significant increase in coaching fidelity (increases in 7/10 dyads). Significant gains were seen on two Griffiths-III subscales (Language/Communication-9/10 improved, Foundations of Learning-10/10 improved) and on the General Developmental Quotient (9/10 improved). Significant gains were also seen on two Vineland Adaptive Behaviour Scales (Third Edition) subscales (Communication-9/10 improved, Socialization-6/10 improved) and in the Adaptive Behaviour Standard Score (9/10 improved). Caregiver sense of competence improved in 7/10 caregivers and caregiver stress in 6/10 caregivers. CONCLUSIONS: This proof-of-principle pilot study of the first cascaded task-sharing NDBI in Sub-Saharan Africa provided fidelity and intervention outcome data which supported the potential of such approaches in low-resource contexts. Larger studies are needed to expand on the evidence-base and answer questions on intervention effectiveness and implementation outcomes.

A tablet-based game for the assessment of visual motor skills in autistic children.

Increasing evidence suggests that early motor impairments are a common feature of autism. Thus, scalable, quantitative methods for measuring motor behavior in young autistic children are needed. This work presents an engaging and scalable assessment of visual-motor abilities based on a bubble-popping game administered on a tablet. Participants are 233 children ranging from 1.5 to 10 years of age (147 neurotypical children and 86 children diagnosed with autism spectrum disorder [autistic], of which 32 are also diagnosed with co-occurring attention-deficit/hyperactivity disorder [autistic+ADHD]). Computer vision analyses are used to extract several game-based touch features, which are compared across autistic, autistic+ADHD, and neurotypical participants. Results show that younger (1.5-3 years) autistic children pop the bubbles at a lower rate, and their ability to touch the bubble's center is less accurate compared to neurotypical children. When they pop a bubble, their finger lingers for a longer period, and they show more variability in their performance. In older children (3-10-years), consistent with previous research, the presence of co-occurring ADHD is associated with greater motor impairment, reflected in lower accuracy and more variable performance. Several motor features are correlated with standardized assessments of fine motor and cognitive abilities, as evaluated by an independent clinical assessment. These results highlight the potential of touch-based games as an efficient and scalable approach for assessing children's visual-motor skills, which can be part of a broader screening tool for identifying early signs associated with autism.

Maternal adverse childhood experiences, child mental health, and the mediating effect of maternal depression: A cross-sectional, population-based study in rural, southwestern Uganda.

OBJECTIVES: This study aimed to examine the intergenerational effects of maternal adverse childhood experiences (ACEs) and child mental health outcomes in rural Uganda, as well as the potentially mediating role of maternal depression in this pathway. Additionally, we sought to test the extent to which maternal social group membership attenuated the mediating effect of maternal depression on child mental health. METHODS: Data come from a population-based cohort of families living in the Nyakabare Parish, a rural district in southwestern Uganda. Between 2016 and 2018, mothers completed surveys about childhood adversity, depressive symptoms, social group membership, and their children's mental health. Survey data were analyzed using causal mediation and moderated-mediation analysis. RESULTS: Among 218 mother-child pairs, 61 mothers (28%) and 47 children (22%) showed symptoms meeting cutoffs for clinically significant psychological distress. In multivariable linear regression models, maternal ACEs had a statistically significant association with severity of child conduct problems, peer problems, and total child difficulty scores. Maternal depression mediated the relationship between maternal ACEs and conduct problems, peer problems, and total difficulty, but this mediating effect was not moderated by maternal group membership. CONCLUSIONS: Maternal depression may act as a potential mechanism linking maternal childhood adversity with poor child mental health in the next generation. Within a context of elevated rates of psychiatric morbidity, high prevalence of childhood adversity, and limited healthcare and economic infrastructures across Uganda, these results emphasize the prioritization of social services and mental health resources for rural Ugandan families.

Development of the Family Togetherness Scale: A Mixed-Methods Validation Study in Kenya.

Family functioning is an important target of clinical intervention and research given its close ties with mental health outcomes of both children and adults. However, we lack family functioning measures validated for use in many low- and middle-income country (LMIC) settings. In this mixed-methods prospective diagnostic accuracy study, we first used formative qualitative data to develop an extensive battery of screening items to measure family functioning in Kenya. We then recruited 30 Kenyan families (N = 44 adults; 30 youth aged 8-17 years) to complete the questionnaires and participate in clinical interviews conducted by local interviewers. Quantitative and qualitative analyses were then conducted to select a subset of screening items that balanced conceptual understanding of family distress with diagnostic efficiency and accuracy to yield a brief but valid scale. The final index test consisting of 30 items correctly identified distressed families in 89% of cases according to adult-report and 76% of cases according to child-report. The optimal cutoffs are associated with estimates of sensitivity/specificity of 0.88/0.90 and 0.75/0.77 for adult-report and child-report measures, respectively. The final measure-the Family Togetherness Scale (FTS)-assesses global family functioning, including items related to family organization, emotional closeness, and communication/problem-solving. In addition to general items, the scale also includes items explicitly assessing family responses to stressors common in LMIC settings. Results establish a strong rationale for larger-scale validation studies.