RESUMO
Background: The negative impacts of maternal depression on child mental health outcomes are well-documented. However, some children show adaptive functioning following exposure to maternal depression, demonstrating resilience. In a large birth cohort from Brazil, a middle-income country, we examined direct and indirect pathways, considering socioeconomic, family, and individual factors, contributing to the development of resilience. Methods: Using data from the 2004 Pelotas Birth Cohort (N = 4231), we restricted the sample to those exposed to maternal depression up to age 6 years (depression present at ≥2 out of 5 assessment waves; n = 1132; 50% boys). Resilience was defined as scoring below or equal to the mean of the unexposed group on all four problem subscales of the parent-report Strengths and Difficulties Questionnaire at age 11 years. We examined pathways from socioeconomic status (SES; measured at birth) to resilience via cognitive stimulation (CS) (at 24 and 48 months) and Intelligence quotient (IQ) (at 6 years), and from CS to resilience via IQ, using counterfactual mediation. Results: A minority of children exposed to maternal depression showed resilience (12.4%). There was evidence of indirect pathways from SES to resilience via CS (odds ratio (OR) = 1.76, 95% confidence interval (CI) 1.02-3.38) and IQ (OR = 1.19, 95% CI 1.01-1.42), such that higher SES was associated with resilience via both higher levels of CS and higher IQ, which, in turn, were each positively associated with resilience. Furthermore, there was evidence of a direct (OR = 1.86, 95% CI 1.01-3.76) and total effect (OR = 1.94, 95% CI 1.05-3.89) of CS on resilience, even after controlling for SES. However, these effects varied depending on how persistent and severe depression was defined. Conclusions: These findings suggest that CS in early childhood may represent a modifiable protective factor for children exposed to maternal depression and a promising intervention target to promote child resilience in the context of maternal depression exposure.
RESUMO
BACKGROUND: Childhood trauma is a proposed transdiagnostic risk factor for psychopathology, but epidemiological evidence from low-income and middle-income countries (LMICs) is scarce. We investigated associations between trauma and child psychiatric disorders in a birth cohort in Brazil. METHODS: The 2004 Pelotas Birth Cohort is an ongoing, population-based, prospective birth cohort, including all hospital births occurring between Jan 1 and Dec 31, 2004, in the city of Pelotas, Brazil. When the children were aged 6 and 11 years, trained psychologists administered the Development and Well-Being Assessment clinical interview to caregivers to assess current child psychiatric disorders (anxiety disorders, mood disorders, ADHD and hyperactivity disorders, and conduct and oppositional disorders), and lifetime trauma exposure (ie, experiencing or witnessing life-threatening events) including interpersonal and non-interpersonal events. Analyses used multiple imputation and logistic regression models. OUTCOMES: Of 4263 live births, 4231 children were included in the study sample, and 4229 (2195 [51·9%] boys and 2034 [48·1%] girls; 2581 [61·7%] with White mothers and 1600 [38·3%] with Black or mixed race mothers) were included in the imputed analyses. 1154 (34·3%) of 3367 children with complete data at age 11 years had been exposed to trauma by that age. After adjusting for confounders, at age 6 years, trauma was associated with increased odds of anxiety disorders (adjusted odds ratio 1·79 [95% CI 1·33-2·42]) and any psychiatric disorder (1·59 [1·22-2·06]), and at age 11 years, with any psychiatric disorder (1·45 [1·17-1·79]) and all four specific diagnostic classes of anxiety disorders (1·47 [1·04-2·09]), mood disorders (1·66 [1·08-2·55]), ADHD and hyperactivity disorders (1·47 [1·01-2·13]), and conduct and oppositional disorders (1·76 [1·19-2·61]). Interpersonal trauma and non-interpersonal trauma were each associated with increased odds of multiple psychiatric disorders, even when adjusting for their co-occurrence. INTERPRETATION: A considerable mental health burden associated with childhood trauma is already evident by middle childhood in this sample from Brazil. Evidence-based efforts to reduce the incidence of childhood trauma in Brazil and address its consequences are urgently needed. FUNDING: Children's Pastorate, WHO, National Support Program for Centres of Excellence, Brazilian National Research Council, Brazilian Ministry of Health, São Paulo Research Foundation, University of Bath, Wellcome Trust. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.