Effectiveness of Mental Health Psychosocial Interventions for mothers and children across the world

Lic. Analia Henriquez Cross, MSc Global Mental Health

To efficiently meet established Global Mental Health goals, special attention must be paid to mental health from the moment of life conception and thought the vulnerabilities of childhood as a global public health urgency. Evaluating and creating locally appropriate Mental Health Psychosocial Interventions (MHPIs) where culture is a crucial variable in the creation of such interventions is imperative; to assure a life with a healthy beginning for everyone.

First, complications of the mother during and after pregnancy can represent risks, not just to the child, but to women’s mental health (Horwitz et al., 2009). As risks differ depending on geographical and cultural context, an understanding of specific risks associated with a mother’s mental health in each community is needed for culturally appropriate interventions. To support this, Parsons and colleagues (2012) collected data showing that in Low- and Middle-Income Countries (LMICs) mothers’ mental health can be more vulnerable than in High-Income Countries (HICs). They present India as an example, where not meeting child gender expectations is associated with Postnatal Depression (PND), and contrast it with African countries, where an absence of a support network is the most common risk factor for PND. MHPIs should be targeted to decrease these most specific common risk factors mothers face in each community.

Where MHPIs are effective, they reduce the impact of risks mentioned above and alleviate the impact of PND on a child’s development. Parsons and colleagues (2010) showed that in LMICs, mothers have the greatest responsibility in child caregiving, which makes it especially difficult with PND. For example, mothers must manage services -such as water sanitation and child medical treatments- that in HICs public services already, support that mothers in LMICs do not have. They argue that a mother with PND would not feel able to carry out these activities because depression impacts her sleeping patterns and mood. As shown above, PND and social determinants can make a great impact on the quality of care mothers give to their children.

The implementation of perinatal MHPIs in LMICs should consider the scarcity of resources and must assure acceptability, cultural appropriateness and effectiveness. In most countries, including LMICs like Jamaica and South African communities (Parsons et al., 2012), most locally adequate programs proven acceptable and effective are normally delivered by local health workers (Rahman, 2013). A specific example could be The Thinking Healthy Programme in rural Pakistan, proven more effective when delivered by local peer-volunteers under supervision (Atif et al., 2019).

Stronger evidence concerning the effectiveness to reduce PND is mostly found for Psychological Interventions (PIs) more than any other, specially CBT-based ones, in both LMICs and HICs (Clarke et al., 2013). However, obstacles presented by Clarke (2013) about perinatal PIs must be considered, as they require many human resources and time. Because of this, they propose Health Promotion Interventions (HPIs) to add to PIs. Most of the acceptable HPIs they encountered are more socially focused and can address the risks factors mentioned above, even for the long-term, which PIs cannot. According to this data, local health workers who are not necessarily specialists play a crucial role in the effectiveness of perinatal MHPIs. Local workers consider how motherhood is lived and understood within their same community which can increase acceptability and cultural appropriateness. To increase effectiveness, HPIs should be used to alleviate the impact of common risks factors for mothers, and PIs to reduce PND symptoms, both with a social focus and delivered in groups.

The mother’s emotional well-being is crucial for the quality of caregiving and, consequently, for the baby’s development (Pritchett, 2013; Horwitz et al., 2009). Therefore, locally specific interventions can prevent developmental problems derived from a sub-optimal mother-infant relationship. Interventions that educate mothers about children's development, stimulation, affection, and responsiveness can improve mother-infant relationships as well as maternal mental health (Rahman, 2013). Anyhow, these interventions should consider which specific interactive styles can hinder or improve the mother-infant relationship, and how interactive styles differ across the globe.

Understanding how certain mother-infant interactions relate to attachment problems is the first step to developing efficacious MHPIs. Tomlinson, Cooper & Murray (2005) and Breidenstine, Bailey, Zeanah and Larrieu (2011) concluded that what should be targeted in MHPIs to improve attachment styles is the way mothers interact with their children. For example, an intrusive style pattern of interacting with the child, disengagement, coercion and sensitivity predict attachment (Tomlinson, Cooper & Murray, 2005). Unpredictable behaviour can lead to disorganized attachments (Breidenstine, Bailey, Zeanah & Larrieu, 2011), and severe and chronic disrupted interactive styles can lead to Adverse Childhood Experiences (ACEs) that could have long-term effects on the child’s mental health (Breidenstine, Bailey, Zeanah & Larrieu, 2011). According to this data, it can be interpreted that MHPIs must therefore target specific disruptive interactive styles in order to be efficacious.

Understanding how mother-infant interactions take place in different regions of the world may work as another step to developing culturally appropriate strategies. For example, in Khayelitsha, South Africa, most of the disorganized attachment styles are due to fearful, and hostile interaction styles produced by region-specific stressors like the high rates of HIV/AIDS in Africa, or high rates of domestic violence that add to maternal stress (Tomlinson, Cooper & Murray, 2005). In Mali, West Africa, maternal sensitivity does not predict infant security different from Khayelitsha (McMahan True, Pisani & Oumar, 2001), but the fearful interactive style predicts attachment in both regions. Additionally, Van Ijzendoorn & Kroonenberg (1988) found enough evidence that shows cross-cultural differences in attachment styles. They discussed that the avoidant attachment style is more common in Europe than in countries like Japan and Israel, where a resistant attachment is more common. These data present that interaction styles and attachment consequences vary across the globe which must be considered when developing and implementing MHPIs. As mother-infant interaction is predictive of disorganized attachment styles, the urgency to consider the how and where in the design of early interventions for children deserves special attention to prevent further mental health complications.

Early interventions are efficacious because they can prevent mental health problems and promote relationship skills (Barnes, 2018; Baker-Henningham, 2014), and schools are the main place where children and adolescents can attain emotional and social skills to improve their development and mental health (Fazel, Patel, Thomas & Tol, 2014; Goldberg et al., 2019). Goldberg and colleagues (2019) support this by discussing that the school is where they spend most of their time; it is also optimal because it lacks the stigma healthcare environments carry (Fazel, Patel, Thomas & Tol, 2014). HPIs are practical and beneficial to link people to the health system when needed (Fazel, Patel, Thomas & Tol, 2014).

There are some variables that can be associated with the efficacy of school-based interventions. Goldberg and colleagues (2019) found that variables like poor training, teachers’ self-efficacy and involvement are related to the efficacy of the programmes, along with Whole-School Interventions (WSIs) because they involve multiple factors. Additionally, the efficacy of these interventions depends on the quality of the implementation (Dix et al., 2012; Goldberg et al., 2019). Early childhood MHPIs are efficacious for improving cognition and behaviour in the classroom, teacher-student relationship, academic performance and motivation (Baker-Henningham, 2014). Baker-Henningham (2014) synthesize that the long-term impact of these interventions depends on the involvement and training of the caregiver, and improving their mental health. In LMICs, effectiveness depends on resource availability (Barnes, 2018), and interventions are effective in these settings, as they improve wellbeing, coping strategies and motivation (Barry, Clarke, Jenkins & Patel, 2013). In LMICs settings, WSIs can be incorporated into community programmes about, for example, HIV/AIDS (Barry, Clarke, Jenkins & Patel, 2013). According to this data, to improve the effectiveness of WSIs, training and involvement of teachers and caregivers, quality of implementation, and resource availability must be considered. These variables sometimes depend on the other, as the quality of implementation can hinder the involvement of teachers, and lack of their involvement can change the involvement of caregivers.

An example of an efficacious WSI is the Olweus Bullying Prevention Program. This programme has decades of implementation in several settings proven to be efficacious for reducing behavioural problems due to the involvement of parents, school rules concerning bullying, regular meetings, a committee for bullying prevention, training, supervision and assessment (Hong, 2008). Nevertheless, in LMICs this program cannot manage aggression in low resource neighbourhoods, nor resources for teachers to implement the program, and teachers have stressors that can hinder their ability to carry out the intervention (Hong, 2008). The experience from this well established and studied intervention shows that periodic assessment, supervision and follow up of the programs, as well as examining the barriers to adapting them to LMICs countries, are crucial for their effectiveness.

Efficacious school-based interventions have been proven to yield different results depending on the country where they are implemented. In HICs, Goldberg and colleagues (2019) found that US interventions were more efficacious than in other countries, for example, Australia and European countries, because of their attachment to training and manuals.

They also found that the level of support by the country affects efficacy because the power educational stakeholders have can affect policies and provide resources. The picture is different in LMICs, where people have specific stressors such as conflict, inequalities and violence (Fazel, Patel, Thomas & Tol, 2014). These authors discuss that MHPIs in schools cannot address the impact of this type of social determinant. Variables accountable for variance in efficacy of WSIs are structure and duration (Fazel, Patel, Thomas & Tol, 2014). Another example of LMICs is classroom-based interventions to address trauma, where (Fazel, Patel, Thomas & Tol, 2014) compared its efficacy in different countries. They argue that the data shown by research shows efficacy in Indonesia and Nepal because of the supportive family environment children have, different from Sri Lanka and Burundi where family support is scarce, violence is chronic and efficacy results are not optimal. In Sri Lanka, Tol and colleagues (2013) found that WSIs are specific for war exposed children and are efficacious for boys and damaging for girls. They also found these are efficacious for reducing anxiety, improving conduct, and enhancing sociability. Interpreting these results, the context in which interventions are being implemented needs to be evaluated for facilitators and barriers for each program. Gender differences, resources and greater social stressors should be evaluated before implementation.

As certain context can bring specific and bigger stressors for children as noted above, such as experiencing violence, strategies to improve protection from abuse is a human rights concern. Child maltreatment can be neglect and physical, sexual and emotional abuse (WHO, 2016). Child abuse can have effects until adulthood such as suicide, depression, anxiety, cancer, diabetes, heart disease, premature death, obesity and more public health threats (WHO, 2016). Child maltreatment normally comes from caregivers, and it can be prevented with certain interventions (WHO, 2016).

Several approaches exist to prevent child abuse across the world, and most include the caregiver as a key component. Parenting programmes are effective to prevent child abuse in the long term (Chen & Chan, 2016). They reduce parental risk factors such as depression, stress, child-rearing errors, and abusive styles, and improve development stages and sensitivity (Chen & Chan, 2016). In LMICs, there is little evidence of child abuse prevention (Skeen & Tomlinson, 2013). In Pakistan, for example, Asad and colleagues (2013) discussed that the involvement of parents by educating them on the effects of displacement and providing them with parenting skills can improve child development in disaster contexts. In Brazil, after the psychosocial intervention, children working on the streets presented reduced mental health problems, interpreted because of parents without psychiatric symptoms and reduced neglect (Hoffmann et al., 2017). Along with perinatal interventions, sensitivity, disruptive styles and parental mental health problems are key targets for interventions. This leads to the conclusion interventions without caregivers are inefficacious and targeting parent variables in the perinatal period is better to reduce the need to use resources in child abuse protection.

The INSPIRE Intervention is an evidence-based approach that synthesizes seven strategies to prevent child abuse (WHO, 2016). Each of these seven strategies targets different sectors of society (WHO, 2016) which makes it comprehensive, and, according to WHO (2016), they are proven effective in LMICs. In low-income settings of South Africa, violence can be prevented by assuring most INSPIRE strategies are being implemented (Falconer et al., 2020). These authors found that four strategies of the INSPIRE approach are effective to reduce community violence in LMICs. Results from this study are encouraging for other LMICs to assess the efficacy of INSPIRE in their settings, baseline evaluations and implementation impact measures.

A healthy beginning in life can ensure the emotional and social skills needed to excel further in life. This can be assured by working with the mother’s emotional well-being as a first step. Once caregivers are emotionally stable, the next step is to correct and educate them in healthy ways to interact with their babies. Once children are old enough to go to school, WSIs must assure the involvement, education and training of parents are crucial to be efficacious. While ensuring a mental health-promoting environment during development, protecting children from abuse should be done simultaneously. MHPIs should be evidence-based and locally appropriate, as risk factors and culture permeate how childhood and motherhood are understood and lived.