The impact of caregiver mental health on child prosocial behavior: A longitudinal analysis of children and caregivers in KwaZulu-Natal, South Africa.

BACKGROUND: Prosocial behavior has positive social, cognitive, and physical health effects on the individual exhibiting the behavior as well as on society as a whole, and is integral to overall mental and physical wellbeing. The development of prosocial behavior is rooted in early childhood and learned through observation. As such, those spending time with children, especially their caregiver, play a critical role in their prosocial development. The current study investigates the impact of caregiver mental health on the prosocial development of young children over time. METHODS: This paper presents a secondary analysis of child prosocial development in the Asenze Study, a longitudinal, population-based cohort study based in KwaZulu-Natal, South Africa. Children were followed-up over time from an average age of five to seven years along with their caregivers. Linear GEE regression analysis was used to assess whether a change in presence of a mental health disorder in a caregiver during this 2-year interval (using the Client Diagnostic Questionnaire) impacted the development of their child's prosocial behavior (using the Strengths and Difficulties Questionnaire). RESULTS: After adjusting for early child-care, child HIV status, SDQ child prosocial subscale, SDQ total difficulties score, and household order score (CHAOS), children whose caregivers acquired a mental health disorder had a significantly smaller increase in prosocial behavioral development compared to children whose caregivers never had a mental health disorder. CONCLUSIONS: Identifying contextually relevant modifiable factors such as this will help stimulate the development of interventions to promote prosocial development in childhood.

Exploring the effect of early menarche on sexual violence among adolescent girls and young women in southeastern Ghana: a longitudinal mediation analysis.

Research from several high-income countries links early menarche with an increased risk for sexual violence. However, the role of early menarche in adolescent girls' and young women's sexual violence risk in sub-Saharan Africa, where sexual violence rates are high, is not well understood. The current study explores the association between early menarche and sexual violence in Ghana with secondary analysis of data collected from 700 adolescent girls and young women followed over three years. Logistic regressions were used to assess the cross-sectional association between early menarche and sexual violence. Generalised estimating equations were used to assess whether the association between early menarche and sexual violence persisted over time. Inverse odds weighting was used to test potential mediators of the association between early menarche and sexual violence. Sexual violence was fairly common in the study sample, with 27% reporting having experienced sexual violence at baseline, and approximately 50% at year three. Early menarche was associated with 72% greater odds of having experienced sexual violence at baseline (95% confidence interval: 1.01-2.93). However, the odds ratio attenuated and lost significance over the three-year study period, with a lower risk of sexual violence among girls with early menarche at year three. Neither child marriage nor early sexual initiation significantly mediated the association between early menarche and sexual violence. The findings suggest that early-maturing girls may be particularly vulnerable to sexual violence in early adolescence, thus necessitating prevention interventions around the time of menarche to reduce the risk for sexual violence.

Preterm Birth and Other Measures of Infant Biological Vulnerability: Associations with Maternal Sensitivity and Infant Cognitive Development.

INTRODUCTION: Low birth weight (LBW), biological vulnerability that includes preterm birth (PTB) and small for gestational age (SGA), is associated with reduced maternal sensitivity ("making accurate inferences about an infant's physical and emotional needs and responding appropriately") and impaired infant cognitive development. However, research does not examine if preterm birth, SGA, or both drive these associations. This study separated these measures of biological vulnerability to examine associations of LBW, PTB, and SGA with maternal sensitivity and infant cognitive development (controlling for maternal depression, breastfeeding, and demographic covariates). METHODS: The sample included 6900 9-month-old infants from the Early Childhood Longitudinal Study-Birth Cohort and used birth certificate data, maternal interviews, assessments of maternal sensitivity and infant cognitive development. Multiple linear regressions examined LBW, PTB, and SGA associations with concurrent measures of maternal sensitivity and infant cognition. RESULTS: Of the biological vulnerabilities, preterm birth had the strongest negative association with maternal sensitivity (F1,6450 = 29.48 versus 15.33 and 5.51, ps < .001) and infant cognitive development (F1,6450) = 390.65 versus 248.02 and 14.43, ps < .001). In the final regression model, preterm birth and maternal sensitivity were uniquely associated with infant cognitive development (R2 = .05, p < .001), after controlling for maternal depression, breastfeeding, and demographics. CONCLUSION: In this nationally representative infant sample infants, PTB had a stronger negative association with both maternal sensitivity and infant cognitive development in comparison to SGA or LBW. The LBW designation combines infants born preterm with SGA infants, potentially minimizing differences in developmental outcomes of PTB and SGA infants.

Association between caregiver and household alcohol use and child behavior problems in KwaZulu Natal, South Africa.

We explored the association between household alcohol use and behavior problems among South-African children, using data from the Asenze study, a population-based cohort of South African children and their caregivers. Household alcohol use and child behavior were assessed when children were 6-8 years old. To examine the association, we performed linear regressions. The sample included 1383 children with complete data under the care of 1251 adults. Children living in a household where self-reported caregiver alcohol use was scored as hazardous (4.6%) had higher levels of problem behavior (ß = 1.94, 95% CI 0.06-3.82). There were no statistically significant associations between reported hazardous alcohol use by another member of the household (14.5%) and child problem behavior. Hazardous household alcohol use was associated with child problem behavior and this effect appeared to be mainly driven by primary caregiver use.

The Asenze Cohort Study in KwaZulu-Natal, South Africa: protocol and cohort profile.

The Asenze cohort is set in South Africa, a middle-income country impacted by one of the highest global rates of people living with HIV/AIDS and high levels of socioeconomic inequality. This longitudinal population-based cohort of children and their primary caregivers assesses household and caregiver functioning, child health, social well-being, and neuro-development from childhood through adolescence. Almost 1,600 children born at the peak of the human immunodeficiency virus epidemic (2003-2005) were followed (with their primary caregivers) in 3 waves, between 2008 and 2021, at average ages of 5, 7, and 16. Wave 3 is currently underway, having assessed over 1,100 of the original wave 1 children. Wave 4 begins in 2022. The study, with a dyadic structure, uses a broad range of measures, validated in South Africa or recommended for global use, that address physical, social and neuro-development in childhood and adolescence, and the social, health, and psychological status of children's primary caregivers. The Asenze study deepens our understanding of childhood physical, cognitive, and social abilities and/or disabilities, including risk-taking behaviors, and biological, environmental, and social determinants of health. We anticipate the findings will contribute to the development of community-informed interventions to promote well-being in this South African population and elsewhere.

Does breastfeeding account for the association between maternal sensitivity and infant cognitive development in a large, nationally representative cohort?

BACKGROUND: Previous research has established that exposure to high maternal sensitivity is positively associated with advances in infant cognitive development. However, there are many fixed and modifiable factors that influence this association. This study investigates whether the association between maternal sensitivity and infant cognitive development in the first year of life is accounted for by other factors, such as breastfeeding, maternal depressive symptoms, maternal alcohol use, infant birth weight or demographic covariates. METHODS: Using data from the Early Childhood Longitudinal Study-Birth (ECLS-B) Cohort, a nationally representative sample of U.S. born children, multi-variable regression analyses was used to examine whether breastfeeding, maternal depressive symptoms and alcohol use were associated with maternal sensitivity, as measured by the Nursing Child Assessment Teaching Scale (NCATS), and with infant cognitive development, as measured by the Bayley Scales of Infant Development, Short Form, Research Edition, after controlling for demographic covariates (infant sex, maternal age, education, race/ethnicity, income, parity, family structure) and infant birth weight. RESULTS: Breastfeeding, depressive symptoms and alcohol use were not associated with maternal sensitivity scores after controlling for demographic covariates and infant birth weight. However, breastfeeding (ß = .079, p < .001), depressive symptoms (ß = -.035, p < .05), and maternal sensitivity (ß = .175, p < .001) were each significantly associated with infant cognitive development scores, even after controlling for demographic covariates and birthweight (R2 = .053, p < .001). The association between maternal sensitivity and infant cognitive development did not attenuate after adjusting for breastfeeding. Instead, both sensitivity and breastfeeding independently contributed to higher infant cognitive development scores. CONCLUSION: Maternal sensitivity and breastfeeding are separate means to advancing infant cognitive development. This study is significant because it is the first to examine breastfeeding, maternal depressive symptoms and alcohol use together, upon the association between maternal sensitivity and infant cognitive development, after adjusting for demographic covariates and infant birthweight. Maternal sensitivity, a measurable quality, advances infants' cognitive development. Moreover, sensitivity and breastfeeding had independent effects upon cognitive development after controlling for multiple fixed and modifiable covariates. Understanding factors impacting the association between sensitivity and infant cognitive development provide avenues for developing more effective parenting interventions.

Adverse childhood experiences (ACEs) and child behaviour problems in KwaZulu-Natal, South Africa.

BACKGROUND: Adverse childhood events (ACEs) are associated with negative health effects in adulthood. Despite knowledge of these later impacts, little is known about the earlier effect of ACEs on later child behaviour in low- and middle-income countries (LMIC). METHODS: The population-based Asenze cohort study was implemented in a peri-rural area of KwaZulu-Natal, South Africa, comprising five Zulu tribal areas. Two waves of data were examined: family information and ACEs exposure when children were on average 5 years old and child behaviour problems (Strengths and Difficulties Questionnaire [SDQ]) approximately 2 years later (average age 7 years). Logistic regression analysis was used to examine unadjusted and adjusted relationships between cumulative ACEs experienced and the SDQ total scores (dichotomized as top 10% vs. the rest) as well as selected SDQ subscales. RESULTS: A significant relationship between increased ACE exposure and SDQ total score was observed. The same relationship was also seen for the SDQ emotional symptoms and conduct problem subscales, but not for hyperactivity. The results of a sensitivity analysis excluding intimate partner violence from the ACEs measure demonstrated similar results. CONCLUSIONS: There is an association between exposure to ACEs and later child behaviour problems within this LMIC population demonstrating an early negative impact for ACEs. While previous research has focused on the effects of ACEs on adult health, this study provided evidence for an earlier relationship between ACEs and child behaviour problems that may be a part of the mechanism through which later health effects arise.

A Systematic Review of Household and Family Alcohol Use and Adolescent Behavioural Outcomes in Low- and Middle-Income Countries.

Exposure to alcohol misuse is considered an adverse childhood experience impacting on neurodevelopmental and behavioural outcomes in adolescents including substance use, mental illness, problem behaviours, suicidality, and teenage pregnancy. Most research on this issue has focussed on higher income countries, whereas patterns of alcohol use and related factors may be different in low- and middle-income countries (LMICs). This systematic review therefore seeks to collate all published studies from 1990-2020 on the topic set in LMICs. 43 studies were included, totalling 70,609 participants from 18 LMICs. Outcomes assessed included: substance use; depression/anxiety; suicidal ideation; problem behaviour; emotional dysfunction; teenage pregnancy; and self-harm. Despite heterogeneity in the studies identified, this review documented some association between exposure to household alcohol misuse and adverse adolescent outcomes in LMICs, including mental health problems, problem behaviours, and suicidality. The mechanisms leading to these outcomes are likely varied, and further research in different socio-economic and cultural contexts, particularly in the form of longitudinal studies, is called for.

A Systematic Review of Household and Family Alcohol Use and Childhood Neurodevelopmental Outcomes in Low- and Middle-Income Countries.

Childhood exposure to alcohol misuse by household adults has been related to childhood developmental delay, cognitive impacts, mental illness, and problem behaviours. Most evidence comes from high income countries. This systematic review only included studies from low- and middle-income countries (LMICs). Five databases were searched from 1990-2020. Twenty-eight studies of children 0-12 years were included, with 42,599 participants from 11 LMICs. The most common outcome was behavioural problems/disorders (19 studies). Despite varying study designs, this review found that alcohol misuse by household members in LMICs is associated with adverse child neurodevelopmental outcomes, although casual inferences cannot be drawn in the absence of well conducted prospective studies. Statistically significant correlations were described between parental alcohol misuse and child emotional and behavioural difficulties, cognitive delay, and risky behaviours. In future, prospective cohort studies are recommended, with adjustment for confounders.

Cognitive and Language Development at Age 4-6 Years in Children HIV-Exposed But Uninfected Compared to Those HIV-Unexposed and to Children Living With HIV.

Perinatal HIV infection is associated with delayed neurocognitive development, but less is known about children perinatally HIV-exposed but uninfected (CHEU). We compared cognitive and language outcomes in 4-6-year old CHEU versus children HIV-unexposed and uninfected (CHUU) and children living with HIV (CLHIV). We enrolled 1,581 children (77% of the child population) in five communities in KwaZulu-Natal, South Africa. Children completed: Grover-Counter Scale of cognitive development, sub-scales of the Kaufman Assessment Battery for Children, Reynell Developmental Language Scales. HIV status of children and primary caregivers was determined by repeated rapid tests or report of prior testing. We conducted a cross-sectional multivariable linear regression on 922 dyads with complete data (257 CHEU, 627 CHUU, 38 CLHIV). On all outcome measures, CHEU and CHUU groups had comparable scores; CLHIV scored significantly lower. Emerging global progress toward the elimination of vertical HIV transmission may not only reduce mortality, but also positively impact child development.

Neurocognitive testing in West African children 3-6 years of age: Challenges and implications for data analyses.

OBJECTIVE: When testing African children with developmental and cognitive standardized tests from high-income countries (HIC), investigators are uncertain as to whether to apply the HIC norms for these tests when standardizing a child's raw-score performance on the basis of age. The present study compared the construct validity of both raw and HIC-based standardized scores for the Mullen Scales of Early Learning (MSEL) and the Kaufman Assessment Battery in Children - 2nd edition (KABC-II) for Beninese children in a rural setting from three to six years of age. METHODS: Seventy-four children 3-4 yrs of age were assessed with the MSEL, and 61 eligible older children (5-6 yrs of age) were assessed with the KABC-II. Assessors spoke the instructions to the children and caregivers for the assessment items in the local language. The developmental quality of the home environment was evaluated with the Caldwell Home Observation for Measurement of the Environment (HOME) inventory, and a material possessions and housing quality checklist was used as a measure of socio-economic status (SES). Children's mothers were given the Raven's Progressive Matrices test (nonverbal cognitive ability), and the Edinburgh Postpartum Depression Scale (EPDS) (emotional wellbeing). RESULTS: For the MSEL, the 4-yr old group performed significantly better than the 3-yr old group on both the raw and standardized score comparisons for all scales. These differences were attenuated when using standardized scores, although the MSEL standardized cognitive composite score was still highly significant between years of age. When comparing 5- to 6-yr olds on KABC-II subtest and global scale performance, comparisons between the raw and standardized mean score performances were much less consistent. Generally, 6-yr olds performed significantly better than 5-yr olds on the raw score comparisons on the KABC-II subtests, but not so for standardized scores. Parent-child interactions assessed through the HOME measure was associated with both raw and standardized MSEL cognitive composite score outcomes on a multiple regression analysis. SES was the only significant predictor for KABC-II raw and standardized outcomes. CONCLUSION: Standardization using HIC norms was not optimal, resulting in minimal impact to account for age when using the MSEL, and lower scores for oldest children compared with youngest children when using the KABC2. This is likely due to children in Benin drifting away from HIC-based norms with each passing year of age, systematically lowering standardized performance measures. These findings support the importance of having a local comparison group of reference or control children to allow for adjusted (for age, HOME, and SES) raw score comparisons when using western-based tests for developmental and neuropsychological evaluation.

Screening for Mental Health Among Young South African Children: The Use of the Strengths and Difficulties Questionnaire (SDQ).

BACKGROUND: Little is known about the prevalence of child mental health (MH) problems in sub-Saharan Africa, where poverty, HIV, and family disruption increase risk. One barrier is the lack of MH assessment tools lay staff can validly and reliably administer in settings with few MH professionals. METHODS: In a South African (SA) peri-urban cohort, we examined psychometric properties of the Strengths and Difficulties Questionnaire (SDQ), a widely used measure of child emotional and behavioral functioning. Data come from a large population-based study (N=1581) of children 4-6 years old. Lay fieldworkers administered the SDQ in isiZulu to caregivers at baseline and two years later. Exploratory factor analysisexamined whether the established SDQ five-factor structure and Total Difficulties score would be replicated. The psychometric model was tailored for ordinal items, and target factor rotation was used. RESULTS: Total Difficulties, Emotional symptoms and Prosocial behavior factors were supported, with partial support for Conduct problems. Peer relationships and Hyperactivity/inattentive subscale items loaded poorly. Subscale Cronbach's alphas ranged from 0.29 (Peers) to 0.62 (Emotional). Internal consistency of Total Difficulties score was acceptable (0.74); 30% scored in the abnormal range on Total Difficulties, based on UK norms. CONCLUSIONS: SDQ scores in our sample suggest young children in SA are at high risk for MH problems. The SDQ, particularly the Total Difficulties score, may be a useful screening tool in SA. Yet, some subscales did not work in this language and context; if social skills and hyperactivity/inattention arebeing considered, modification or additional measures may be needed.

Screening for developmental disabilities in HIV positive and HIV negative children in South Africa: Results from the Asenze Study.

BACKGROUND: While neurodevelopmental abnormalities are common in children with HIV infection, their detection can be challenging in settings with limited availability of health professionals. The aim of this study was to assess the ability to identify developmental disability among HIV positive and HIV negative children living in South Africa with an internationally used screen. METHODS AND FINDINGS: This analysis uses a sample of 1,330 4-6 year old children and 1,231 of their caregivers in KwaZulu-Natal, South Africa, including administration of the Ten Questions (TQ) screen, a standardized medical history and physical examination conducted by a medical doctor, with hearing and vision screening, psychological assessment for cognition and language delay, and voluntary HIV testing. There was a high prevalence of disability among the sample. Compared to HIV negative children, HIV positive children were more likely to screen positive on at least one TQ item (59.3 vs 42.8%, p = 0.01), be delayed in sitting, standing or walking (OR 3.89, 95% CI = 2.1-7.2) and have difficulty walking or weakness in the arms or legs (OR = 2.7, 95%CI = 0.8-9.37). By medical doctor assessment, HIV positive children were more likely to be diagnosed with gross motor disability (OR = 3.5, 95%CI = 1.3-9.2) and hearing disability (OR = 2.5, 95%CI = 1.2-5.3). By independent psychological assessment, HIV positive children were more likely to have cognitive delay (OR = 2.2, 95%CI = 1.2-3.9) and language delay (OR = 4.3, 95%CI = 2.2-8.4). Among HIV positive children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 100% and 51.2%, respectively. Among HIV-negative children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 90.2% and 63.9%, respectively. CONCLUSIONS: In this first report of the use of the TQ screen in the isiZulu language, it was found to have high sensitivity for detecting serious developmental disabilities in children, especially HIV positive children. The performance of the TQ in this sample indicates utility for making best use of limited neurodevelopmental resources by screening HIV positive children.

Consequences of prenatal geophagy for maternal prenatal health, risk of childhood geophagy and child psychomotor development.

OBJECTIVE: To investigate the relationship between prenatal geophagy, maternal prenatal haematological indices, malaria, helminth infections and cognitive and motor development among offspring. METHODS: At least a year after delivery, 552 of 863 HIV-negative mothers with singleton births who completed a clinical trial comparing the efficacy of sulfadoxine-pyrimethamine and mefloquine during pregnancy in Allada, Benin, responded to a nutrition questionnaire including their geophagous habits during pregnancy. During the clinical trial, helminth infection, malaria, haemoglobin and ferritin concentrations were assessed at 1st and 2nd antenatal care visits (ANV) and at delivery. After the first ANV, women were administered daily iron and folic acid supplements until three what? post-delivery. Singleton children were assessed for cognitive function at age 1 year using the Mullen Scales of Early Learning. RESULTS: The prevalence of geophagy during pregnancy was 31.9%. Pregnant women reporting geophagy were more likely to be anaemic (AOR = 1.9, 95% CI [1.1, 3.4]) at their first ANV if they reported geophagy at the first trimester. Overall, prenatal geophagy was not associated with maternal haematological indices, malaria or helminth infections, but geophagy during the third trimester and throughout pregnancy was associated with poor motor function (AOR = -3.8, 95% CI [-6.9, -0.6]) and increased odds of geophagous behaviour in early childhood, respectively. CONCLUSIONS: Prenatal geophagy is not associated with haematological indices in the presence of micronutrient supplementation. However, it may be associated with poor child motor function and infant geophagy. Geophagy should be screened early in pregnancy.

Factors associated with the health and cognition of 6-year-old to 8-year-old children in KwaZulu-Natal, South Africa.

OBJECTIVE: To investigate 6-year-old to 8-year-old children's health, nutritional status and cognitive development in a predominantly rural area of KwaZulu-Natal, South Africa. METHODS: Cohort study of 1383 children investigating the association of demographic variables (area of residence, sex, pre-school education, HIV status, height for age and haemoglobin level) and family variables (socioeconomic status, maternal and paternal level of education), with children's cognitive performance. The latter was measured using the Grover-Counter Scale of Cognitive Development and subtests of the Kaufman Assessment Battery for Children, second edition (KABC-II). General linear models were used to determine the effect of these predictors. RESULTS: Area of residence and height-for-age were the statistically significant factors affecting cognitive test scores, regardless of attending pre-school. Paternal level of education was also significantly associated with the cognitive test scores of the children for all three cognitive test results, whereas HIV status, sex and their socioeconomic status were not. CONCLUSION: Children with low cognitive scores tended to be stunted (low height-for-age scores), lacked pre-school education and were younger. Area of residence and their parents' educational level also influenced their cognition.

Intimate Partner Violence and Child Behavioral Problems in South Africa.

BACKGROUND: Research in high-income countries has repeatedly demonstrated that intimate partner violence (IPV) experienced by women negatively affects the health and behavior of children in their care. However, there is little research on the topic in lower- and middle-income countries. The population-based Asenze Study gathered data on children and their caregivers in KwaZulu-Natal, South Africa. This data analysis explores the association of caregiver IPV on child behavior outcomes in children <12 years old and is the first such study in Africa. METHODS: This population-based study was set in 5 Zulu tribal areas characterized by poverty, food insecurity, unemployment, and a high HIV prevalence. The Asenze Study interviewed caregivers via validated measures of IPV, alcohol use, caregiver mental health difficulties, and child behavior disorders in their preschool children. RESULTS: Among the 980 caregivers assessed, 37% had experienced IPV from their current partner. Experience of partner violence (any, physical, or sexual) remained strongly associated with overall child behavior problems (odds ratio range: 2.46-3.10) even after age, HIV status, cohabitation with the partner, alcohol use, and posttraumatic stress disorder were accounted for. CONCLUSIONS: Childhood behavioral difficulties are associated with their caregiver's experience of IPV in this population, even after other expected causes of child behavior difficulties are adjusted for. There is a need to investigate the longer-term impact of caregiver partner violence, particularly sexual IPV, on the health and well-being of vulnerable children in lower- and middle-income countries. Studies should also investigate whether preventing IPV reduces the occurrence of childhood behavior difficulties.

Validation of the Client Diagnostic Questionnaire to Assess Mental Health in South African Caregivers of Children.

BACKGROUND: Given the high prevalence of mental health (MH) and substance abuse problems in low-to-middle income countries, the scarcity of MH professionals and the negative impact of psychiatric disorders on caregivers of young children, there is significant need for brief evidence-based screening tools for lay counselors to assist with MH assessment. This study aimed to validate a brief screening tool to assess psychiatric and substance use disorders, the Client Diagnostic Questionnaire (CDQ), in South Africa (SA). METHODS: Data are from a longitudinal study of health and psychosocial needs in preschool children in SA. Participants included 322 Zulu-speaking, female caregivers. Following procedures of the US CDQ validation study, lay counselors interviewed participants using the translated Zulu CDQ. Subsequently a psychologist conducted a full psychiatric assessment guided by the CDQ questions. Analyses examined sensitivity, specificity and overall accuracy, comparing lay counselor and psychologist assessment. RESULTS: Sensitivity (73%), specificity (81%) and overall accuracy (79%) were good for the variable indicating presence of 'any diagnosis.' Among those cases identified by the psychologist as having any psychiatric diagnosis, over 70% were correctly identified by lay counselors using the CDQ (i.e., positive predictive value was greater than 70%). The false positive rate was relatively low (19%). Specificity for 'any disorder' (including substance use) and 'any psychiatric disorder' were 81% and 79%. CONCLUSIONS: The isiZulu CDQ is a sensitive and valid MH diagnostic screener that can be used by lay counselors with limited MH training to identify those in need of treatment and target extremely scarce MH professionals. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: South Africa (SA), a country heavily impacted by poverty, HIV and the legacy of Apartheid, has a high prevalence of mental health (MH) and substance abuse problems. In SA and other low-and-middle-income-countries (LMIC) there is a dearth of MH professionals. This study examined use and validity of the Client Diagnostic Questionnaire (CDQ), a brief diagnostic MH screening tool designed for use by lay counselors in HIV-affected populations. Comparing lay counsellor diagnoses on the CDQ to clinician assessment, sensitivity, specificity and overall accuracy were good at the level of 'any diagnosis.' The CDQ can be used effectively in SA and other LMIC with limited MH services to enable appropriate and efficient referral of individuals in primary care settings, supporting caregivers and the children in their care.

Examining the Intersection of Bullying and Physical Relationship Violence Among New York City High School Students.

Research is just beginning to explore the intersection of bullying and relationship violence. The relationship between these forms of youth aggression has yet to be examined in diverse urban centers, including New York City (NYC). This study seeks to identify intersections of joint victimization from bullying and electronic bullying (e-bullying) with physical relationship violence (pRV). This study examines data from the NYC Youth Risk Behavior Survey (YRBS), a representative sample of NYC public high school students, to assess the concurrent victimization from bullying at school and e-bullying with pRV, operationalized as physical violence by a dating partner in the past 12 months. Students who reported being bullied at school and e-bullied had increased odds (bullied: OR = 2.5, 95% CI [2.1, 2.9]; e-bullied: OR = 3.0, 95% CI [2.6, 3.5]) of also being victimized by pRV compared with those who did not report being bullied or e-bullied. In logistic regression models, being bullied at school and being e-bullied remained significant predictors of students' odds of reporting pRV (bullied: AOR = 2.6, 95% CI [2.2, 3.1]; e-bullied: AOR = 3.0, 95% CI [2.5, 3.6]) while controlling for race, gender, sexual orientation, and age. This research is the first to assess the intersection of victimization from bullying and e-bullying with pRV in a large, diverse, random sample of urban high school students. In this sample, students who report being bullied or e-bullied are more likely also to report pRV than students who have not been bullied or e-bullied. This research has potential implications for educators, adolescent health and social service providers, and policy makers to tailor programs and enact policies that jointly address bullying and pRV. Future studies are needed to longitudinally assess both victimization from and perpetration of bullying and pRV.