Evaluation of a community health worker home visit intervention to improve child development in South Africa: A cluster-randomized controlled trial.

BACKGROUND: Effective integration of home visit interventions focused on early childhood development into existing service platforms is important for expanding access in low- and middle-income countries (LMICs). We designed and evaluated a home visit intervention integrated into community health worker (CHW) operations in South Africa. METHODS AND FINDINGS: We conducted a cluster-randomized controlled trial in Limpopo Province, South Africa. CHWs operating in ward-based outreach teams (WBOTs; clusters) and caregiver-child dyads they served were randomized to the intervention or control group. Group assignment was masked from all data collectors. Dyads were eligible if they resided within a participating CHW catchment area, the caregiver was at least 18 years old, and the child was born after December 15, 2017. Intervention CHWs were trained on a job aid that included content on child health, nutrition, developmental milestones, and encouragement to engage in developmentally appropriate play-based activities, for use during regular monthly home visits with caregivers of children under 2 years of age. Control CHWs provided the local standard of care. Household surveys were administered to the full study sample at baseline and endline. Data were collected on household demographics and assets; caregiver engagement; and child diet, anthropometry, and development scores. In a subsample of children, electroencephalography (EEG) and eye-tracking measures of neural function were assessed at a lab concurrent with endline and at 2 interim time points. Primary outcomes were as follows: height-for-age z-scores (HAZs) and stunting; child development scores measured using the Malawi Developmental Assessment Tool (MDAT); EEG absolute gamma and total power; relative EEG gamma power; and saccadic reaction time (SRT)-an eye-tracking measure of visual processing speed. In the main analysis, unadjusted and adjusted impacts were estimated using intention-to-treat analysis. Adjusted models included a set of demographic covariates measured at baseline. On September 1, 2017, we randomly assigned 51 clusters to intervention (26 clusters, 607 caregiver-child dyads) or control (25 clusters, 488 caregiver-child dyads). At endline (last assessment June 11, 2021), 432 dyads (71%) in 26 clusters remained in the intervention group, and 332 dyads (68%) in 25 clusters remained in the control group. In total, 316 dyads attended the first lab visit, 316 dyads the second lab visit, and 284 dyads the third lab visit. In adjusted models, the intervention had no significant impact on HAZ (adjusted mean difference (aMD) 0.11 [95% confidence interval (CI): -0.07, 0.30]; p = 0.220) or stunting (adjusted odds ratio (aOR) 0.63 [0.32, 1.25]; p = 0.184), nor did the intervention significantly impact gross motor skills (aMD 0.04 [-0.15, 0.24]; p = 0.656), fine motor skills (aMD -0.04 [-0.19, 0.11]; p = 0.610), language skills (aMD -0.02 [-0.18, 0.14]; p = 0.820), or social-emotional skills (aMD -0.02 [-0.20, 0.16]; p = 0.816). In the lab subsample, the intervention had a significant impact on SRT (aMD -7.13 [-12.69, -1.58]; p = 0.012), absolute EEG gamma power (aMD -0.14 [-0.24, -0.04]; p = 0.005), and total EEG power (aMD -0.15 [-0.23, -0.08]; p < 0.001), and no significant impact on relative gamma power (aMD 0.02 [-0.78, 0.83]; p = 0.959). While the effect on SRT was observed at the first 2 lab visits, it was no longer present at the third visit, which coincided with the overall endline assessment. At the end of the first year of the intervention period, 43% of CHWs adhered to monthly home visits. Due to the COVID-19 pandemic, we were not able to assess outcomes until 1 year after the end of the intervention period. CONCLUSIONS: While the home visit intervention did not significantly impact linear growth or skills, we found significant improvement in SRT. This study contributes to a growing literature documenting the positive effects of home visit interventions on child development in LMICs. This study also demonstrates the feasibility of collecting markers of neural function like EEG power and SRT in low-resource settings. TRIAL REGISTRATION: PACTR 201710002683810; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=2683; South African Clinical Trials Registry, SANCTR 4407.

Eye tracking: empirical foundations for a minimal reporting guideline.

In this paper, we present a review of how the various aspects of any study using an eye tracker (such as the instrument, methodology, environment, participant, etc.) affect the quality of the recorded eye-tracking data and the obtained eye-movement and gaze measures. We take this review to represent the empirical foundation for reporting guidelines of any study involving an eye tracker. We compare this empirical foundation to five existing reporting guidelines and to a database of 207 published eye-tracking studies. We find that reporting guidelines vary substantially and do not match with actual reporting practices. We end by deriving a minimal, flexible reporting guideline based on empirical research (Section "An empirically based minimal reporting guideline").

The stability of early developing attentional bias for faces and fear from 8 to 30 and 60 months in the FinnBrain Birth Cohort Study.

Most infants exhibit an attentional bias for faces and fearful facial expressions. These biases reduce toward the third year of life, but little is known about the development of the biases beyond early childhood. We used the same methodology longitudinally to assess attention disengagement patterns from nonface control pictures and faces (neutral, happy, and fearful expressions) in a large sample of children at 8, 30, and 60 months (N = 389/393/492, respectively; N = 72 for data in all three assessment; girls > 45.3% in each assessment). "Face bias" was measured as a difference in disengagement probability (DP) from faces (neutral/happy) versus nonface patterns. "Fear bias" was calculated as a difference in DP for fearful versus happy/neutral faces. At group level, DPs followed a nonlinear longitudinal trajectory in all face conditions, being lowest at 8 months, highest at 30 months, and intermediate at 60 months. Face bias declined between 8 and 30 months, but did not change between 30 and 60 months. Fear bias declined linearly from 8 to 60 months. Individual differences in disengagement were generally not stable across age, but weak correlations were found in face bias between 8- and 60-month, and in DPs between 30- and 60-month (rs = .22-.41). The results suggest that prioritized attention to faces-that is, a hallmark of infant cognition and a key aspect of human social behavior-follows a nonlinear trajectory in early childhood and may have only weak continuity from infancy to mid childhood. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Assessing infant cognition in field settings using eye-tracking: a pilot cohort trial in Sierra Leone.

OBJECTIVES: To investigate the feasibility of eye-tracking-based testing of the speed of visual orienting in malnourished young children at rural clinics in Sierra Leone. DESIGN: Prospective dual cohort study nested in a cluster-randomised trial. SETTING: 8 sites participating in a cluster-randomised trial of supplementary feeding for moderate acute malnutrition (MAM). PARTICIPANTS: For the MAM cohort, all infants aged 7-11 months at the eight sites were enrolled, 138 altogether. For controls, a convenience sample of all non-malnourished infants aged 7-11 months at the same sites were eligible, 60 altogether. A sample of 30 adults at the sites also underwent eye-tracking tests as a further control. INTERVENTIONS: Infants with MAM were provided with supplementary feeding. OUTCOME MEASURES: The primary outcomes were feasibility and reliability of eye-tracking-based testing of saccadic reaction time (SRT). Feasibility was assessed by the percent of successful tests in the infants. Reliability was measured with intraclass correlation coefficients (ICCs). Secondary outcomes were mean SRT based on nutritional state as well as and changes in mean SRT after supplementary feeding of MAM children. RESULTS: Infants exhibited consistent orienting to targets on a computer screen (>95% of valid trials). Mean SRTs had moderate stability within visits (ICCs 0.60-0.69) and across the 4-week test-retest interval (0.53) in infants; the adult control group had greater SRT stability (within visit ICC=0.92). MAM infants had a trend toward higher adjusted SRT at baseline (difference=12.4 ms, 95% CI -2 to 26.9, p=0.09) and improvement in SRT 4 weeks thereafter (difference=-14 ms, 95% CI -26.2 to -1.7, p=0.025) compared with age-matched controls. CONCLUSIONS: The results demonstrate the feasibility of eye-tracking-based testing in a resource-poor field setting and suggest eye-tracking measures have utility in the detection of group level effects of supplementary feeding.

Signaled night awakening and its association with social information processing and socio-emotional development across the first two years.

STUDY OBJECTIVES: Night awakening is common in infancy, and some infants continue to have signaled night awakenings throughout early childhood. However, the influence of signaled night awakening on children's social development is less explored. In the present study, longitudinal associations between signaled night awakening, social information processing, and socio-emotional development were measured within the CHILD-SLEEP birth cohort in two groups formed based on parent-reported night awakenings. METHODS: At 8 months, there were 77 infants in the waking group (≥3 awakenings) and 69 infants in the nonwaking group (≤1 awakening). At 8 and 24 months, social information processing was measured as children's attention to neutral and emotional faces, and at 24 months, parent-reported socio-emotional behavior was measured with the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) questionnaire. RESULTS: The two groups showed different patterns of attention to emotional faces. The waking group had a more pronounced attentional bias to fearful versus happy faces, whereas in the nonwaking group, attention to fearful and happy faces did not differ. In addition, at 24 months, the waking group had more dysregulation problems and lower social competence than the nonwaking group, but no clear differences in internalizing or externalizing problems were found. CONCLUSIONS: Our results contribute to the literature by showing that during the first 2 years of life, signaled night awakening is associated with social information processing and socio-emotional behavior.

Converging neural and behavioral evidence for a rapid, generalized response to threat-related facial expressions in 3-year-old children.

Electrophysiological studies on adults suggest that humans are efficient at detecting threat from facial information and tend to grant these signals a priority in access to attention, awareness, and action. The developmental origins of this bias are poorly understood, partly because few studies have examined the emergence of a generalized neural and behavioral response to distinct categories of threat in early childhood. We used event-related potential (ERP) and eye-tracking measures to examine children's early visual responses and overt attentional biases towards multiple exemplars of angry and fearful vs. other (e.g., happy and neutral) faces. A large group of children was assessed longitudinally in infancy (5, 7, or 12 months) and at 3 years of age. The final ERP dataset included 148 infants and 132 3-year-old children; and the final eye-tracking dataset included 272 infants and 334 3-year-olds. We demonstrate that 1) neural and behavioral responses to facial expressions converge on an enhanced response to fearful and angry faces at 3 years of age, with no differentiation between or bias towards one or the other of these expressions, and 2) a support vector machine learning model using data on the early-stage neural responses to threat reliably predicts the duration of overt attentional dwell time for threat-related faces at 3 years. However, we found little within-subject correlation between threat-bias attention in infancy and at 3 years of age. These results provide unique evidence for the early development of a rapid, unified response to two distinct categories of facial expressions with different physical characteristics, but shared threat-related meaning.

Pupillary and Attentional Responses to Infant Facial Expressions in Mothers Across Socioeconomic Variations.

Maternal responses to infant facial expressions were examined in two socioeconomically diverse samples of South African mothers (Study I, N = 111; and Study II, N = 214; age: 17-44 years) using pupil and gaze tracking. Study I showed increased pupil response to infant distress expressions in groups recruited from private as compared to public maternity clinics, possibly reflecting underlying differences in socioeconomic status (SES) across the groups. Study II, sampling uniformly low-SES neighborhoods, found increased pupil dilation and faster orientation to expressions of infant distress, but only in the highest income group. These results are consistent with maternal physiological and attentional sensitivity to infant distress cues but challenge the universality of this sensitivity across socioeconomic diversity.

Associations between individual variations in visual attention at 9 months and behavioral competencies at 18 months in rural Malawi.

Theoretical and empirical considerations suggest that individual differences in infant visual attention correlate with variations in cognitive skills later in childhood. Here we tested this hypothesis in infants from rural Malawi (n = 198-377, depending on analysis), who were assessed with eye tracking tests of visual orienting, anticipatory looks, and attention to faces at 9 months, and more conventional tests of cognitive control (A-not-B), motor, language, and socioemotional development at 18 months. The results showed no associations between measures of infant attention at 9 months and cognitive skills at 18 months, either in analyses linking infant visual orienting with broad cognitive outcomes or analyses linking specific constructs between the two time points (i.e., switching of anticipatory looks and manual reaching responses), as correlations varied between -0.08 and 0.14. Measures of physical growth, and family socioeconomic characteristics were also not correlated with cognitive outcomes at 18 months in the current sample (correlations between -0.10 and 0.19). The results do not support the use of the current tests of infant visual attention as a predictive tool for 18-month-old infants' cognitive skills in the Malawian setting. The results are discussed in light of the potential limitations of the employed infant tests as well as potentially unique characteristics of early cognitive development in low-resource settings.

Associations Between Neonatal Cry Acoustics and Visual Attention During the First Year.

It has been suggested that early cry parameters are connected to later cognitive abilities. The present study is the first to investigate whether the acoustic features of infant cry are associated with cognitive development already during the first year, as measured by oculomotor orienting and attention disengagement. Cry sounds for acoustic analyses (fundamental frequency; F0) were recorded in two neonatal cohorts at the age of 0-8 days (Tampere, Finland) or at 6 weeks (Cape Town, South Africa). Eye tracking was used to measure oculomotor orienting to peripheral visual stimuli and attention disengagement from central stimuli at 8 months (Tampere) or at 6 months (Cape Town) of age. Only a marginal positive correlation between fundamental frequency of cry (F0) and visual attention disengagement was observed in the Tampere cohort, but not in the Cape Town cohort. This correlation indicated that infants from the Tampere cohort with a higher neonatal F0 were marginally slower to shift their gaze away from the central stimulus to the peripheral stimulus. No associations between F0 and oculomotor orienting were observed in either cohort. We discuss possible factors influencing the current pattern of results suggesting a lack of replicable associations between neonatal cry and visual attention and suggest directions for future research investigating the potential of early cry analysis in predicting later cognitive development.

Newborn left amygdala volume associates with attention disengagement from fearful faces at eight months.

After 5 months of age, infants begin to prioritize attention to fearful over other facial expressions. One key proposition is that amygdala and related early-maturing subcortical network, is important for emergence of this attentional bias - however, empirical data to support these assertions are lacking. In this prospective longitudinal study, we measured amygdala volumes from MR images in 65 healthy neonates at 2-5 weeks of gestation corrected age and attention disengagement from fearful vs. non-fearful facial expressions at 8 months with eye tracking. Overall, infants were less likely to disengage from fearful than happy/neutral faces, demonstrating an age-typical bias for fear. Left, but not right, amygdala volume (corrected for intracranial volume) was positively associated with the likelihood of disengaging attention from fearful faces to a salient lateral distractor (r = .302, p = .014). No association was observed with the disengagement from neutral or happy faces in equivalent conditions (r = .166 and .125, p = .186 and .320, respectively). These results are the first to link the amygdala volume with the emerging perceptual vigilance for fearful faces during infancy. They suggest a link from the prenatally defined variability in the amygdala size to early postnatal emotional and social traits.

The role of TPH2 variant rs4570625 in shaping infant attention to social signals.

TPH2, the rate-limiting enzyme in the synthesis of serotonin, has been connected to several psychiatric outcomes. Its allelic variant, rs4570625, has been found to relate to individual differences in cognitive and emotion regulation during infancy with T-carriers of rs4570625 showing a relatively heightened attention bias for fearful faces. A significant gene-environment interaction was also reported with the T-carriers of mothers with depressive symptoms showing the highest fear bias. We investigated these associations in a sample of 8-month old infants (N = 330), whose mothers were prescreened for low/high levels of prenatal depressive and/or anxiety symptoms. Attention disengagement from emotional faces (neutral, happy, fearful, and phase-scrambled control faces) to distractors was assessed with eye tracking and an overlap paradigm. Maternal depressive symptoms were assessed at several time points during pregnancy and postpartum. The mean levels of symptoms at six months postpartum and the trajectories of symptoms from early pregnancy until six months postpartum were used in the analyses (N = 274). No main effect of the rs4570625 genotype on attention disengagement was found. The difference in fear bias between the genotypes was significant but in an opposite direction compared to a previous study. The results regarding the interaction of the genotype and maternal depression were not in accordance with the previous studies. These results show inconsistencies in the effects of the rs4570625 genotype on attention biases in separate samples of infants from the same population with only slight differences in age.

Maternal Depressive Symptoms During the Pre- and Postnatal Periods and Infant Attention to Emotional Faces.

We examined how infants' attentional disengagement from happy, fearful, neutral, and phase-scrambled faces at 8 months, as assessed by eye tracking, is associated with trajectories of maternal depressive symptoms from early pregnancy to 6 months postpartum (decreasing n = 48, increasing n = 34, and consistently low symptom levels n = 280). The sample (mother-infant dyads belonging to a larger FinnBrain Birth Cohort Study) was collected between 5/2013-6/2016. The overall disengagement probability from faces to distractors was not related to maternal depressive symptoms, but fear bias was heightened in infants whose mothers reported decreasing or increasing depressive symptoms. Exacerbated attention to fearful faces in infants of mothers with depressive symptoms may be independent of the timing of the symptoms in the pre- and postnatal stages.

Cross-cultural analysis of attention disengagement times supports the dissociation of faces and patterns in the infant brain.

Infants are slower to disengage from faces than non-face patterns when distracted by novel competing stimuli. While this perceptual predilection for faces is well documented, its universality and mechanisms in relation to other aspects of attention are poorly understood. We analysed attention disengagement times for faces and non-face patterns in a large sample of 6-to 9-month-old infants (N = 637), pooled from eye tracking studies in socioculturally diverse settings (Finland, Malawi, South Africa). Disengagement times were classified into distinct groups of quick and delayed/censored responses by unsupervised clustering. Delayed disengagement was frequent for faces (52.1% of trials), but almost negligible for patterns (3.9% of trials) in all populations. The magnitude of this attentional bias varied by individuals, whereas the impact of situational factors and facial expression was small. Individual variations in disengagement from faces were moderately stable within testing sessions and independent from variations in disengagement times for patterns. These results point to a fundamental dissociation of face and pattern processing in infants and demonstrate that the bias for faces can be robust against distractors and habituation. The results raise the possibility that attention to faces varies as an independent, early-emerging social trait in populations.

Atypical Pattern of Frontal EEG Asymmetry for Direct Gaze in Young Children with Autism Spectrum Disorder.

This study examined approach-motivation related brain activity (frontal electroencephalogram [EEG] asymmetry) in response to direct and averted gaze in 3- to 6-year-old typically developing (TD) children, children with autism spectrum disorder (ASD), and those with intellectual disability (ID). We found that, in TD children, direct gaze elicited greater approach-related frontal EEG activity than did downcast gaze. This pattern of activity was in contrast to that observed in children with ASD, who showed greater approach-related activity in response to downcast gaze than to direct gaze. ID children did not differ in their responses to different gaze conditions. These findings indicate that another person's direct gaze does not elicit approach-motivation related brain activity in young children with ASD.

Early development of visual attention in infants in rural Malawi.

Eye tracking research has shown that infants develop a repertoire of attentional capacities during the first year. The majority of studies examining the early development of attention comes from Western, high-resource countries. We examined visual attention in a heterogeneous sample of infants in rural Malawi (N = 312-376, depending on analysis). Infants were assessed with eye-tracking-based tests that targeted visual orienting, anticipatory looking, and attention to faces at 7 and 9 months. Consistent with prior research, infants exhibited active visual search for salient visual targets, anticipatory saccades to predictable events, and a robust attentional bias for happy and fearful faces. Individual variations in these processes had low to moderate odd-even split-half and test-retest reliability. There were no consistent associations between attention measures and gestational age, nutritional status, or characteristics of the rearing environment (i.e., maternal cognition, psychosocial well-being, socioeconomic status, and care practices). The results replicate infants' early attentional biases in a large, unique sample, and suggest that some of these biases (e.g., bias for faces) are pronounced in low-resource settings. The results provided no evidence that the initial manifestation of infants' attentional capacities is associated with risk factors that are common in low-resource environments.

Infants' attention bias to faces as an early marker of social development.

Infants have a strong tendency to look at faces. We examined individual variations in this attentional bias in 7-month-old infants by using a face-distractor competition paradigm and tested in a longitudinal sample whether these variations were associated with outcomes reflecting social behavior at 24 and 48 months of age (i.e., spontaneous helping, emotion understanding, mentalizing, and callous-unemotional traits; N = 100-138). The results showed a robust and distinct attention bias to faces at 7 months, particularly when faces were displaying a fearful expression. This bias declined between 7 and 24 months and there were no significant correlations in attention dwell times between 7 and 24 months of age. Variations in attention to faces at 7 months were not associated with emotion understanding or mentalizing abilities at 48 months of age, but increased attention to faces at 7 months (regardless of facial expression) was related to more frequent helping responses at 24 months and reduced callous-unemotional traits at 48 months of age. Thus, while the results fail to associate infants' face bias with later-emerging emotion understanding and mentalizing capacities, they are consistent with a model whereby increased attention to faces in infancy is linked with the development of affective empathy and responsivity to others' needs.

Early development of attention to threat-related facial expressions.

Infants from an early age have a bias to attend more to faces than non-faces and after 5 months are particularly attentive to fearful faces. We examined the specificity of this "fear bias" in 5-, 7-, and 12-month-old infants (N = 269) and 36-month-old children (N = 191) and whether its development is associated with features of the early rearing environment, specifically maternal anxiety and depression symptoms. Attention dwell times were assessed by measuring the latencies of gaze shifts from a stimulus at fixation to a new stimulus in the visual periphery. In infancy, dwell times were shorter for non-face control stimuli vs. happy faces at all ages, and happy vs. fearful, but not angry, faces at 7 and 12 months. At 36 months, dwell times were shorter for non-faces and happy faces compared to fearful and angry faces. Individual variations in attention dwell times were not associated with mothers' self-reported depression or anxiety symptoms at either age. The results suggest that sensitivity to fearful faces precedes a more general bias for threat-alerting stimuli in early development. We did not find evidence that the initial manifestation of these biases is related to moderate variations in maternal depression or anxiety symptoms.

Atypical physiological orienting to direct gaze in low-functioning children with autism spectrum disorder.

Reduced use of eye contact is a prominent feature in individuals with autism spectrum disorder (ASD). It has been proposed that direct gaze does not capture the attention of individuals with ASD. Experimental evidence is, however, mainly restricted to relatively high-functioning school-aged children or adults with ASD. This study investigated whether 2-5-year-old low-functioning children with severe ASD differ from control children in orienting to gaze stimuli, as measured with the heart rate deceleration response. Responses were measured to computerized presentations of dynamic shifts of gaze direction either toward (direct) or away (averted) from the observing child. The results showed a significant group by gaze direction interaction effect on heart rate responses (permuted P = .004), reflecting a stronger orienting response to direct versus averted gaze in typically developing (N = 17) and developmentally delayed (N = 16) children but not in children with ASD (N = 12). The lack of enhanced orienting response to direct gaze in the ASD group was not caused by a lack of looking at the eye region, as confirmed by eye tracking. The results suggest that direct gaze is not a socially salient, attention-grabbing signal for low-functioning children with ASD. Autism Res 2017, 10: 810-820. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

Mothers' pupillary responses to infant facial expressions.

BACKGROUND: Human parental care relies heavily on the ability to monitor and respond to a child's affective states. The current study examined pupil diameter as a potential physiological index of mothers' affective response to infant facial expressions. METHODS: Pupillary time-series were measured from 86 mothers of young infants in response to an array of photographic infant faces falling into four emotive categories based on valence (positive vs. negative) and arousal (mild vs. strong). RESULTS: Pupil dilation was highly sensitive to the valence of facial expressions, being larger for negative vs. positive facial expressions. A separate control experiment with luminance-matched non-face stimuli indicated that the valence effect was specific to facial expressions and cannot be explained by luminance confounds. Pupil response was not sensitive to the arousal level of facial expressions. CONCLUSIONS: The results show the feasibility of using pupil diameter as a marker of mothers' affective responses to ecologically valid infant stimuli and point to a particularly prompt maternal response to infant distress cues.