Psychological, social & biological predictors of child mental health and development: shared and distinctive risk and protective factors in UK & India

WHO figures estimate mental health problems affect 12.8% of children in India, which equates to 60 million children. There is an urgent need for culturally sensitive longitudinal studies of community samples starting in pregnancy, designed to examine the earliest origins of child mental health problems to optimally inform the development of new and early interventions. Our study aims to do this in India and the UK. Research in western settings suggest that child mental health problems arise from a complicated mix of social, psychological and biological influences, in which key factors probably include, prenatal stress, early infant temperament, and harsh parenting as risks, and warm parenting as protective factors. There is now good evidence that individual variations and environmental exposures in early life contribute to risk for mental health problems in later childhood and beyond. However, previous research has been conducted almost exclusively in countries with Westernised standards of medical care and family arrangements, and where additional risks such as low birth weight and under-nutrition are rare. The aims of the proposed research are to compare early risk and protective factors for childhood mental health problems in UK and India to identify those that are common to Western and South Asian populations and those that are distinctive.
We propose to follow up around 741 families of children in the Bangalore Child Health and Development study (BCHADS) who are living in the urban slums of Bangalore city, at age 4.5 years and age 7 years. We will compare the information we gather on these children's lives to that of the children taking part in our UK Wirral Child Health and Development Study (already collected). In both studies we have two rich data sets with parallel measures of risk and protective factors for child mental health outcomes from pregnancy onwards, including age 8-10 wks, 6 months, 14 months, 2 years, 4 years and 7 years of age. We have gathered detailed repeated measurement of key likely 'shared risks' and associated 'mechanisms' for conferring risk (e.g., gene activity, stress reactivity) and these include measures of early life stress, social support, poverty and economic adversity, early temperament, and caregiving (touch, interaction quality, parenting quality), cognitive and physical development. We will also assess risk and protective factors that may be 'distinctive' or particularly relevant to the South Asian setting: maternal nutrition in pregnancy, early immune function and gender discrimination associated with cultural favouring of the male child, and the practice of shared-caregiving as opposed to primary maternal rearing in Western societies.
We also aim to advance cross-cultural measurement methods and develop new culturally sensitive measures of gender discrimination and the 'shared caregiving' parenting environment in India. This work will aid clinicians and researchers to refine their measurements in clinical practice and be able to conduct more reliable research when trying to combine data from multiple cohorts. Finally, this is a joint UK-Indian study and together we will run a series of training events to build capacity and share expertise in conducting longitudinal cohort studies, sampling and retention, measurement issues, data management and state of the art statistical methods needed in longitudinal analysis of complex data sets.

We will conduct a longitudinal investigation using two established cohorts to identify shared and distinctive risks and protective factors for child mental health in India and the UK. We have established a cohort infrastructure in the urban slums of Bangalore, successfully following up over 740/909 families (78.5%) through 6 waves of rich data collection from pregnancy to age 2. The Bangalore Child Health and Development Study (BCHADS) was designed with timed assessment, and parallel measurement to our UK Wirral Child Health and Development Study (WCHADS). We propose following up the families of children in the BCHADS study at age 4.5 years and age 7 years with parallel measurement to the WCHADS (already collected). This will make two rich data sets with parallel measures of risk and protective factors for child mental health outcomes from pregnancy onwards, including age 8-10 wks, 6 months, 14 months, 2 years, 4 years and 7 years of age. The two cohorts are unusually well phenotyped with detailed repeated measurement of key likely 'shared risks' and associated 'mechanisms' for conferring risk. We will also assess risk and protective factors that may be 'distinctive' or particularly relevant to the South Asian setting; maternal nutrition in pregnancy, early immune function and associated chronic inflammatory states (given likely increased exposure to infection, poverty and pollution in the slum setting), gender discrimination with cultural favouring of the male child, and the practice of shared-caregiving as opposed to primary maternal rearing in Western societies. We will also advance cross-cultural measurement technologies by developing indices of differential item functioning for common measures, to use in analyses to reduce inferential error when conducting joint analyses of multiple cohort datasets. We will develop new culturally sensitive measures of 'shared' caregiving and gender discrimination in India.

The MRC/ICMR BCHAD study funded for 3 years has allowed us to develop a cohort infrastructure in urban Bangalore, successfully following up over 78.5% of participants over 6 waves of rich data collection in parallel to our UK WCHADS. We await primary outcomes at age 2 (March 2019). Important early findings are already informing the field of intervention. For example Co-I Rahman, assigned by the WHO to revise its maternal mental health strategies including the Thinking Healthy Programme (developed by Rahman and adopted by the WHO for global dissemination) is using the findings to develop more culturally nuanced approaches in the revised THP which has the potential to improve mental health outcomes for children not just in India but globally. The early BCHADS results on patterns of early caregiving, relevant to mental health outcomes in UK and India, have been presented at key international conferences and have received much attention (Marce 2018; WAIMH 2018). We have trained 12 Indian researcher clinicians in observational measures and 28 biostatisticians from all over India in advanced approaches to longitudinal analyses. New funding will allow further dissemination of these skills. We have developed new links with researchers in Pakistan and Malawi (through the SHARE network in Pakistan and the Liverpool-Glasgow Malawi Wellcome Tropical Centre in Malawi, respectively - UoL and NIMHANS are key partners of both). Researchers from these sites are planning their own cohorts and will use common measures with a view to combining data-sets, potentially leading to one of the world's largest multi-site database on early risks to mental health.
We anticipate continued impact in three areas: 1) Advancement of the field of developmental psychopathology including cross-cultural measurement technologies, 2) Capacity building of LMIC researchers, and 3) Public health and policy (See Pathways to Impact). The findings will further advance our understanding of how individual, family, environmental and biological factors contribute to multiple child outcomes, including physical, cognitive, socio-emotional and behavioural development. The research will lead to the further development of common measures for future epidemiological studies in the South Asian and UK settings and continue to inform early life-course interventions that can help prevent mental health problems in later childhood and adolescence. By extending the cohort to middle childhood, we will understand factors that influence critical developmental periods including early schooling. Schools will be key community stakeholders in our work. The project will lead to the development of further capacity in Indian researchers including to conduct biological studies. New links with Pakistan and Malawi will allow sharing of capacity to conduct complex studies of this nature (See Table-Pathways to Impact). Our close collaboration with a number of academic groups, including the WHO (see academic beneficiaries) have the potential to inform integrated interventions that holistically target physical, cognitive and socioemotional development. We have developed powerful platforms by actively engaging non-academic beneficiaries (families, the wider community, the voluntary sector and the media) thereby raising public awareness and understanding of the development of childhood emotional, behavioural and developmental problems and achieving clinical and policy change. Scalable integrated interventions that address parental mental health, stimulation, parenting and nutrition have great potential to improve the developmental potential, physical and mental health of the children of India. Rahman, with his global expertise in early interventions, will work with Indian researchers to tailor interventions to make them more effective and tailored to the global context. We plan to apply for further collaborative grants to develop, implement and evaluate interventions.