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Externalizing behavior in preschool children in a South African birth cohort: Predictive pathways in a high-risk context

Published online by Cambridge University Press:  15 March 2022

Susan Malcolm-Smith*
ACSENT Laboratory, Department of Psychology, University of Cape Town, Cape Town, South Africa
Marilyn T. Lake
Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
Akhona Krwece
Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
Christopher P. du Plooy
Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
Nadia Hoffman
Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
Kirsten A. Donald
Neuroscience Institute, University of Cape Town, Cape Town, South Africa Division of Developmental Paediatrics, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
Heather J. Zar
Department of Paediatrics & Child Health, South African Medical Research Council (SAMRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
Dan J. Stein
Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa Neuroscience Institute, University of Cape Town, Cape Town, South Africa South African Medical Research Council (SAMRC) Unit on Risk and Resilience in Mental Disorders, Cape Town, South Africa
Corresponding author: Susan Malcolm-Smith, email:


Mental health problems often begin in early childhood. However, the associations of various individual and contextual risk factors with mental health in the preschool period are incompletely understood, particularly in low- to middle-income countries (LMICs) where multiple risk factors co-exist. To address this gap, we prospectively followed 981 children in a South African birth cohort, the Drakenstein Child Health Study, assessing pre-and postnatal exposures and risk factors. The predictive value of these factors for child mental health (assessed by the Child Behavior Checklist) was modeled using structural equation modeling. We identified two key pathways to greater externalizing behavior: (1) prenatal exposure to substances (alcohol and smoking) directly predicted increased externalizing behavior (β = 0.24, p < 0.001); this relationship was partially mediated by an aspect of infant temperament (negative emotionality; β = 0.05, p = 0.016); (2) lower socioeconomic status and associated maternal prenatal depression predicted more coercive parenting, which in turn predicted increased externalizing behavior (β = 0.18, p = 0.001). Findings in this high-risk LMIC cohort cohere with research from higher income contexts, and indicate the need to introduce integrated screening and intervention strategies for maternal prenatal substance use and depression, and promoting positive parenting across the preschool period.

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© The Author(s), 2022. Published by Cambridge University Press

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Externalizing behavior in preschool children in a South African birth cohort: Predictive pathways in a high-risk context
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