BACKGROUND:Caregivers facing mental and social stressors risk negative outcomes. The UNICEF Caring for the Caregiver package is a counselling approach and behaviour change intervention that can be integrated into routine home-visiting by frontline workers, in a demand-responsive way, at a population level. We aimed to evaluate caregiver outcomes and explore intervention experiences in six low-income and middle-income countries. METHODS:Using a non-randomised pragmatic design, we recruited caregivers of children using community-based sampling. Caregivers reported dose exposure and completed pre-post outcome measures of self-efficacy (General Self-Efficacy scale); social support (Multidimensional Scale of Perceived Social Support); depression (Patient Health Questionnaire-9); anxiety (General Anxiety Disorder 7-item scale); and parenting stress (Parenting Stress Index-36). Using pooled data, two-way fixed-effects regressions examined change and variations in outcomes, by dose. Perception data were collected from caregivers and frontline workers. FINDINGS:In Bhutan, Brazil, Serbia, Sierra Leone, Rwanda, and Zambia we trained 198 frontline workers and recruited 822 pregnant and postnatal caregivers receiving home-visiting from them (April, 2021, to July, 2022). At endline (3-6 months post-baseline) we assessed 682 (83%) of 822 caregivers. We observed higher self-efficacy (β=2·63 [95% CI 1·9 to 3·3]) and social support (4·17 [2·9 to 5·4]), and lower depression (-2·23 [-2·7 to -1·7]), anxiety (-1·43 [-1·8 to -1·0]), and parenting stress (-12·35 [-15·0 to -9·7]). Higher dose was associated with greater change across outcomes. The majority of caregivers and frontline workers reported positive intervention experiences. INTERPRETATION:Across settings, the UNICEF Caring for the Caregiver intervention was positively experienced by caregivers and frontline workers and was associated with positive changes in multiple outcomes. It has potential at population level, but evidence in controlled and longitudinal studies is needed. FUNDING:UNICEF and the LEGO Foundation. TRANSLATIONS:For the Dzongkha, Portuguese, Krio, Serbian, Kinyarwanda and Chichewa translations of the abstract see Supplementary Materials section.

We previously constructed a qualitative, 3D ultrasound derived atlas of the normative spatiotemporal dynamics of fetal brain maturation. Here, using the same healthy multi-national cohort, we applied deep learning methods to 4205 fetal brain scans from 18-27 weeks' gestation, to produce an extensive, quantitative description of the growth of 16 fetal brain structures associated with satisfactory domain-specific neurodevelopmental scores at 2 years of age. The methodology, which is publicly available, takes less than 10 seconds per scan. We define 28 region-specific, functionally relevant, normative growth trajectories, a ratio between the relative volumes of the insular (rILV) and parietal (rPLV) lobes reflecting asynchronous maturation of fetal brain regions, and introduce a fetal brain maturation index that quantifies biological age and deviations from chronological age. Finally, the very low percentage of variance explained by between site differences (0.6% to 5.8% of the total variance) reinforces a fundamental biological principle: fetal growth and development across populations with diverse ancestries is similar provided that environmental constraints on growth are minimal.

We examined how adolescents living with HIV in rural KwaZulu-Natal, South Africa, navigate privacy boundaries in disclosure-related issues. We conducted small group discussions with 31 adolescents (aged 16-19 years) recruited from three HIV clinics. Reflexive thematic data analysis was conducted through the lens of communication privacy management theory. Three major themes emerged: (1) ownership and control of private information, in which adolescents demonstrated varying levels of autonomy over their HIV status information, often developing strategies to manage medication discreetly; (2) managing disclosure and privacy boundaries, in which participants developed nuanced privacy rules influenced by stigma, context, and family dynamics; and (3) emotional and social support in disclosure management, highlighting the significant role of support systems in the disclosure process. Overall, participants actively managed privacy boundaries through careful information control, selective disclosure, and strategic coordination with family members and healthcare providers. Our findings show that adolescents in a rural setting actively manage privacy boundaries around their HIV status through well-developed information management strategies. There is a complex interplay between personal agency, family dynamics, and cultural context in shaping disclosure decisions. These insights can provide more effective support interventions for adolescents living with HIV in resource-limited settings.

Most research on facial emotion recognition has focused on participants from a narrow range of Western cultures, thereby limiting its applicability to diverse populations. This study aimed to validate a culturally relevant subset of facial emotion photographs for use in regions of Sub-Saharan Africa. We selected 206 emotional expressions from models of Black African descent from the Racially Diverse Affective Expression (RADIATE) dataset (Conley et al., 2018). Fifty-four students from the University of Limpopo, South Africa, rated these stimuli. Using a 75% rater agreement threshold, we refined the set to 131 validated images, termed the Limpopo facial emotion stimulus set. This subset demonstrated high recognition of the intended facial expressions and strong consistency between raters. We present psychometric results describing these open-access stimuli, which we hope will be informative for other researchers. Our validation process underscores the importance of adapting materials to match the cultural and social context of the target population. The Limpopo facial emotion stimulus set enhances the ecological validity of emotion research in Sub-Saharan Africa, filling a gap in the availability of culturally appropriate cognitive and emotional assessment tools.

Abstract This chapter explores the purpose and structure of booster sessions that may be offered several months after formal therapy ends, emphasizing their role in consolidating skills, addressing challenges, and preventing relapse. It outlines how to introduce these sessions as a “testing ground” for parents to apply therapeutic strategies independently before reconnecting with the therapist. In the first booster session, the therapist reviews successes, challenges, coping mechanisms, and unhelpful patterns, using tools like Worksheet 22 to encourage reflection. The second session builds on this by refining strategies, updating the Staying Well Plan, and preparing the parent for the end of therapy. Finally, the chapter reinforces that setbacks are normal and manageable, offering an opportunity for growth and resilience as parents transition beyond structured support.

Abstract This chapter introduces the workbook and describes postnatal/postpartum depression. Many parents experience mood swings, tearfulness, irritability, feeling anxious, or difficulty sleeping. These symptoms generally get better after a few weeks, but some parents continue to feel low and develop depression. Depression can also develop several months after childbirth or even be a continuation of depression that has begun during pregnancy. Overall, about 10%–15% of mothers develop postpartum depression. Depression in fathers is also common. but less research has been done on this. The chapter describes six parents from different backgrounds who have developed postpartum depression. The symptoms of postpartum depression are then described followed by how it develops and can get stuck in a negative cycle. Finally, there is a description of which treatments are effective. The Oxford Postnatal Programme, described in this workbook, is based on cognitive behavioral therapy (CBT) with a focus on behavioral activation (BA).

Background: Climate-exacerbated flooding triggers global public health crises, costing lives, livelihoods, and jeopardising fragile healthcare systems. Despite well-established disaster management frameworks, the timely communication of rapid, locally actionable information remains lacking—leaving vulnerable populations at risk. We developed and operationally validated an open-access monitoring system across six South Asian nations, reporting the public health impact of the 2025 floods and executing live daily nowcasting during the July 2026 monsoon emergency to better understand who is in harms’ way, democratise anticipatory disaster intelligence, and support healthcare resilience. Methods: We engineered a multi-stakeholder co-designed ensemble pipeline for flood-health intelligence by fusing observations from six synthetic aperture radar and optical satellites with hydrological, demographic, agricultural, transportation, and infrastructure datasets. We estimated cumulative exposure for children and adults, alongside functional disruption to healthcare facilities, built-up areas, road networks, and cropland across remote, rural, and urban areas of Pakistan, India, Bangladesh, Bhutan, Nepal, and Sri Lanka. The 2025 analysis was benchmarked against publicly-available official surveillance reports and independent field-validation. The 2026 deployment is ongoing live, externally field-validated against 8 ground-sensor stations along the Indus River system. Findings: Our analysis revealed a critical gap in current surveillance. In 2025, continuous monitoring identified 257.67 million exposed individuals (29.1% in rural areas) including 89.3 million children under 18 (34.6%). A five-fold increase (72.19 million additional people) was found over the 18.97 million captured in official episode-level reports for Pakistan, Bangladesh, and Sri Lanka. Over 460, 000 km² of agricultural land was exposed (18.5 % to >2m deep water), having significant implications for the region’s predominantly agrarian economy.Across publicly unmonitored regions and flood episodes, an estimated 237 million flood-exposed people were left in a data vacuum, completely missing from publicly-available mapping. Functionally, 22,818 low-lying healthcare facilities were inundated (3,041 functionally disrupted), severing last-mile care for 46.79 million people, including 28.54 million exposed to deep-water flooding (>2m). In each country, access to at least 5% healthcare facilities was disrupted. Our rapid monitoring of the July–August 2026 crisis has already reported 11,905 km² of inundation, 92,140 km of submerged roads, 5.19 million exposed people including 1.6 million children (30.8%), and disruption to 1,900 basic health units, community clinics, pharmacies, and hospitals. Interpretation: This first region-wide, multi-year study demonstrates that current global disaster response relies on severely incomplete or inaccessible data, effectively disenfranchising the world's most underserved and climate-vulnerable populations from healthcare when most needed. Rapid, reliable, and scalable precision intelligence is not a technical luxury but a necessary and achievable instrument for health equity and climate justice. To counter 21st-century global health threats, we recommend: (1) prioritising anticipatory planning for children and vulnerable communities via national action plans and community toolkits, (2) democratising disaster data through digital public infrastructure to inform e

Background:Blended digital mental health interventions combining technology with human support are more effective than stand-alone treatments. However, limited research has examined how to train and supervise personnel delivering human support components. The Kuamsha app, a gamified digital intervention for adolescent depression based on behavioral activation, was designed to be paired with low-intensity telephone-based peer support. A structured training and supervision program for peer supporters was codeveloped through workshops with mental health professionals and youth with lived experience of mental health challenges in South Africa and Uganda. To the best of our knowledge, this is the first study to evaluate a structured peer mentor model within a digital mental health intervention in low- and middle-income countries. Objective:This study assessed the feasibility, acceptability, and fidelity of a training and supervision program for peer supporters delivering a digital mental health intervention in South Africa and Uganda. Methods:We conducted a mixed methods evaluation of the peer mentor program. Quantitative metrics assessed the feasibility of recruitment, retention, and attendance among peer mentors (n=13, South Africa; n=4, Uganda), as well as training acceptability. Fidelity, adherence, and competence were scored at the session level and converted to percentages of the maximum possible score. Linear mixed-effects regression models with a random intercept for provider and site estimated adjusted marginal means (95% CI). In-depth interviews and focus group discussions explored program acceptability and implementation factors. Results:The peer mentor training and supervision program was feasible and acceptable in both settings, with high recruitment (South Africa: n=13/19, 68%; Uganda: 4/4, 100%), retention (South Africa: 9/13, 69%; Uganda: 4/4, 100%), and training attendance rates (89%-92% in South Africa and 100% in Uganda), alongside qualitative reports of high satisfaction. All peer mentors met a minimum posttraining competency threshold (≥50%), with median competency scores of 70.7% (IQR 45.8%-78.2%) in South Africa and 75.4% (IQR 73.8%-77.3%) in Uganda. Independent ratings of recorded calls indicated high overall fidelity in South Africa (84.7%, 95% CI 80.3%-89.0%) and Uganda (87.7%, 95% CI 83.4%-92.1%). Adherence was higher in Uganda than South Africa (adjusted mean difference [AMD] 13.30 percentage points, 95% CI 8.99-17.61; P<.001), as was competence (AMD 4.88 percentage points, 95% CI 1.23-8.53; P=.009). The AMD in overall fidelity (3.06 percentage points, 95% CI -0.98 to 7.10) was not statistically significant (P=.14). The qualitative findings emphasized the value of ongoing supervision and capacity development, interactive training approaches, and blended delivery models. Conclusions:Locally adapted training and supervision models can strengthen peer mentor capabilities to support digital interventions. Adequate supervisory capacity and incentive structures are critical to sustain engagement, retention, and fidelity. In settings with frequent network disruptions, periodic in-person contact between peer mentors and supervisors may enhance fidelity. Future research should examine how peer mentor fidelity influences user engagement and mental health outcomes.

Background Perinatal depression is prevalent and associated with impairment and multigenerational consequences. Effective treatments exist but are often challenging to access. We aimed to assess the efficacy of a novel, tiered system of care for treating perinatal depression relative to perinatal psychiatric care. Methods In this randomised controlled trial investigating efficacy, women between 28 weeks’ gestation and 6 months postpartum who scored at least 11 on the Edinburgh Postnatal Depression Scale were recruited from University of California, Los Angeles (UCLA; CA, USA) obstetrics clinics in the USA. Participants were randomly assigned (1:1) to one of two options: first, a tiered system called Screening and treatment for anxiety and depression (STAND) that included digital cognitive behavioural therapy (CBT) with coaching for women with moderate depression, and CBT delivered by psychology doctoral trainees, with pharmacotherapy as needed delivered by psychiatry residents, for women with severe depression or with suicidal intention; or second, perinatal psychiatric care (PPC) involving supportive therapy, pharmacotherapy if needed, and community referrals, delivered by psychiatry residents, regardless of depression severity. Participants were assessed for depression severity measured by the Computerized Adaptive Test for Mental Health (CAT-MH) depression (primary outcome) from baseline to follow-up week 26. The trial is registered with ClinicalTrials.gov, NCT05056454, and is complete. Findings Between Aug 5, 2021, and Oct 5, 2023, we enrolled and randomly allocated 166 participants (78 to STAND; 88 to PPC), of whom 71 (91%) in STAND and 80 (91%) in PPC were included in the primary efficacy analyses. In the STAND group, 50 (76%) women received digital CBT with coaching, 16 (24%) received face-to-face CBT, and seven (11%) of these 66 received pharmacotherapy. In the PPC group, 56 (76%) women received pharmacotherapy. Depression severity decreased over time in both groups (STAND: β=–0·04 [95% CI –0·05 to –0·04], p<0·0001; PPC: β=–0·05 [–0·05 to –0·04], p<0·0001; overall: β=0·05 [–0·05 to –0·04], p<0·0001), but did not differ by intervention (β=0·06 [–0·20 to 0·32], p=0·65) or time × intervention (β=0·004, [–0·004 to 0·010], p=0·38), with equivalence bounds as low as –1, 1 (all p<0·0001). There was one serious adverse event in the PPC group (unstable suicidality), which was regarded by investigators as unrelated to treatment. Interpretation A tiered system of care in which three quarters of participants received digital CBT with coach support without pharmacotherapy (STAND) was as efficacious for perinatal depression as psychiatric care in which three quarters of participants received pharmacotherapy (PPC). The STAND tiered system could increase access to care for perinatal depression. Funding Charitable donations to the UCLA Depression Grand Challenge.

Background Adolescents and young people (AYP) aged 10–24 years in Africa experience a high burden of mental health disorders but face significant barriers to accessing care, including a severe shortage of mental health professionals, stigma, and limited integration of mental health services into primary healthcare. Digital mental health interventions (DMHIs) offer a promising avenue to bridge these gaps by providing accessible, scalable, and potentially equitable support. However, little is known about the effectiveness, acceptability, and equity impacts of these interventions among African AYP. Objective This systematic review aims to identify, characterize, and synthesize evidence on DMHIs targeting adolescents and young people in Africa, focusing on mental health outcomes, engagement, feasibility, and equity considerations. Methods We will search PubMed, Scopus, Web of Science, and EBSCOhost databases, as well as the PsyberGuide repository, for empirical studies published between January 1, 2015, and April 3, 2025. Eligible studies must evaluate a digital mental health intervention among AYP aged 10–24 years living in Africa. Study designs will include randomized controlled trials, quasi-experimental studies, observational studies, and mixed-methods studies. Outcomes of interest include mental health symptom reduction (depression, anxiety, stress), psychological well-being, engagement, feasibility, acceptability, and equity-related factors such as gender inclusivity and digital access. Risk of bias will be assessed using RoB 2 and ROBINS-I tools, and evidence quality will be rated using the GRADE approach. Quantitative synthesis will be conducted where feasible, otherwise narrative synthesis will be employed. Conclusion This review will provide a comprehensive synthesis of available evidence on DMHIs for adolescents and young people in Africa, offering critical insights into their effectiveness, feasibility, and contribution to promoting mental health equity. The findings aim to inform the development, implementation, and policy integration of digital mental health strategies tailored to young populations in diverse African contexts.

Objective:Effective and scalable interventions to address adolescent depression are urgently needed. This study evaluated the feasibility, acceptability, and preliminary efficacy of digitally delivered Behavioral Activation therapy. Method:A pilot randomized controlled trial was conducted in rural northeastern South Africa. Adolescents 15 to 19 years of age with mild-to-moderately severe depression on the Xitsonga version of the Patient Health Questionnaire-Adolescent Version (PHQ-A) were recruited from 11 high schools. Participants were randomly assigned (1:1) to receive the Kuamsha app, which delivers Behavioral Activation therapy through an interactive narrative game with telephone guidance from peer mentors or a control app. We used a mixed-methods design to assess the feasibility, acceptability, and preliminary efficacy of the Kuamsha app in reducing symptoms of depression compared to a digital control. Results:Between April and September 2022, a total of 195 adolescents were randomized. Primary outcome data were available on 195 adolescents (100%). In the Kuamsha group, 77 participants (80.2%) adhered to the treatment protocol (completed at least 4 of 6 app modules), indicating favorable engagement. In-depth interviews and questionnaire responses revealed high acceptability. Reductions in depressive symptoms were modest, with no significant between-group differences at 11 weeks (adjusted mean difference = -0.37, 95% CI = -1.96, 1.22) or 24 weeks (adjusted mean difference = -0.11, 95% CI = -1.70, 1.48). Exploratory analyses suggested greater efficacy among participants who met a cut-off for moderate baseline depression symptoms (PHQ-A ≥10) and greater app engagement. Conclusion:The Kuamsha app is a feasible and acceptable treatment for depression among adolescents in rural South Africa. Following adaptations, a larger trial is warranted to assess its effectiveness in reducing symptoms of depression. Diversity & Inclusion Statement:We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper self-identifies as living with a disability. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

BACKGROUND:Evidence regarding the dynamics of the longitudinal reciprocal associations between maternal and paternal depression over time is lacking. The current study examines reciprocal longitudinal associations between maternal and paternal depressive symptoms (DS) from pregnancy (18 weeks-gestation) to 11 years 2 months (study child's age) to gain insights into the joint course of DS. METHODS:The study sample comprised 6296 mothers and fathers from the UK-based birth cohort, the Avon Longitudinal Study of Parents and Children. Reciprocal longitudinal associations between maternal and paternal DS, assessed at nine time-points (Edinburgh Postnatal Depression Scale; continuous scores), were examined using random intercept cross-lagged panel models to differentiate between stable covariance (between-person differences in DS) and dynamic processes (within-person level). Analyses were adjusted for parental and socioeconomic confounders. RESULTS:There were strong correlations between random intercepts of maternal and paternal DS (β = 0.305, SE = 0.015, p ≤ 0.001), suggesting positive associations between the overall mean levels of parental DS (i.e., a between-person association). There were strong stability effects for maternal and paternal DS across all nine measurement occasions (i.e., within-person associations), with larger effects evident for both maternal and paternal DS later in childhood (between ages 5 and 11 years). There was evidence for bidirectional longitudinal within-person effects between maternal and paternal DS at some but not other measurement occasions. CONCLUSIONS:These findings have important implications for screening, prevention and intervention programmes. Depression in one parent may require screening efforts directed at the other parent, with prevention and intervention programmes focused on the family, rather than one parent.

Background:Adolescents and young people (AYP) aged 10-24 years in Africa experience a high burden of mental health disorders but face significant barriers to accessing care, including a severe shortage of mental health professionals, stigma, and limited integration of mental health services into primary healthcare. Digital mental health interventions (DMHIs) offer a promising avenue to bridge these gaps by providing accessible, scalable, and potentially equitable support. However, little is known about the effectiveness, acceptability, and equity impacts of these interventions among African AYP. Objective:This systematic review aims to identify, characterize, and synthesize evidence on DMHIs targeting adolescents and young people in Africa, focusing on mental health outcomes, engagement, feasibility, and equity considerations. Methods:We will search PubMed, Scopus, Web of Science, and EBSCOhost databases, as well as the PsyberGuide repository, for empirical studies published between January 1, 2015, and April 3, 2025. Eligible studies must evaluate a digital mental health intervention among AYP aged 10-24 years living in Africa. Study designs will include randomized controlled trials, quasi-experimental studies, observational studies, and mixed-methods studies. Outcomes of interest include mental health symptom reduction (depression, anxiety, stress), psychological well-being, engagement, feasibility, acceptability, and equity-related factors such as gender inclusivity and digital access. Risk of bias will be assessed using RoB 2 and ROBINS-I tools, and evidence quality will be rated using the GRADE approach. Quantitative synthesis will be conducted where feasible, otherwise narrative synthesis will be employed. Conclusion:This review will provide a comprehensive synthesis of available evidence on DMHIs for adolescents and young people in Africa, offering critical insights into their effectiveness, feasibility, and contribution to promoting mental health equity. The findings aim to inform the development, implementation, and policy integration of digital mental health strategies tailored to young populations in diverse African contexts.

BACKGROUND:Small for gestational age is a complex perinatal syndrome associated with increased neonatal morbidity, mortality, and impaired childhood growth and neurodevelopment. Current classifications rely primarily on birthweight, which does not capture the heterogeneity of the condition nor predict long-term health outcomes. Here we aim to identify and characterize distinct small for gestational age subgroups and assess their neonatal and early childhood health trajectories. OBJECTIVE:To refine the classification of small for gestational age by identifying subgroups based on maternal, fetal, and environmental factors and evaluating their associations with neonatal morbidity, growth, and neurodevelopment at age 2. STUDY DESIGN:Prospective cohort study. In six countries worldwide, between 2012 and 2018, the INTERBIO-21st Study enrolled small for gestational age and non-small for gestational age newborns defined by the <10th centile of international standards with moderate (≥third-<10th centile) and severe (<third centile) small for gestational age subgroups; we assessed their growth, health, nutrition, motor development, and neurodevelopment up to age 2. We used 2-step cluster analysis to identify small for gestational age subgroups, and a probabilistic approach to choose the optimal subgroup model based on a statistical measure of fit. We performed logistic regression analysis (odds ratio; 95% confidence interval) to assess health and development outcomes among subgroups using the non-small for gestational age as reference group, adjusting for key confounders. RESULTS:We enrolled 5153 non-small for gestational age and 1549 small for gestational age newborns: moderate (≥third-<10th centile) small for gestational age=947 and severe (<third centile) small for gestational age=602. We identified 9 small for gestational age subgroups: "no main condition detected" (29.0%); "previous low birthweight or preterm birth" (14.6%); "severe maternal disease" (12.0%); "maternal short stature" (11.6%); "hypertensive disorders" (9.6%); "extrauterine infection" (6.8%); "previous miscarriage(s)" (6.5%); "smoking" (5.2%); and "maternal undernutrition" (4.7%). Severe small for gestational age newborns in the "severe maternal disease" (odds ratio, 3.2; 95% confidence interval, 1.8-6.0), "previous low birthweight or preterm birth" (odds ratio, 2.8; 95% confidence interval, 1.6-4.8), and "smoking" (odds ratio, 5.4; 95% confidence interval, 1.3-21.8) subgroups had increased risk of neonatal and long-term morbidity and low anthropometric measures at age 2 as compared to the non-small for gestational age group. Moderate small for gestational age newborns in the "hypertensive disorders" subgroup had increased risk of neonatal morbidity (odds ratio, 2.6; 95% confidence interval, 1.5-4.6) and higher odds of scoring <10th centile of normative values in language (odds ratio, 3.5; 95% confidence interval, 1.0-12.0) and positive behavior (odds ratio, 2.2; 95% confidence interval, 1.1-4.5). The "severe maternal disease" subgroup had also higher risk of deficit (<10th centile of normative values) in language (odds ratio, 5.7; 95% confidence interval, 1.3-24.8) and positive behavior (odds ratio, 3.4; 95% confidence interval, 1.5-7.6). CONCLUSION:Small for gestational age comprises heterogeneous subgroups with distinct patterns of neonatal morbidity, postnatal growth, and neurodevelopmental outcomes up to age 2.

IntroductionPaternal postnatal depression (PND) and its likely adverse impact on child development are receiving increased attention. However, research that examines processes transmitting risks of paternal PND to adverse child outcomes remains limited.MethodsThis study examines pathways from paternal PND (Edinburgh Postnatal Depression Scale; 8 months) to child emotional and behavioral development (Strengths and Difficulties Questionnaire; 7 years) through paternal parenting confidence, warmth, and father-child conflict (birth-4 years) in a UK-based birth cohort, the Avon Longitudinal Study of Parents and Children (N = 9,628). Analyses were adjusted for socioeconomic, familial, parental, and child characteristics, including maternal PND during early postnatal period.ResultsAdjusted models revealed evidence of total associations between paternal PND, child emotional symptoms, peer problems, and hyperactivity (albeit with wide 95% CIs), but not conduct problems. Indirect effects emerged from paternal PND to child emotional symptoms, hyperactivity, and peer problems through the combination of all paternal parenting factors, with no evidence of direct effects. Specificity analyses revealed indirect effects through paternal parenting confidence and father-child conflict in the associations between paternal PND and child emotional symptoms, hyperactivity, and peer problems (albeit with wide 95% CIs).ConclusionsTargeted intervention to increase paternal parenting confidence and decrease father-child conflict may improve outcomes in children whose fathers experience postnatal depression.

Abstract Background Posttraumatic stress (PTS) and anxiety are common mental health problems among parents of babies admitted to a neonatal unit (NNU). This review aimed to identify sociodemographic, pregnancy and birth, and psychological factors associated with PTS and anxiety in this population. Method Studies published up to December 2022 were retrieved by searching Medline, Embase, PsychoINFO, Cumulative Index to Nursing and Allied Health electronic databases. The modified Newcastle–Ottawa Scale for cohort and cross-sectional studies was used to assess the methodological quality of included studies. This review was pre-registered in PROSPERO (CRD42021270526). Results Forty-nine studies involving 8,447 parents were included; 18 studies examined factors for PTS, 24 for anxiety and 7 for both. Only one study of anxiety factors was deemed to be of good quality. Studies generally included a small sample size and were methodologically heterogeneous. Pooling of data was not feasible. Previous history of mental health problems (four studies) and parental perception of more severe infant illness (five studies) were associated with increased risk of PTS, and had the strongest evidence. Shorter gestational age (≤ 33 weeks) was associated with an increased risk of anxiety (three studies) and very low birth weight (< 1000g) was associated with an increased risk of both PTS and anxiety (one study). Stress related to the NNU environment was associated with both PTS (one study) and anxiety (two studies), and limited data suggested that early engagement in infant’s care (one study), efficient parent-staff communication (one study), adequate social support (two studies) and positive coping mechanisms (one study) may be protective factors for both PTS and anxiety. Perinatal anxiety, depression and PTS were all highly comorbid conditions (as with the general population) and the existence of one mental health condition was a risk factor for others. Conclusion Heterogeneity limits the interpretation of findings. Until clearer evidence is available on which parents are most at risk, good communication with parents and universal screening of PTS and anxiety for all parents whose babies are admitted to NNU is needed to identify those parents who may benefit most from mental health interventions.