Research suggests that rumination places adolescents at risk for psychopathology. However, little is known about the association between parenting and rumination. Moreover, relevant theoretical models suggest that parents contribute to the development of rumination both explicitly through their suggestions about how to cope and implicitly through the context of the mother-adolescent relationship. However, prior work has not examined implicit and explicit factors within the same investigation, precluding exploration of their unique and interactive effects. To address these gaps, the present study examined links between mother-adolescent relationship quality, maternal coping suggestions, and adolescent rumination. Participants were early adolescent girls (M age = 12.41 years) and their primary female caregivers. Findings suggested that maternal disengagement suggestions and mother-adolescent relationship quality were each uniquely associated with adolescent rumination. Moreover, the effect of maternal disengagement suggestions depended on the level of maternal engagement suggestions and mother-adolescent relationship quality. Follow-up analyses revealed that these findings were specific to the maladaptive ruminative brooding component of rumination. Future directions for research were elaborated.

Background: Adolescents living with HIV have elevated mental distress and suboptimal antiretroviral therapy (ART) adherence.Setting: Two urban clinics in Kigali, Rwanda. Methods: A 2-arm individual randomized controlled trial compared Trauma-Informed Cognitive Behavioral Therapy enhanced to address HIV (TI-CBTe) with usual care (time-matched, longstanding, unstructured support groups) with 356 12-to 21-year-old (M = 16.78) Rwandans living with HIV. TI-CBTe included 6 groupbased 2-hour sessions led by trained and supervised 21-to 25-yearold Rwandans living with HIV. Participants reported their ART adherence, depression/anxiety, and Post-Traumatic Stress Disorder symptoms at baseline, 6, 12, and 18 months.Results: ART adherence was relatively high at baseline, and youth reported elevated rates of depression/anxiety and trauma symptoms. There were no differential treatment effects on adherence, but depression/anxiety improved over time. Youth with lower depression/anxiety at baseline seemed to benefit more from TI-CBTe than usual care, whereas women with high baseline distress seemed to benefit more from usual care. Youth were less likely to score in high Post-Traumatic Stress Disorder symptom categories at the follow-up, with no differential treatment effects.Conclusions: TI-CBTe did not outperform usual care on ART adherence, possibly reflecting relatively high adherence at baseline, simplified medication regimens over time, a strong comparison condition, or because youth assigned to TI-CBTe returned to their support groups after the intervention. TI-CBTe was more effective for youth with lower depression/anxiety symptoms, whereas youth with high distress benefitted more from the support groups. TI-CBTe was feasible and acceptable, and young adults living with HIV were able to deliver a mental health intervention with fidelity. The powerful nature of the comparison group, ongoing support groups, points to the potential value of locally crafted interventions in lowresource settings.

Abstract Though mental and substance use disorders are a leading cause of disability worldwide, mental health systems are vastly under-resourced in most low- and middle-income countries and the majority of people with serious mental health needs receives no formal treatment. Despite international calls for the integration of mental health into routine care, availability of outpatient mental health services and integration of mental health into the broader healthcare system remain weak in many countries. Efforts to strengthen mental healthcare systems must be informed by the local context, with attention to key health system components. The current study is a qualitative analysis of stakeholder perspectives on mental health system strengthening in one low-income country, Sierra Leone. It utilizes locally grounded knowledge from frontline healthcare providers to identify constraints and opportunities for strengthening mental health care within each component of the health system. In-depth semi-structured interviews were conducted with 43 participants including doctors, nurses, community health workers, mental health advocates, mental health specialists, and traditional healers recruited from the Bo, Moyamba and Western Area Urban Districts. Interview transcripts were content-coded in NVivo using both a priori and emergent codes and aggregated into broader themes, utilizing the World Health Organization Health Systems Framework. Participants described an extremely limited system of mental health care, with constraints and obstacles within each health system component. Participants identified potential strategies to help overcome these constraints. Findings reinforce the importance of factors outside of the healthcare system that shape the implementation of mental health initiatives, including pervasive stigma towards mental illness, local conceptualizations of mental illness and an emphasis on traditional treatment approaches. Implications for mental health initiatives in Sierra Leone and other low-income countries include a need for investment in primary care clinics to support integrated mental health services and the importance of engaging communities to promote the utilization of mental health services.

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