Little is known about the prevalence of maternal mental health challenges in Khyber Pakhtunkhwa, Pakistan and the ways in which it may influence the development outcomes of young children. This study describes the prevalence of three measures of maternal mental health: depression, anxiety and parenting stress, and assesses whether they independently or jointly predict early child development (ECD) even after accounting for stressors such as poverty, low access to quality education and limited social assistance. A population-proportionate, cluster-randomized household survey was conducted collecting data from a total of 1397 children aged 0-35-months-old and 705 children aged 36-72-months-old and their mothers. Unadjusted and adjusted Ordinary Least Squares linear regression analyses were run for the independent and joint association of maternal depression, anxiety, and parenting stress on ECD. There is a substantial prevalence of mental health concerns among the mothers in our sample-with several mental health concerns co-occurring. Maternal depression, anxiety, and parenting stress have a significant, negative and compounding interaction on child development for younger and older children, even after controlling for stressors and other covariates. Policy improvements are needed that focus on at-risk communities, providing mental health services and reducing exposure to stressors within communities and households.
Introduction Children born extremely preterm (EP; <28 weeks' gestation) and/or extremely low birth weight (ELBW; <1000 g) are at increased risk of difficulties across a range of neurodevelopmental domains and respiratory outcomes long term. The Victorian Infant Collaborative Study (VICS) in Australia has tracked detailed perinatal and developmental outcomes across four distinct EP/ELBW birth cohorts: 1991-1992, 1997, 2005 and 2016-2017. Improvements in 2-year developmental outcomes were reported in the VICS 2016-2017 cohort compared with previous eras; however, whether these improvements are sustained to school-age is not known. The aim of the follow-up study is to assess neurodevelopmental and respiratory outcomes at school-age in the VICS 2016-2017 cohort and examine the effect of EP/ELBW birth on school-age functioning across the VICS epochs. Methods and analysis This is a follow-up of the VICS 2016-2017 cohort, a prospective longitudinal cohort study of children born EP/ELBW and a contemporaneous group of term-born controls born in the state of Victoria, Australia. Children were previously assessed at 2 years' corrected age.Follow-up at 8-9 years' corrected age includes a comprehensive assessment of cognitive, motor, social and behavioural development and lung function.Follow-up at 8-9 years' corrected age includes a comprehensive assessment of cognitive, motor, social and behavioural development and lung function. Ethics and dissemination The study has approval from the Royal Children's Hospital Human Research Ethics Committee, Melbourne, Australia. The findings will be disseminated via peer-reviewed journal publications, conference presentations, digital and print media and through parent support/network groups.
Background The long-term effects of antidepressant use in pregnancy on child neurodevelopment are unclear; meanwhile antidepressant use in pregnancy is increasing. We aimed to clarify associations between prenatal maternal depression and/or antidepressant exposure and neurodevelopmental outcomes in school-age children. Methods and findings This population-wide cohort study included 167,447 children born in Wales, UK between 2009 and 2016, followed until 2022 (mean age 5.68 years) using linked primary care, maternity and education records. Exposures were one or more antidepressant prescriptions during pregnancy or up to one month before conception, and/or maternal depression diagnosis recorded in the two years before delivery. Outcomes were all-cause and cause-specific special educational need (SEN), including autism spectrum disorder (ASD), sensory impairment, communication difficulties, learning difficulties, physical and medical difficulties, and behavioral-emotional-social difficulties, as well as attention deficit hyperactivity disorder (ADHD). Generalized estimating equation models with an interaction term between maternal depression and antidepressant exposure were used to investigate SEN and causes of SEN. Predicted probabilities and marginal effects were derived to quantify absolute risk. Separate models were fitted for individual antidepressant classes and combinations. Cox proportional hazards regression and flexible parametric survival models were used for time to ADHD diagnosis. Covariates included child sex, area-level deprivation quintile, ethnicity, age, maternal age, smoking, parity, multiple birth and epilepsy. In total, 12,630 children (7.6%) were exposed to untreated depression during pregnancy; 7,005 (4.2%) to treated depression; and 5,996 (3.6%) to antidepressant medication without a recorded depression diagnosis. SEN was associated with both maternal depression (adjusted odds ratio (aOR) 1.25 (95% CI [1.20,1.31])) and antidepressant medication exposure (aOR 1.46 (95% CI [1.38,1.56])). Predicted probabilities of all-cause SEN were highest among children exposed to both maternal depression and antidepressants (26.5 per 100 children (95% CI [25.5,27.5])) and lowest among unexposed children (20.0 per 100 (95% CI [19.8,20.2])). Depression alone was associated with an increase to 23.6 per 100 children (95% CI [22.9,24.3]), while antidepressant exposure without depression was associated with an increase to 26.3 per 100 (95% CI [25.3,27.4]). Antidepressant exposure was associated with a 6.3% absolute increase in SEN risk (95% CI [5.2,7.4]) among children of mothers without depression and 2.9% absolute increase (95% CI [1.7,4.1]) among children of mothers with depression. Associations with antidepressant exposure were observed across multiple outcomes including ASD (aOR 1.59 (95% CI [1.31,1.92])) and ADHD (adjusted hazard ratio (aHR) 1.89 (95% CI [1.57,2.27])). No antidepressant class showed a markedly different association with SEN risk, although tricyclic antidepressants (TCAs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) had significant differences in absolute risk of SEN when comparing treated and untreated depression (TCAs 8.8% (95% CI [3.2,14.4]); SNRIs 8.8% (95% CI [2.6,15.0])). Key limitations include potential confounding by indication and depression severity, as women prescribed antidepressants likely represent a more severely depressed group. Conclusions Offspring of mothers with depression have a higher risk of SEN that cannot be attributed solely to antidepressant exposure. Prenatal exposure to antidepressants may confer a small additional absolute risk, but findings may partly represent confounding by depression severity. Further research is needed.
As artificial intelligence becomes increasingly integrated into children's therapeutic environments, social robots are emerging as one of the most clinically complex AI applications for pediatric autism spectrum disorder (ASD). This mini-review examines three under-validated "blind-spot" domains: robot-wearable sensor integration, immersive VR-robot hybrid systems, and generative AI conversational interfaces. Although these technologies offer promising opportunities for adaptive and personalized intervention, current evidence remains limited by small pilot studies, insufficient longitudinal validation, and unresolved developmental safety concerns. Key risks include pediatric sensor intolerance, cognitive overload during immersive exposure, privacy concerns related to continuous data collection, and unconstrained AI-generated dialogue that may reinforce maladaptive communicative patterns in vulnerable children. We propose a five-module clinical validation roadmap focused on pediatric calibration standards, standardized developmental outcome measures, multisite randomized controlled trials, longitudinal monitoring, and human-supported safety architectures. Conclusion Adaptive social robotics offers a promising but currently unvalidated frontier in pediatric ASD care. These systems cannot yet be supported as primary therapeutic interventions, as pediatric-specific calibration standards, standardized developmental outcome measures, and adequately powered longitudinal trials remain absent. The proposed validation framework outlines a pathway for ensuring AI-supported interventions augment rather than replace authentic human-centered developmental care. What is known • Social robots can produce measurable short-term gains in social and communication skills in children with autism spectrum disorder. • Supporting evidence derives largely from small, short-duration pilot studies conducted in controlled settings, limiting clinical applicability. What is new • Three under-validated blind-spot domains are identified: robot-wearable sensor integration, VR-robot hybrid systems, and generative AI conversational interfaces. • A five-module Clinical Validation Roadmap is proposed to move these domains from pilot demonstration toward pediatric standard of care.
This review article examines the evolution and impact of a widely used measure of early self-regulation and executive function (EF) in children: the Head-Toes-Knees-Shoulders (HTKS) task. We discuss the importance of SR and EF for children's school success and provide an overview of how these constructs have been conceptualized and operationalized. After situating the HTKS among other SR/EF measures, we trace its development from the original Head-Toes Task, to the HTKS and the HTKS-R and, most recently, the HTKS-Kids digital app and describe how the HTKS has been applied across populations and contexts. We synthesize evidence highlighting its measurement properties (e.g., reliability, validity, developmental change, and associations with academic performance) across diverse cultural and developmental contexts. Special attention is given to the need to extend and validate the HTKS across various educational and practice settings, with an emphasis on the roles of educators in supporting equitable assessment practices. We discuss recent advancements in measurement, including gamified digital administration, adaptations for neurodiverse populations and extensions of the HTKS into adolescence and adulthood. Finally, we identify limitations and directions for research and practice.
Introduction Globally, parenting interventions have been shown to improve caregiving practices and child development. However, rigorous evidence from sub-Saharan Africa remains limited, particularly for programmes that leverage multiple community-based delivery platforms. We evaluated the effectiveness of the Moments that Matter (MTM) parenting programme delivered by community volunteers in partnership with faith leaders on child development and caregiving-related outcomes in Kenya. Methods We conducted a cluster-randomised controlled trial in two counties in western Kenya. Villages were randomly assigned to the MTM parenting programme or a standard-of-care waitlist control, stratified by county. Eligible participants were primary caregivers of children aged 0-18 months. The intervention consisted of monthly group sessions and home visits delivered over 18 months. Caregivers were surveyed at baseline and endline. The primary outcome was child development measured using the Caregiver Reported Early Development Instruments. Intervention effects were estimated using mixed-effects models with a difference-in-differences, intention-to-treat approach. Results Between February and March 2023, 595 caregiver-child dyads in 46 villages were enrolled and randomly assigned to the intervention (n=310) or control (n=285). At endline, there were no overall intervention effects on child development outcomes. Moderate-to-large effects were observed across multiple secondary outcomes, including caregiver stimulation, harsh discipline, caregiver mental health, social support, intimate partner violence victimisation, child dietary diversity, and male caregiver engagement, as reported by female primary caregivers. Exploratory subgroup analyses revealed treatment heterogeneity by county, with small significant improvements in child language and socioemotional development in one county but null effects in the other. Conclusions A multicomponent parenting programme delivered in partnership between community volunteers and faith leaders improved multiple caregiving and family well-being outcomes but did not lead to overall improvements in child development. Findings highlight the potential of integrating multiple community-based platforms for delivering parenting programmes, while underscoring the need for implementation research to enhance impacts on child development at scale. Trial registration number NCT05796934.
This study uses difference-in-differences models to evaluate the impact of early social media use on academic performance among children aged 7-16 years. A dataset comprising 5,227 students from northern Italy was constructed by merging data from a questionnaire on lifetime digital media habits with longitudinal standardized test scores in Italian, English and mathematics. Participants who created a personal social media account in 6th, 7th or 8th grade were separately matched with late adopters who initiated their first social media account in the 9th grade or later. The findings provide compelling evidence that early engagement with social media adversely affects learning outcomes. Additional findings on the effects of early social media use on other academic outcomes for which we do not have longitudinal data are in line with our main findings. We also find supporting evidence that a substantial part of this negative effect is mediated by students' smartphone pervasiveness in key moments of the day.
Background To investigate the geographic distribution of multiple neurodevelopmental disorders (NDDs) across different US states. Methods Using data from 2016 to 2023 National Survey of Children's Health, we estimated the prevalence and combinations of multiple NDDs (defined as having ≥2 NDDs) at the state level among 272 598 children and adolescents aged 3-17 years. We also reported state-level prevalence estimates and combinations stratified by sociodemographic characteristics. Results Participant numbers ranged from 4391 in the Nevada to 11 275 in California during 2016-2023. Over half were male (51.7%), with a mean age of 10.2 years (standard deviation: 4.5). The national multiple NDDs prevalence was 8.1% (95% Confidence Interval [CI]: 7.9%-8.3%), with Kentucky reporting the highest prevalence at 10.5% (95% CI: 9.3%-11.8%) across states. Stratified analyses by period, age groups, sex, ethnicity, country of birth, household income, insurance coverage, and family education levels consistently showed the highest prevalence in southern states such as Florida, Kentucky, Louisiana, Maine, New Hampshire, and Oklahoma. Across states, the most common multiple NDDs combination was attention-deficit/hyperactivity disorder concurrent with learning disabilities (18.2%). Conclusion Disparities in multiple NDDs prevalence were observed across US states. These state-level estimates can help decision-makers target programs and allocate resources to address community needs.
Background Pediatric dental behavior management is difficult to teach because learners need safe opportunities to practice. Digital simulation tools offer new opportunities for safer and more structured training. However, the use of these approaches in pediatric dental behavior management education has not been systematically synthesized. Objective This systematic review aimed to synthesize the evidence on digital simulation tools in pediatric dental behavior management education, focusing on their design, implementation, and educational outcomes, and the extent to which virtual reality (VR) and serious game-based approaches have been studied. Methods Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, Scopus, Web of Science, Embase, the Cochrane Library, and the CNKI were searched for studies published between January 1, 2015, and December 10, 2025. An updated search using the same strategy across all 6 databases was performed on June 5, 2026. Only original research studies were eligible. Study characteristics, intervention design, implementation approaches, and educational outcomes were extracted, including technical skill acquisition, soft-skill and affective competency development, and learner experience and acceptability. Risk of bias was assessed independently by 2 reviewers using design-specific appraisal tools. Due to substantial heterogeneity in study designs, interventions, and outcome measures, findings were synthesized narratively rather than through meta-analysis. Results A total of 21 studies were included, including 20 studies identified in the original search and 1 study identified in the updated search. The identified evidence focused mainly on VR, haptic virtual reality simulation systems, augmented reality, 3D-printed models, and AI-driven chatbots. No eligible studies on gamification or serious games were identified, despite the inclusion of serious games and gamification terms in the search strategy. VR scenario simulations enhanced learners' empathy and self-efficacy in communicating with child patients, although these effects appeared to require reinforcement through repeated use. Haptic virtual reality simulation showed advantages in supporting specific procedural skills. Augmented reality improved local anesthesia training efficiency. The 3D-printed models and role-playing with professional actors enhanced clinical realism and communication skills, while AI-driven chatbots improved caregiver oral health knowledge and behaviors. Across studies, these tools were positioned as complements, rather than replacements for, traditional teaching. Conclusions Evidence suggests that digital simulation tools, especially VR-based approaches, may support pediatric dental behavior management education by enhancing procedural practice, empathy, communication, confidence, and caregiver-related learning. However, substantial heterogeneity, reliance on self-reported measures, and the rapid evolution of digital simulation technologies limit the strength and currency of the evidence. The absence of eligible serious game studies indicates an important research gap. This review highlights their practical value for curriculum development and future educational tool design. Future work should evaluate VR and serious game-based approaches using stronger study designs, standardized outcomes, longer follow-up, and implementation strategies.
Background Improved survival in pediatric intestinal failure (IF) necessitates a focus on neurodevelopmental outcomes. Existing cross-sectional research demonstrates increased risk of developmental delay. This novel study explores longitudinal motor and cognitive outcomes, and associated risk factors, in a single cohort across infancy to early school age. Material and methods Retrospective review of children admitted to an IF program < 4 months of age between 2011 and 2016, who completed: motor assessment between 4 and 15 months corrected age (CA), motor and cognitive assessment between 12 and 32 months CA and 4-8 years. Descriptive analysis of medical, socio-demographic variables and assessment scores. Outcomes were assessed using linear mixed methods, with multi-variable analyses to explore main effects and significant interactions with time. Results Study population included 41 children (56% male), median (IQR) gestational age 33 (28.5, 35.5) weeks and length of first year hospitalization 209 (140.8, 255) days. Five children (12%) had central nervous system (CNS) co-morbidities. Gross motor scores were below average at pre-school time-points, with significant improvement by school age; whereas fine motor and cognitive scores significantly decreased at 26-32 months CA, compared to largely average scores at 12-15-months CA and school age. Main effects predicting poorer scores included: birth weight, early motor delay, CNS co-morbidity, auditory impairment, NEC diagnosis, surgeries, sepsis, and prolonged hospitalization. Conclusions Children with IF demonstrate developmental vulnerably in infancy and preschool years, with promising motor and cognitive gains observed by early school age. Identification of key risk factors can guide IF teams in providing targeted therapeutic interventions, mitigating longer term developmental risks.
