Digital Support Systems to Improve Child Health and Development in Peru: Protocol for a Randomized Controlled Trial.

BACKGROUND: Children living in low and middle-income countries (LMICs) are at greater risk for experiencing adversities that can undermine their health and early development. Recently launched digital early childhood development (ECD) programs attempt to support families with young children in their home environments using digital technologies. However, relatively little is known regarding the effectiveness of these new technologies. OBJECTIVE: The goal of this study is to rigorously assess the reach, effectiveness, and cost-effectiveness of a newly developed digital ECD platform called Afini. The Afini platform was designed to support parents of young children in low-resource settings to improve ECD and interact with caregivers through messenger services and a chatbot. METHODS: This is a 3-arm cluster randomized controlled trial. In total, 2471 caregivers and their 3- to 9-month-old children were enrolled in the study across 164 study clusters in the San Marcos, Cajabamba, and Cajamarca provinces of Peru. Clusters of participants were randomly assigned to 1 of 3 groups: a control group (72 community clusters and 980 caregiver-child dyads), a home visit intervention group (20 community clusters and 316 caregiver-child dyads), and an Afini intervention group (72 community clusters and 1175 caregiver-child dyads). Families in the control group receive no focused ECD intervention. The home visit group is receiving biweekly home visits by a trained field staff following the national ECD program (Programa Nacional Cuna Más) curriculum and training guidelines. Caregivers in the Afini group are receiving ECD activities and advice through the digital platform. The primary study outcome is children's overall development at the age of 2.5 years, using the internationally validated long form of the Global Scales for Early Development. Secondary outcomes include caregiver engagement; caregiver mental health; screen time; as well as caregiver reports of children's motor, cognitive, language, and socioemotional development measured through locally piloted and validated tools. RESULTS: Enrollment started in September 2021 and ended in March 2023. Endline assessments will take place between August 2023 and September 2024. CONCLUSIONS: This study is, to our knowledge, the first to rigorously assess the effectiveness and cost-effectiveness of digital ECD technologies in LMICs. Given the large number of children in LMICs currently receiving only limited external support, the evaluated platform has the potential to improve the short- and long-term well-being of millions of children and their parents globally. TRIAL REGISTRATION: ClinicalTrials.gov NCT05202106; https://clinicaltrials.gov/ct2/show/NCT05202106. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50371.

Digital tools to improve parenting behaviour in low-income settings: a mixed-methods feasibility study.

INTRODUCTION: Digital parenting interventions could be potentially cost-effective means for providing early child development services in low-income settings. This 5-month mixed-methods pilot study evaluated the feasibility of using Afinidata, a comprehensive Facebook Messenger-based digital parenting intervention in a remote rural setting in Latin America and explored necessary adaptations to local context. METHODS: The study was conducted in three provinces in the Cajamarca region, Peru, from February to July 2021. 180 mothers with children aged between 2 and 24 months and regular access to a smartphone were enrolled. Mothers were interviewed three times in-person. Selected mothers also participated in focus groups or in-depth qualitative interviews. RESULTS: Despite the rural and remote study site, 88% of local families with children between 0 and 24 months had access to internet and smartphones. Two months after baseline, 84% of mothers reported using the platform at least once, and of those, 87% rated it as useful to very useful. After 5 months, 42% of mothers were still active on the platform, with little variation between urban and rural settings. Modifications to the intervention focused on assisting mothers in navigating the platform independently and included adding a laminated booklet with general information on child development, sample activities and detailed instructions on how to self-enrol in case of lost phones. CONCLUSIONS: We found high access to smartphones and the intervention was well received and used in very remote areas of Peru, suggesting that digital parenting interventions could be a promising path forward for supporting low-income families in remote parts of Latin America.

Child welfare involvement and adjustment among care alumni and their children: A systematic review of risk and protective factors.

BACKGROUND: Recent research and policy recognize care alumni (i.e., adults formerly in out-of-home care [OHC]) as a population with a high accumulation of disadvantages well into adulthood, often in combination with early parenthood compared to the general population. OBJECTIVE: The aim of this systematic review is to provide an overview on the impact of parental OHC on outcomes for both parents (i.e. parental adjustment, parenting) and their children (i.e. prevalence rates of OHC or child welfare system (CWS) involvement, adjustment, development), as well as protective and risk factors associated with those outcomes. METHODS: Relevant articles were searched in four electronic databases from conception to 16 February 2022 according to PRISMA guidelines for systematic reviews; supplemented with hand-searched citations from relevant references. Evidence was synthesized via a qualitative summary. RESULTS: A total of 38 studies were included (19 quantitative, 14 qualitative, and 5 mixed-methods studies). Studies confirm increased rates of early parenthood among care alumni and an elevated risk of OHC among their children. However, most children remain with their care alumni parents, and some parents were met with the needed support to cope with challenging circumstances. Qualitative studies point to a great need for specialized services, including parenting programs that address past trauma and attachment issues. They also highlight potential protective factors. CONCLUSIONS: Findings suggest that care alumni parents experience compounding disadvantage, which may increase their children's risk of OHC. More research is needed on child adjustment, and on protective factors that can be leveraged to design effective interventions that decrease transgenerational CWS involvement.

Mental disorders among adults formerly in out-of-home care: a systematic review and meta-analysis of longitudinal studies.

While children and adolescents placed in child welfare or juvenile justice out-of-home care show higher prevalence rates of mental disorders compared to the general population, it remains unclear whether this pattern persists into adulthood. A quantitative synthesis of existing studies is lacking. The aim of this meta-analysis was to estimate the prevalence rates for mental disorders among adults with a foster or residential child welfare or juvenile justice care history, comparing them where possible to rates among the general population. PubMed, PsycInfo, EMBASE, and Web of Science were systematically searched for epidemiological studies published up to 28 October 2020. Nineteen studies, totaling 604,257 participants, met our inclusion criteria. Random-effects models were used for prevalence rates and odds ratios (OR) of mental disorders, and study quality was rated. A prevalence rate of 30% [95% CI (23.36, 37.36)] for any mental disorder in adults with a child welfare care history was found (3-17% for specific disorders). A prevalence rate of 45% [95% CI (42.38, 47.38)] for any mental disorder was found in adults with a juvenile justice care history (6-66% for specific disorders). For out-of-home placement history, adult mental disorders were significantly higher than in the general population (OR = 1.33-2.76). Studies differed in terms of methodology and the disorder groups considered, so heterogeneity between effect sizes ranged from low to high. Our findings suggest that the high risk that mental health issues will persist in adults with an out-of-home placement history needs to be taken seriously in the transition from adolescence to adulthood. The care systems involved need to collaborate and to be aware of these risks.

Shared residential placement for child welfare and juvenile justice youth: current treatment needs and risk of adult criminal conviction.

BACKGROUND: Although child welfare youth and juvenile offenders in residential care have different judicial placement reasons, there seems to be overlap in their demographic and psychosocial backgrounds. This could raise the question whether these adolescents should be placed in strictly separated institutions based on their judicial title (civil or criminal law) or together based on their needs. As systematic knowledge on the effects of shared placement of these groups is limited, the aim of the current paper is to examine the demographic, crime-related and psychosocial characteristics of child welfare and juvenile justice youths in shared residential care and subsequently examine its relationship with offending behavior in adulthood. METHODS: The sample was drawn from the Swiss study for clarification and goal-attainment in youth welfare and juvenile justice institutions (MAZ.) and consisted 354 juveniles (252 child welfare, 102 juvenile justice; 223 boys, 131 girls) between 10 and 18 years. Mental health problems were assessed with the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2), official adult criminal conviction data up to 10 years later was obtained from the Swiss Federal Office of Statistics. Three sets of logistic regressions were conducted investigating any, violent and non-violent convictions. RESULTS: Univariate results showed that that the child welfare sample included more females, more juveniles with the Swiss nationality, and was younger at the time of assessment and at first placement compared to the juvenile justice sample. Furthermore, child welfare youths showed less alcohol/drug use problems and offending behavior than their juvenile justice counterparts. Unadjusted models demonstrated that committing authority predicted adult criminal convictions, but that this distinction disappeared when it was controlled for demographic, crime-related and psychosocial factors. Gender and time at risk were found to be related to adult conviction in all three models. In addition, alcohol/drug use problems were risk factors for general, previous convictions for violent, and traumatic experiences for non-violent convictions in adulthood. CONCLUSIONS: Our results support the approach of placement in residential care institutions based on treatment needs instead of on judicial title. Special attention should be devoted to trauma informed care and substance use coping. However, more research is needed.

A Longitudinal Study of the Bidirectional Relations Between Anxiety Symptoms and Peer Victimization in Urban Adolescents.

The current study examined bidirectional relations between anxious symptoms and two forms of peer victimization (i.e., overt and relational) within an underrepresented sample of urban adolescents during key transition periods (i.e., elementary to middle school; middle school to high school) and the following 2 years. A predominantly African American sample (91%) of 358 adolescents (56% female, mean age = 12.10 years) living in low-income urban areas were assessed annually across 4 years. Using self-report measures, adolescents reported on their past year experiences of anxiety and peer victimization. Longitudinal path analyses tested progressively complex models for each type of victimization. Anxious symptoms predicted both overt and relational victimization at the time of transition (Wave 1 to Wave 2) and the following year (Wave 2 to Wave 3). Furthermore, whereas previous levels of victimization and future anxious symptoms were positively correlated over time, only relational victimization at Wave 1 predicted anxious symptoms at Wave 2. Prior levels of each construct were the strongest predictor of future outcomes (e.g., anxious symptoms at Wave 1 predicting anxious symptoms at Wave 2). Overall, there was little support for bidirectional relations between anxiety symptoms and peer victimization. Intervention and prevention programs seeking to reduce peer victimization or anxiety should start by targeting the symptom/behavior of interest. Interventions that target anxious thoughts and feelings during these key transition times in adolescence should be assessed as areas of priority.

Schooling while incarcerated as a turning point for serious juvenile and young adult offenders.

INTRODUCTION: Attending school and working are consistently associated with positive outcomes for juvenile offenders returning to the community. METHODS: Using longitudinal data from the Pathways to Desistance Study, we used structural equation modeling to test whether better school experiences while incarcerated was positively connected to adjustment upon release among serious juvenile offenders (91% male) in the U.S. Adjustment was assessed as attending school for 310 legal minors (<18 years), and engaging in work for 259 emerging adults (≥18 years), as well as self-reported delinquency for all participants. RESULTS: Accounting for incarceration and school history, results showed that facility school attachment, but not grades, was associated with decreased delinquency 12 months after release across sex in both age groups. Additionally, facility school attachment predicted engagement in school for returning minors. However, facility school experience was not related to engaging in work for returning emerging adults. CONCLUSIONS: Results indicate that facility school climate matters for all juvenile offenders returning to their communities and that correctional education done right presents an important opportunity to reconnect returning minors with school, an important normative context of development. Conversely, results suggest that returning offenders who have 'aged out' of high school are a separate vulnerable group who may need additional support for successful reentry.

Community violence exposure, family management practices, and substance use in youth: a cross-cultural study.

Associations between community violence exposure, family management practices, and substance use were compared in a sample of early adolescents in low-income communities from the United States (N = 151; M age = 12.71 years, standard deviation = 0.65; 50.3% female) and South Africa (N = 175; M age = 12.55 years, standard deviation = 0.85; 64.6% female) using home interviews with youth and their maternal caregivers. Past year victimization was associated with recent youth substance use. The moderating role of family management practices varied by type of practice (e.g., parental knowledge, control, solicitation, or child disclosure), reporter, and country. High parental knowledge reported by caregiver was protective against substance use only for South African youth. In youth reports, parental knowledge was protective across the United States and South Africa. Youth reports of their disclosure to parents were negatively associated with substance use in the United States but not South Africa. These data highlight the importance of considering both ecological context and reporter in the links between violence exposure, parenting, and substance use in youth.

Emotion dysregulation, anticipatory cortisol, and substance use in urban adolescents.

Anticipatory cortisol is associated with risk for substance use in adolescents. The present study extended prior literature by testing a model linking family emotional climate, emotion dysregulation, anticipatory cortisol, and substance use. Participants were 229 adolescents (M = 11.94 years, SD = 1.55; 41% male; 92% African American) enrolled in a 4-wave study of stressors, physiological stress responses, and substance use. Caregivers completed measures of family emotional climate at baseline and adolescents' emotion dysregulation one and two years later; adolescents reported on their substance use at baseline and three years later at Wave 4. Adolescents completed a stress task at Wave 4; saliva samples taken immediately prior to the task were analyzed for cortisol. Longitudinal path models revealed that a negative emotional climate at home was associated with elevated emotion dysregulation at subsequent waves for all youth. Emotional dysregulation was prospectively associated with blunted anticipatory cortisol, which in turn was associated with elevated substance use, controlling for baseline substance use and age. However, these associations only were observed for females. This study suggests that helping girls in particular manage their emotional responses to stress more effectively may impact their physiological responses and reduce risk for substance use.

The Relationship between Trauma, Arrest, and Incarceration History among Black Americans: Findings from the National Survey of American Life.

Prior research indicates an association between exposure to trauma (e.g., being victimized) and perpetration of crime, especially in the context of chronic victimization. This study examines the relationship between trauma exposure, posttraumatic stress disorder (PTSD), and history of arrest and incarceration among a representative sample of black Americans from the National Survey of American Life (N = 5,189). One-third had a history of arrest, and 18 percent had a history of incarceration. Frequency of trauma exposure was associated with involvement with the criminal justice system. Relative to never experiencing trauma, experiencing ≥4 traumas was associated with elevated odds of arrest (odds ratio [OR] = 4.03), being jailed (OR = 5.15), and being imprisoned (OR = 4.41), all p <.01. PTSD was also associated with likelihood of incarceration among those with a history of trauma (OR = 2.18, p <.01). Both trauma exposure and trauma-associated psychopathology are associated with increased likelihood of arrest and incarceration in adulthood among black Americans.

What parents don't know: Disclosure and secrecy in a sample of urban adolescents.

Research with two-parent European households has suggested that secrecy, and not disclosure of information per se, predicts adolescent adjustment difficulties. The present study attempted to replicate this finding using data from a 4-wave study of 358 poor, urban adolescents (47% male; M age = 12 yrs) in the United States, most of whom (>92%) were African American. Adolescents self-reported secrecy, disclosure, depressive symptoms, and delinquency at each wave. Confirmatory factor analyses revealed that a two-factor model with secrecy and disclosure as separate, but correlated, factors was a better fit than a one-factor model. However, predictive models differed from previous research. Secrecy did not predict depressive symptoms, rather depressive symptoms predicted secrecy. For delinquency, there were significant paths from both secrecy to delinquency and delinquency to secrecy, as well as from delinquency to disclosure. These results did not differ by age or sex. Comparisons with previous findings are discussed.

Parental emotional competence and parenting in low-income families with adolescents.

Ample research has demonstrated that alexithymia, which is characterized by difficulty processing emotions, is associated with disruptions in parenting infants and toddlers. Individuals suffering from alexithymia have among other negative outcomes difficulty building and maintaining interpersonal relationships. Research on emotional expression and recognition has documented the importance of these competencies for the quality of the parent-child relationship and for skills critical for parents of adolescents, such as effective monitoring. However, literature linking parental alexithymia to parenting behaviors and related constructs during adolescents is lacking. The present study closes this gap by examining how mothers' (M age = 39.42 years, SD = 7.62; Range = 23-67) alexithymia affects parent-reported behaviors of solicitation and control, as well as youths' (53.6% female; M age = 12.13 years, SD = 1.62; Range = 9-16) reported disclosure and felt acceptance by their mothers among a sample of 358 primarily urban, African American families. Structural equation models (SEM) revealed that mothers' alexithymia was prospectively related to less parental solicitation 2 years later for both males and females, and to lower levels of felt acceptance for males. Multiple group analyses revealed that these models fits equally well for younger and older youth. Contrary to hypotheses, alexithymia was not related to control or to disclosure. Taken together, these findings indicate that parents' difficulty in processing emotions contributes to parenting beyond early childhood.

"Cause That's the Only Skills in School You Need": A Qualitative Analysis of Revenge Goals in Poor Urban Youth.

Revenge goals are correlated with maladjustment, and retaliation is a factor driving youth violence. However, revenge might be an important social tool adolescents use to achieve (self-)justice in environments where institutionalized interventions from authorities such as teachers or police are limited. This qualitative secondary analysis of 50 revenge scenarios from a larger study (N = 358 youth-caregiver dyads) expands one-dimensional knowledge from closed-answer vignettes to the rich real-world experiences of youth (aged 10-16; 30 boys, 20 girls), from an urban community sample. Ten patterns of qualitative differences in cognition and emotion of revenge scenarios emerged and are discussed within the revised model of social information processing (SIP). Importance of reputation, confidence in non-violent solutions, and the influence of intense emotions were among the themes. Gender differences and implications for prevention are discussed.

Use of prescription drugs and future delinquency among adolescent offenders.

Non-medical use of prescription drugs (NMUPD) by adolescents is a significant public health concern. The present study investigated the profile of NMUPD in 1349 adolescent offenders from the Pathways to Desistance project, and whether NMUPD predicted future delinquency using longitudinal data. Results indicated that increased frequency and recency of NMUPD in adolescent offenders are related to some demographic factors, as well as increased risk for violence exposure, mental health diagnoses, other drug use, and previous delinquency, suggesting that severity of NMUPD is important to consider. However, ANCOVA analyses found that NMUPD was not a significant predictor of drug-related, non-aggressive, or aggressive delinquency 12 months later beyond other known correlates of delinquency. Age, sex, exposure to violence, lower socioeconomic status, more alcohol use, and having delinquency histories were more important than NMUPD in predicting future delinquency. These findings suggest that although NMUPD is an important risk factor relating to many correlates of delinquency, it does not predict future delinquency beyond other known risk factors.

Peer victimization and subsequent disruptive behavior in school: The protective functions of anger regulation coping.

Peer victimization is linked to adjustment problems in youth, including aggressive behavior, yet not all victimized youth are aggressive. The present study investigated whether youth's anger regulation coping might attenuate the positive association between peer victimization and subsequent aggressive behavior. Longitudinal data from 485 7th-grade students (55% female, mean age = 12.84 years) and their teachers were collected in the fall and six months later. Teacher ratings of youth aggressive behavior at follow-up were the primary outcome, with statistical adjustments for baseline aggressive behavior and demographics. Results from multilevel models showed significant interactive effects of baseline anger regulation and peer victimization on residualized teacher-rated aggressive behaviors that were consistent with the hypothesis that anger regulation played a protective role: under high levels of peer victimization, youth with higher levels of anger regulation displayed lower levels of aggressive behavior than their counterparts with lower levels of anger regulation. These findings suggest that targeting and improving students' ability to regulate their anger may be protective in the face of peer victimization and reduce subsequent aggressive behavior.