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Peer-reviewedCC BY 4.0Child and Adolescent Psychiatry and Mental Health

Association of early life adversity with internalizing and externalizing behavior across 3 low- and middle-income countries

  • Sheri-Michelle Koopowitz1
  • Richard Shadwell2,3
  • Nadia Hoffman1
  • Heather J. Zar2,3
  • Giovanni Salum4,5
  • Pedro M. Pan6
  • Gauri Divan7
  • Supriya Bhavnani7
  • Dan J. Stein1,8
8 affiliations
  1. 1Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
  2. 2Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
  3. 3South African Medical Research Council (SAMRC) Unit on Child and Adolescent Health, Cape Town, South Africa
  4. 4Global Programs, Child Mind Institute, New York, USA
  5. 5Universidade Federal do Rio Grande do Sul, Hospital de Clínicas, Porto Alegre, Brazil
  6. 6Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
  7. 7Child Development Group, Sangath, India
  8. 8South African Medical Research Council (SAMRC) Unit on Risk and Resilience in Mental Disorders, Cape Town, South Africa
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Abstract

Background: Early life adversity (ELA) is associated with increased internalizing and externalizing behavior in high-income cohorts. However, it is unclear whether these associations generalize to low- and middle-income countries (LMICs). We examined the association between ELA and internalizing and externalizing behaviors in children across three LMIC cohorts.

Methods: Data from three cohorts, the Brazilian High-Risk Cohort (BHRC; n = 1111), Sustainable Programme Incorporating Nutrition and Games (SPRING; n = 601), and Drakenstein Child Health Study (DCHS; n = 708) were pooled. Children (7–10 years) were assessed using the Strengths and Difficulties Questionnaire (SDQ). ELA was measured using a cumulative index. Ordinary Least Squares linear regression models were run to examine the associations of adversity with internalizing and externalizing behaviors while adjusting for child age, sex, and cohort, and to test interactions with child age, sex, and cohort. 2420 children (53.9% boys) were included in analyses.

Results: SDQ measurement invariance was not established across cohorts. ELA associations were strongest in BHRC (SDQ total: B = 6.78, p < .001; internalizing: B = 3.3, p < .001; externalizing: B = 3.48, p < .001), attenuated in SPRING (SDQ total: B = 1.54, p = .014; internalizing: B = 0.81, p < .001; externalizing: B = 0.73, p = .007), and not observed in DCHS (SDQ total: B = 0.12, p = .78; internalizing: B = -0.18, p = .42; externalizing: B = 0.3, p = .29). Interaction analyses indicated cohort heterogeneity and age-related effects, with inconsistent sex moderation across cohorts and outcomes.

Conclusions: In Global South cohorts, while there is an association between ELA and psychopathology, there are also important context-dependent differences across cohorts.

Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s13034-026-01139-9.

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Cite

BibTeXRIS
BibTeX
@article{koopowitz2026association,
  title = {{Association of early life adversity with internalizing and externalizing behavior across 3 low- and middle-income countries}},
  author = {Sheri-Michelle Koopowitz and Richard Shadwell and Nadia Hoffman and Heather J. Zar and Giovanni Salum and Pedro M. Pan and Gauri Divan and Supriya Bhavnani and Dan J. Stein},
  journal = {Child and Adolescent Psychiatry and Mental Health},
  year = {2026},
  month = jul,
  doi = {10.1186/s13034-026-01139-9},
  url = {https://doi.org/10.1186/s13034-026-01139-9},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Association of early life adversity with internalizing and externalizing behavior across 3 low- and middle-income countries
AU  - Sheri-Michelle Koopowitz
AU  - Richard Shadwell
AU  - Nadia Hoffman
AU  - Heather J. Zar
AU  - Giovanni Salum
AU  - Pedro M. Pan
AU  - Gauri Divan
AU  - Supriya Bhavnani
AU  - Dan J. Stein
PY  - 2026
DA  - 2026/07/24
JO  - Child and Adolescent Psychiatry and Mental Health
DO  - 10.1186/s13034-026-01139-9
UR  - https://doi.org/10.1186/s13034-026-01139-9
AB  - Background: Early life adversity (ELA) is associated with increased internalizing and externalizing behavior in high-income cohorts. However, it is unclear whether these associations generalize to low- and middle-income countries (LMICs). We examined the association between ELA and internalizing and externalizing behaviors in children across three LMIC cohorts.  Methods: Data from three cohorts, the Brazilian High-Risk Cohort (BHRC; n = 1111), Sustainable Programme Incorporating Nutrition and Games (SPRING; n = 601), and Drakenstein Child Health Study (DCHS; n = 708) were pooled. Children (7–10 years) were assessed using the Strengths and Difficulties Questionnaire (SDQ). ELA was measured using a cumulative index. Ordinary Least Squares linear regression models were run to examine the associations of adversity with internalizing and externalizing behaviors while adjusting for child age, sex, and cohort, and to test interactions with child age, sex, and cohort. 2420 children (53.9% boys) were included in analyses.  Results: SDQ measurement invariance was not established across cohorts. ELA associations were strongest in BHRC (SDQ total: B = 6.78, p < .001; internalizing: B = 3.3, p < .001; externalizing: B = 3.48, p < .001), attenuated in SPRING (SDQ total: B = 1.54, p = .014; internalizing: B = 0.81, p < .001; externalizing: B = 0.73, p = .007), and not observed in DCHS (SDQ total: B = 0.12, p = .78; internalizing: B = -0.18, p = .42; externalizing: B = 0.3, p = .29). Interaction analyses indicated cohort heterogeneity and age-related effects, with inconsistent sex moderation across cohorts and outcomes.  Conclusions: In Global South cohorts, while there is an association between ELA and psychopathology, there are also important context-dependent differences across cohorts.  Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s13034-026-01139-9.
SN  - 1753-2000
ER  -