Scoping Review of Mental Distress among Caregivers of Children and Adolescents with Behavioral Problems in Low and Middle Income Countries

Scoping Review of Mental Distress among Caregivers of Children and Adolescents with Behavioral Problems in Low and Middle Income Countries | Research Square Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Scoping Review of Mental Distress among Caregivers of Children and Adolescents with Behavioral Problems in Low and Middle Income Countries Ivan Gahima, Lucia D’ Ambruoso, Laetitia Nyirazinyoye, Clarisse Marie Claudine SIMBI, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7934244/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Caregivers play a crucial role in the emotional, social, and behavioral development of children and adolescents. When children exhibit behavioral problems, caregivers often experience considerable burden, reflected in internal perceptions of emotional exhaustion, worry, and psychological strain. This burden is associated with heightened mental distress among caregivers, manifesting as symptoms of depression and anxiety. Individual caregiver factors (e.g., poor mental health, ineffective coping strategies) and contextual factors (e.g., low family income, limited social support, inadequate access to mental health care, stigma) can exacerbate this distress. Despite growing evidence, there is still a scarcity of scoping reviews that examine the burden and associated factors in low- and middle-income countries (LMICs). Objective This scoping review aims to estimate the burden and systematically map the individual and contextual factors associated with mental distress among caregivers of children and adolescents with behavioral problems in low-and middle-income countries (LMICs). Methods Four databases (PubMed, Embase, PsycINFO, and MEDLINE) and google scholar will be searched from their inception to 28 September 2025. Studies will be included if they focused on primary caregivers aged 18 years or older of children and adolescents with behavioral problems, including externalizing behaviors (e.g., aggression, disobedience) and internalizing behaviors (e.g., anxiety, depression), report primary caregivers’ mental distress using validated measures, and be published in English. The review will follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. Critical appraisal will be done using the Newcastle-Ottawa Scale. mental distress caregivers children adolescents behavioral problems low- and middle-income countries Figures Figure 1 Background Caregivers play a pivotal role in nurturing the emotional, social, and behavioral development of children and adolescents. When children exhibit behavioral problems, parents often face substantial mental distress, which may manifest as heightened anxiety, depression, and an overall caregiver burden ( 1 – 3 ). Several studies have demonstrated that elevated parental mental distress is associated with children’s higher externalizing behaviors such as aggression, disobedience ( 4 ) and internalizing behaviors such as anxiety, depression ( 5 ). Globally, it is estimated that one in seven (14%) of 10–19-year-olds experience mental health conditions with behavioral disorders, depression, anxiety and among the leading causes of illness and disability among this age group ( 6 ). Low-and middle-income countries (LMIC) are disproportionately affected ( 7 ). Child and adolescent behavioral issues are a worldwide concern ( 8 ), encompassing actions that negatively affect individual’s daily functioning or pose health risks to themselves or others ( 9 ). Adolescents with behavioral problems often display aggression toward others, damage property, purposefully break rules, react with anger or irritability, and consistently disobey parents and authorities ( 10 , 11 ). Behavioral problems are generally categorized as externalizing behaviors such as physical, verbal, and relational aggression, vandalism, theft, and disobedience ( 12 ), and internalizing behaviors, which include lashing out at oneself through depression, anxiety, substance use and eating disorders ( 13 ). Externalizing behaviors are more prevalent among younger adolescents, whereas emotional disorders tend to be more common in older adolescents( 6 ). Parental mental distress is both a consequence and a determinant of child behavioral problems, highlighting a bidirectional relationship ( 14 ). Elevated parental distress is associated with higher rates of externalizing and internalizing problems in children ( 15 ). Mental distress occurs when the demands and stressors of daily life exceed an individual’s coping capacity ( 16 ). Contextual factors such as marital disruption, (e.g., separation, divorce, marital conflict), low family income, reduced social support, limited access to mental health care, stigma, and exposure to negative life events can exacerbate parental distress ( 17 – 19 ). Individual parental factors, including poor mental health, ineffective coping strategies, and maladaptive parenting behaviors, further increase susceptibility to mental distress and reduce the ability to manage challenging parenting demands ( 20 ). In contexts such as Rwanda, a study conducted among survivors of the 1994 genocide against the Tutsi found that parents with PTSD reported more parenting and child behavior problems, lower parenting satisfaction, higher family violence, and poorer parent-child relationships than parents without PTSD ( 21 ). Moreover, parental education and perceived competence in managing child behaviors significantly influence the extent of mental distress experienced ( 22 ). Parents of children with behavioral problems in LMICs face systemic challenges, including limited family support, scarce mental health services and trained specialists, low public awareness of mental health disorders, and social acceptance of children with behavioral problems ( 23 – 25 ). Emotional burden on parents and unmet needs related to parental mental health have been consistently highlighted in both high- and low-resource settings ( 26 , 27 ). Despite growing evidence on parental mental distress linked to child behavioral problems, studies examining individual and contextual factors in low- and middle-income countries (LMICs) remain scarce. This review focuses on parents of children and adolescents with behavioral problems but without neurodevelopmental disorders, isolating behavioral difficulties not secondary to conditions such as autism or intellectual disability. To our knowledge, it will be the first scoping review to systematically map evidence on parental mental distress in this population within low- and middle income countries (LMICs) Given the limited synthesis of evidence in LMICs, a scoping review is timely and appropriate to estimate the magnitude of mental distress and systematically map the individual and contextual factors associated with it among caregivers of children and adolescents with behavioral problems, providing insights to guide future research, intervention development, and inform policy by highlighting gaps and priorities in existing evidence. Methods This scoping review will be conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) Checklist, which provides structured guidance for each stage of the review process. A completed PRISMA-ScR checklist will be included as a supplementary file to ensure transparency and methodological rigor. 2.2. Eligibility Criteria This review will consider exclusively articles published in the English language. The PICO framework for prevalence studies (Population, Measurement of the disease, Design, and Setting) will guide the choice of eligibility criteria. On this basis, studies will be included if they: ( 1 ) primary caregivers aged 18 years or older of children and adolescents with behavioural problems (Population); ( 2 ) report caregiver mental distress using validated screening tools or established diagnostic criteria (Measurement of the presence of the disease); ( 3 ) employ empirical study design individual-or contextual-level risk and protective factors associated with parental mental distress (Design); and ( 4 ) are conducted in low- and middle-income countries (LMICs), in any type of setting, provided that the study involves community-based or population-based samples (Setting). Studies will be excluded if they focus on caregivers under 18 years of age, caregivers of children with developmental disorders, or disabilities, or caregivers of children with only internalizing problems. 2.3 Information source The literature search will be conducted across four databases: PubMed, Embase, PsycINFO, and MEDLINE, from their inception to 28 September 2025. Additional records will be identified through other sources such as google scholar and by screening the reference lists of included studies to ensure comprehensive coverage of relevant literature. 2.3.1. Search criteria The search strategy for this review will be developed by the principal investigator (PI) in close consultation with supervisors (AM, LD, and LN). The search strategy will include the combination of key terms, free text and vocabulary search terms such as (Medical Subject Heading for Medline and Emtree terms for Embase) for the main big terms of “caregivers,” “mental distress,” “behavioral problems,” “children,” “adolescents,” and “low- and middle-income countries”. Terms within each concept will be combined using the Boolean operator OR, while the major concept will be linked using AND. The search strategy for searched databases is included in the table below. Database Concept Search Terms Context Language Date 1. PubMed 2. Embase 3. PsycINFO 4. Medline 5. Google scholar Mental Distress "mental distress" OR "psychological distress" OR "psychological stress" OR "emotional distress" OR "mental health" OR "mental disorder" OR "mental illness" OR "psychiatric disorder" OR depression OR anxiety OR stress OR "psychological well-being" OR "emotional well-being" OR "emotional problems" OR "emotional disorder" OR "psycho-social stress" "low-income countries" OR "middle-income countries" OR "developing countries" OR "Sub-Saharan Africa" OR "South Asia" OR "Southeast Asia" OR "Latin America" English No restriction caregivers “caregiver” OR “parent” OR “mother” OR “father” OR "primary carer" OR "family member" OR “guardian” OR "single parent" OR "foster parent" OR "relative caregiver" Children/ Adolescents “child” OR “adolescent” OR “youth” OR “teenager” OR “juvenile” OR “pediatric “OR “young” Behavioral problems "Behavior problem" OR "behavior problem" OR "conduct disorder" OR "oppositional defiant disorder" OR "disruptive behavior disorder" OR "externalizing behavior" OR "internalizing behavior" OR "antisocial behavior" 2.3.2. Selection of sources of evidence Following the database searches, all identified records will be imported in Covidence software, which will automatically deduplication and facility the screening and review process. Two reviewers will independently carry out a two-stage screening procedure. In the first stage, titles and abstracts will be screened against the predefined inclusion and exclusion criteria to identify potentially relevant studies. In the second stage, full-text articles of the selected records will be retrieved and assessed for eligibility. Inter-rater reliability will be assessed using percentage agreement, with a minimum threshold of 80% ( 28 ). Any discrepancies between the reviewers at either stage will be discussed and resolved through consensus, with the involvement of a third reviewer if necessary. 2.4 Data charting process A data extraction for will be developed to capture relevant information from all included studies. The form will include items related to study characteristics (author, year of publication ansd citation, study country/region), study design, study setting and population, sample size, and study tools or measures. The two reviewers (IG and SC) will independently extract the data from inckudd studies using this form. These reviewers will meet to resolve data extraction differences with discussion and to reach a consensus on what to extract from the included articles. Table 1 Preliminary charting table Author Publication year Country Study design Study population Sample size Study tools Prevalence of mental distress Individual factors Contexual factors 2.5 Collating, summarizing and reporting the results As a scoping review, the aim will be to map and synthesise the findings to provide a comprehensive overview of the topic and all relevant evidence included in the review. Data will be analysed using descriptive statistics where appropriate, and the results will be summarised narratively and presented in tables and figures to illustrate the distribution of evidence by study design, setting, population, and key themes identified during data charting. Although critical appraisal of included studies is not mandatory in scoping reviews, a quality assessment will be conducted to better understand the strength and credibility of the available evidence and to support interpretation of findings. The Newcastle-Ottawa Quality Assessment Scale (NOS) for cross-sectional studies will be used for quantitative evidence, with minor adaptations to align with the context of this review. Ethics and Dissemination Rather than evaluating the quality of each study separately, this review will provide a comprehensive overview of existing evidence, synthesize the findings, and present a clear summary. Since the review draws solely on publicly available literature, ethical approval is not required. Upon completion, the results will be shared with health administrators, professionals, and researchers through publication in peer-reviewed journals and conference presentations. Additionally, the gaps identified will directly inform the principal investigator’s dissertation proposal. Strength and Limitations To the best of our knowledge, this scoping review will constitute the first systematic attempt to explore, map, and highlight research gaps on this subject, thereby creating a foundation for future research in LMICs. It is also expected to generate valuable insights for policymakers, practitioners, and researchers in shaping targeted interventions. Nonetheless, some limitations must be recognized. Scoping reviews are designed to chart the extent and range of existing evidence rather than to rigorously assess the validity of study findings( 29 , 30 ). They do not aim to produce new knowledge but instead to identify gaps and summarize existing literature. As such, this review will not evaluate study quality or risk of bias, nor will it assess external validity. Rather, the emphasis will be placed on synthesizing the most relevant evidence regarding individual and contextual influences on parental mental distress among parents of children and adolescents with behavioral problems. This review will not impose publication year restrictions in order to ensure comprehensive coverage, particularly given the limited volume of research available in LMICs. However, the inclusion criteria are limited to English-language publications, which may result in the exclusion of relevant studies published in other languages. In addition, the breadth and depth of this review may be influenced by the availability and quality of data in the included studies. It should also be noted that, consistent with the aims of a scoping review, the quality of included studies will not be appraised using a formal critical appraisal too. Nevertheless, ( 31 ), recommend that reviewing multiple databases and at least 10 records reduces the risk of drawing false conclusions. As this review incorporates five electronic databases, we anticipate presenting confident and reliable findings. Declarations Funding This study was supported by the NIHR (NIHR133712) through UK international development funding from the UK Government for global health research. The views expressed here are those of the author(s) and do not necessarily reflect the positions of the NIHR, the UK Government, the Court of the University of Aberdeen, the Boards of Directors of the University of Rwanda, Addis Ababa University, The Sanctuary, or our International Advisory Board Ethical and institutional Review Not appliacble. Consent for publication Not appliacble. Conflict of Interest The authors declare that they are no competing interests. Consent to participate Not applicable . Data availability statement Not applicable, as this is a scoping review protocol. References Meltzer, et al. The burden of caring for children with emotional or conduct disorders. Int J family Med. 2011;2011(1):801203. Ocansey, et al. Anxiety, depression, and stress in caregivers of children and adolescents with mental disorders in Ghana and implications for medication adherence. Ghana Med J. 2021;55(3):173–82. Liu Z, Heffernan C, Tan J. Caregiver burden: A concept analysis. Int J Nurs Sci. 2020;7(4):438–45. Perrotta G, Fabiano G. Behavioural disorders in children and adolescents: Definition, clinical contexts, neurobiological profiles and clinical treatments. Open J Pediatr Child Health. 2021;6(1):005–15. Deković M, Buist KL, Reitz E. Stability and changes in problem behavior during adolescence: Latent growth analysis. J Youth Adolesc. 2004;33(1):1–12. WHO. 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