In this podcast, we are joined by Dr. Andrew Wooyoung Kim, Assistant Professor in biological anthropology at the University of California.
Andrew is the first author of the Journal of Child Psychology and Psychiatry (JCPP) paper ‘Psychological legacies of intergenerational trauma under South African apartheid: Prenatal stress predicts greater vulnerability to the psychological impacts of future stress exposure during late adolescence and early adulthood in Soweto, South Africa’ (doi: 10.1111/jcpp.13672), which is the focus of today’s podcast.
Andrew sets the scene by providing a brief introduction of how he came to be interested in this area of research, before turning to the paper itself and sharing a brief overview of the paper.
Andrew discusses the methodology used, including the challenges faced during the data collection, and shares the main findings from the paper.
Andrew then expands upon two interesting findings; the first being the finding that social support did not moderate the association between prenatal stress and psychiatric outcomes, and the second being that the prenatal stress exposure during apartheid is not directly associated with greater psychiatric morbidity during late adolescence.
With maternal age and past household adversity having been found to have an impact, Andrew also elaborates on these findings and their implications.
Furthermore, Andrew shares what the implications are of his findings for CAMH professionals, and comments on what role we should all be playing in recognising and addressing the ongoing legacies of colonialism, structural violence, and historical traumas, such as apartheid, in order to prevent future mental health inequities from emerging.
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Dr. Kim is an Assistant Professor in Biological Anthropology at the University of California, Berkeley and holds a PhD in anthropology from Northwestern University. He is a former postdoctoral research fellow at the Center for Global Health at Massachusetts General Hospital in Boston, MA, USA. He is also an Honorary Researcher at the Department of Paediatrics at the University of the Witwatersrand in Johannesburg, South Africa.
Dr. Kim’s research integrates biological, epidemiological, and anthropological approaches to understand how social oppression becomes embodied and produces health inequities in historically marginalized communities. His current work traces the biosocial mechanisms underlining the intergenerational mental health effects of violence from apartheid in Soweto and Johannesburg, South Africa. (Bio and Image from andrewwooyoungkim.com)
[00:00:32.040] Jo Carlowe: Hello. Welcome to the In Conversation podcast series for The Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I’m interviewing Dr. Andrew Wooyoung Kim, assistant professor in biological anthropology at the University of California. Andrew is the first author of the paper ‘Psychological legacies of intergenerational trauma under South African apartheid: Prenatal stress predicts greater vulnerability to the psychological impacts of future stress exposure during late adolescence and early adulthood in Soweto, South Africa’. This paper was recently published in the Journal of Child Psychology and Psychiatry and will be the focus of today’s conversation.
The JCPP is one of the three journals produced by The Association for Child and Adolescent Mental Health. ACAMH also produces JCPP Advances and the CAMH. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with the rating or review and do share with friends and colleagues. Andy, thank you for joining me. Can you start with a brief introduction about who you are and what you do.
[00:01:43.300] Dr. Andrew Wooyoung Kim: Thanks so much for having me. My name is Andy Kim, I’m assistant professor in biological anthropology at the University of California, Berkeley and also an honorary researcher at the University of Witwatersrand in Johannesburg, South Africa. I’m broadly interested in the intergenerational effects of trauma on mental and physical health outcomes as well as the underlying biological mechanisms that facilitate these intergenerational effects. And I’m particularly interested in studying these intergenerational processes as mechanisms of health inequalities in contexts of political violence and as pathways for marginalization in historically marginalized communities. So, my work takes me not only in South Africa, but certain communities in the United States and other places across the world.
[00:02:31.470] Jo Carlowe: Could you say more about how you became interested in this particular area of research?
[00:02:36.580] Dr. Andrew Wooyoung Kim: I became interested in this partly from my own lived experience, especially as a child of immigrants having grandparents that survived the Korean War and the transition from Japanese colonialism to Korean independence, as well as the tumultuous reconstruction period after the Korean War. I also became interested in this from my own academic interests in trying to think about how biology and social experience or biology and culture interact together to shape human experience, but also shape the embodiment of these larger social experiences to affect biology, health.
And finally, one area that really brought all this together was really just to think about the social and political consequences of these biological mechanisms of embodiment. How does this type of information affect the people that are affected? Especially when these types of data or knowledge claims have a particular political connotation for the community involved. Of course, in this case, looking at intergenerational trauma as a result of South African apartheid. How does this affect people long term and how does it affect these larger conversations around transitional justice and health inequalities.
[00:03:50.010] Jo Carlowe: Let’s turn to the paper itself. Andy, can you give us a brief overview of the paper.
[00:03:55.267] Dr. Andrew Wooyoung Kim: This study came from a very– this data came from a very historic study called Birth to Twenty now called Birth to Thirty. This study is quite interesting and still ongoing. The study started in 1990 during the dissolution of South African apartheid, where recruited over 3,000 pregnant women specifically in Soweto but also across Johannesburg. So, it started off as a multiracial and multicultural birth cohort study. And after these women gave birth, they followed up on both the mothers and children on a near annual basis. And like I said, the study is still ongoing. So, data collection most recently finished two years ago.
What I was really interested in studying was specifically to understand what the effects of the embodied violence or political violence from apartheid wars on these women who were pregnant during the dissolution of apartheid. It was a very tumultuous time specifically in this Township and Soweto which was really significant in the resistance against the apartheid regime. And trying to see how these effects of embodied effects of political violence may have affected their children 17 to 18 years after in utero exposure. So, exposure to these experiences of political violence during pregnancy. So, they weren’t necessarily directly affected. Another thing that we wanted to examine was this one particular hypothesis to understand the possible mechanisms by which intergenerational trauma manifests across generations. So, we wanted to test this hypothesis called the stress sensitization hypothesis, which specifically proposes that developmental stress may increase individuals reactions to future stressors in their own lives, and thus potentially increasing their risk for psychopathology.
[00:05:44.613] Jo Carlowe: I’m going to turn to the findings in a moment. But before we do, can you say a little bit about the methodology used for the study.
[00:05:51.667] Dr. Andrew Wooyoung Kim: Sure. Yeah. So, like I mentioned that we worked with– Let me start over. So, as I mentioned, we were working with the Birth to Twenty study, which is a prospective longitudinal birth cohort study. And this study design allowed us to eliminate any potential bias that came as a result of retrospective data collection. So, our measure of prenatal stress was collected prospectively as well as these mental health measures just over the multiple waves of data collection.
And I do want to mention that data collection during this time was an extremely difficult endeavour. It was a very difficult time for a lot of the research assistants to collect data. We have some stories where people were telling us that they had to buy new sneakers, and a more flexible pants so that they could run in case there was any sort of violence, whether it was physical violence or maybe gunshots or other types of activity going on in the area. And again, this was a very politically tumultuous time during the dissolution of apartheid. So, I think when we talk about data collection, it seems like such a mundane process, but in actuality, it can be quite a difficult endeavour. So largely is coming from this perspective birth cohort study. And we conducted a series of regression analysis and specifically a moderation analysis to try to see how to test the stress sensitization hypothesis specifically.
[00:07:42.453] Jo Carlowe: I’m glad you mentioned the challenges of the data collection because it really does help set the scene. Andy, let’s turn to the findings, what were the main findings?
[00:07:51.672] Dr. Andrew Wooyoung Kim: We had a number of different questions that we want to ask. So, the first question was to see if there was an association between prenatal stress exposure that mothers reported during the third trimester of pregnancy, and their children’s mental health outcomes 17 to 18 years after in utero exposure. And we saw a positive correlation between the exposure and the outcome, but we did not see– but this association was not significant. So, we did not find evidence for an association between prenatal stress exposure from violence during apartheid and mental health outcomes in their children during adolescence and early adulthood. We also wanted to test a number of potential risk and buffering factors to see if certain experiences or resources could change specifically amplify the effect of prenatal stress exposure or potentially buffer the mental health effects of prenatal exposure. So, in order to look at buffering, we wanted to look at the buffering effect of maternal social support that mothers reported during pregnancy. We did not find any significant results for potential buffering effect during pregnancy.
In order to look at the risk factors we tested a number of different hypotheses that we had developed. Both from our own ethnographic knowledge of the area and in the sample, and also based on the literature of course, the stress sensitization hypothesis being one of these hypotheses that we tested. So, we tested a moderation analysis trying to see if this relationship, the potential intergenerational mental health effects of political violence was amplified among women who gave birth at a younger age. We know that women who were giving birth especially during their teenage years were highly stigmatized, because of the fact that they were giving birth at such a young age. And we did see a significant moderation effect where the intergenerational mental health effects of political violence was significant, especially among women who were younger when they gave birth to their children.
We also wanted to test the stress sensitization hypothesis. So, we ran a moderation analysis looking at the interaction between prenatal stress exposure and later life stress exposure that children experienced and that they reported on. Specifically asking, does the interaction between greater levels of prenatal stress the mothers experience and greater levels of stress that the children experience predict greater levels of psycho-pathological risk among the children? And we do see a significant interaction effect.
[00:10:24.670] Jo Carlowe: In the paper, I was very surprised with the finding that social support did not moderate the association between prenatal stress and psychiatric outcomes. What do you make of that finding?
[00:10:37.287] Dr. Andrew Wooyoung Kim: Yeah. So, when we were conducting these analyses we were also surprised by a null interaction effects from this analysis, showing that social support did not moderate the relationship between prenatal stress and adolescent and later adult mental health outcomes. And one reason as to why this effect was not significant was due to the limited measures we had on social support, of course at the time, because we’re using perspective data that was collected in 1990, we can’t go back and reassess social support at the time. And of course, during data collection, we were collecting a wide variety of different measures. So, we have to be judicious in sort of questions we were asking. So, I attribute the insignificant finding partially due to a potential measurement error that perhaps we didn’t assess different types of social support that could have been meaningful and potentially buffered the long-term effects. That’s one explanation as to why these effects may have not been significant.
[00:11:35.372] Jo Carlowe: But there was another finding that I found surprising. And this was the prenatal stress exposure during apartheid, is not directly associated with greater psychiatric morbidity during late adolescence. Can you elaborate on that finding.
[00:11:50.730] Dr. Andrew Wooyoung Kim: We hypothesized that there would be a positive association between prenatal stress exposure and psychiatric morbidity among the children. And when we look at the literature, we see that these associations tend to be significant. The earlier the outcome measure is assessed. So, when mental health is assessed perhaps during infancy or early childhood, there’s less and less evidence about potential long-term effects of mental health effects of prenatal stress exposure across the life course. So, as we look at studies where children or even adolescents during the later periods of the development or even early adulthood are assessed, but we see fewer studies being conducted and the evidence is quite mixed. So it could be that potentially these effects get washed out over the course of the life course. In our paper we note that, especially in low- and middle-income settings there aren’t many analyses that look at these associations further and further across a life course. So, it could be the case that these effects just may have been washed out due to the fact that we assessed mental health later in the life course. Of course, there could be the possibility that these associations just are not significant and there are not mental health effects as a result of early life stress exposure during pregnancy. But of course, as our paper shows, there may be other mechanisms that could be affected by prenatal stress exposure that make their way to affect mental health in the next generation which of course, is what we find.
[00:13:20.880] Jo Carlowe: Maternal age and past household adversity were found to have an impact as you mentioned earlier. Can you say more about these findings and also their implications.
[00:13:30.320] Dr. Andrew Wooyoung Kim: Part of the rationale for testing the role of maternal age as a potential risk factor was due to our understanding that teenage pregnancy is both a highly stigmatized role but also one that is also morally compromised. So, when talking to especially a lot of women who were giving birth during their teenage years and when looking at the literature in South Africa young women’s experiences with teenage pregnancy are quite difficult and quite fraught. Coming from a variety of different sources, coming from their families, even coming from clinicians and nurses in the hospital. And we find that there’s a fair amount of victim blaming happening among these young women. We wanted to assess what this stigmatizing role could potentially have potentiating the long term impacts of intergenerational trauma. And of course, that’s exactly what we found. We found that the intergenerational mental health effects of trauma were significant, especially among women who gave birth at younger ages.
The household adversity finding was also quite interesting and corresponds with the hypothesis that we were seeking to test. So [INAUDIBLE] the stress sensitization hypothesis predicts that developmental stress, particularly between 0 to 18 could potentiate future experiences, mental health reactions, to future stressors. More specifically worsen these mental health reactions to future stressors. So, the household adversity measure was one that we wanted to test among the children to see if greater levels of household adversity that the children faced would have amplified the intergenerational effects of trauma that their mothers experienced while these children were in utero. And that’s also a hypothesis that we found to be significant.
And while we don’t have biological data to assess the underlying mechanisms by which the stress sensitization hypothesis manifest, and this is a very deep area of research that I’m hoping to follow up on to try to exactly understand what are these proximate mechanisms by which the stress sensitization pathway happens. Are there greater levels of for example, stress physiological dysregulation or psychological dysregulation that children experience as a result of having higher levels of stress exposure in utero? Does exposure to for example, maternal cortisol, maternal immune factors that are related to experiences of stress alter the development of stress physiology in the child in a way that has durable impacts or long-lasting impacts in the child to eventually affect them when they’re facing future stressors in their own lifetime? So that’s something that we’re hoping to test.
[00:16:15.860] Jo Carlowe: What are the implications of your findings for CAMH professionals?
[00:16:20.090] Dr. Andrew Wooyoung Kim: Our findings highlight a number of different important issues. One that early life exposures matter, but not only during the periods of childhood which is I think an area of work that has been going on for many decades, but also that periods of development even before childhood could potentially play an important role in shaping mental health outcomes across the life course of their children. So potentially doing screenings for stress exposure or poor mental health or different types of adversity whether at the household level, the individual level or even societal level as we see in this paper could be important as a way to potentially prevent psychiatric morbidity in their children as well as the mothers across their own life courses.
I think another thing that this study shows is that of course, these pathways of mental health adversity or mental health inequalities aren’t limited to the direct exposure of stress or adversity in the patient when they’re being seen. So that these risk pathways may potentially be much longer or have a much larger time frame than we expect. So, thinking about interventions that occur at the family level or even at the community level may be important for professionals to consider.
In a lot of cases that we see in South Africa, social context is a huge predictor of how people’s psychiatric prognoses are shaped and eventually treated. And focusing more on the social context and thinking more about people’s life histories I think could provide more information for clinicians to provide more tailored treatment modalities for their patients.
[00:17:56.570] Jo Carlowe: You also mentioned earlier in terms of the stigmatization of young pregnant women, I think you mentioned that some of the clinicians were also guilty of that.
[00:18:05.197] Dr. Andrew Wooyoung Kim: Absolutely. Absolutely. Yes. And fortunately, in these contexts and other contexts across the world clinicians may be part of perpetuating these forms of discrimination or oppression. So having clinicians undergoing these types of implicit bias trainings, interviewing clinicians more thoroughly to try to identify any forms of prejudice that they have coming in, even monitoring this across their tenure at a hospital or a treatment facility I think could have huge implications for patient outcomes. And this of course isn’t just limited to sexism or ageism or discrimination against teenage pregnancy but also on the basis of race, on the basis of class, ability, things of that nature.
[00:18:52.370] Jo Carlowe: Thank you, important to emphasize. And is there anything else in the paper that you’d like to highlight?
[00:18:57.917] Dr. Andrew Wooyoung Kim: I think one final point that I would like to share. These types of biomedical and empirical studies may seem to be limited to contributions to the scientific or psychological literature, but in fact, these studies may also have deeper social or political consequences that we might not necessarily fully understand. So of course, with the study we know that part of the intention of conducting this analysis was also to speak to this larger issue around the longer term legacies of apartheid.
Of course, apartheid ended in 1994 legislatively but we see that the socioeconomic, political, and psychological consequences of the apartheid regime are still taking place today. And of course, it’s important to understand to what degree people are affected by these long-term histories of colonialism and racial oppression as a way to identify the health burdens among people who were victimized during the time, and also as a way to potentially identify interventions that are tailored for these individuals and the long term impacts that they may be experiencing.
This paper only provides a small insight into the much larger range of effects that people may be experiencing. The second type of point here is that these effects are potentially reversible and likely are not fixed effects. So, when scientists conduct these types of studies, I think they tend to highlight the potential significant effects of intergenerational trauma and degree that they affect subsequent generations. But there’s this potential risk that comes in with communicating these types of findings, especially for the people who are involved in the study as participants or other communities that have been affected by intergenerational trauma. This potential risk of saying that, of stigmatizing these groups and saying that the things that affect them in the past may affect them for the rest of their lives, and that there’s no hope for these individuals. But in fact, when we look at the scientific literature there’s growing evidence that shows that these effects are malleable. They’re plastic and they are not durable across a life course. So, I think this is also a really important point to highlight in order to provide a more balanced perspective on these findings that could be potentially quite stigmatizing.
[00:21:16.000] Jo Carlowe: Andy your paper concludes, and this is a quote from the paper, ‘in as much as scientists aim to reverse the past impacts of embodied trauma and social oppression, the ongoing legacies of colonialism, structural violence, and historical traumas, such as apartheid, must be recognised and addressed to prevent future mental health inequities from emerging’. What role should we all be playing in that?
[00:21:40.815] Dr. Andrew Wooyoung Kim: Yeah, great. This is a wonderful question. Thanks so much for asking this. As I mentioned before, what we wanted to do with this study was to see the extent to which past historical atrocities or systems of oppression continue to affect people today. And while this one paper looks at how this might operate on the level of health and development, it speaks to a much larger issue which is the potential erasure or amnesia of past historical trauma that continues to affect people today. These are things like imperialism, colonialism, systematic forms of oppression.
And unfortunately, we see that these ongoing legacies of these forms of inequality continue to affect people today both on a smaller scale level through microaggressions or employment discrimination to much larger and more overt cases such as war or housing displacement and obvious forms of discrimination such as police violence.
I think there’s a number of things that we could all be doing in order to start to upend these forms of inequality. First of course, is to recognize the problem. To really make sense of what people’s lived experiences are like especially if one is not affected directly by these systems. I think the second is to also investigate how any individual could potentially be playing a role in perpetuating these types of racial discrimination, class discrimination, other forms of social oppression.
And that could be through speaking with people with experience. Unfortunately, we see so many cases of this in the world that just reading the news could be an ample source. And I think also trying to understand everyone’s potential contribution in all aspects of their lives. Specifically, to try to see what people can do to promote health equity, to promote racial justice either in the workplace, in their family contexts, and their communities. So that could be speaking to children about experiences of everyday racism or classism or other forms of discrimination. That could be at the role of individuals work to try to ensure equitable hiring practices. But also, to think about what are these historical narratives that are being concealed whether through intentional or unintentional ways.
[00:23:58.360] Jo Carlowe: Andy you talked about follow up research earlier, is there anything more you want to say about that?
[00:24:03.190] Dr. Andrew Wooyoung Kim: This study was part of a larger study that I was conducting in Soweto where I was doing a follow up work with the Birth to Twenty sample. For my research, I conducted a follow up study on the second and third generation to try to see how the intergenerational effects of trauma could potentially manifest into the third generation. So, this is looking at the grandchildren. So, I have ongoing work tries to investigate the extent to which prenatal stress exposure manifests across generations as well as looking at potential buffering mechanisms.
I am also quite interested in looking at mechanisms of stress physiological dysregulation. So as part of the study, we’ve collected multiple saliva samples across four days. And I never thought that collecting saliva from people could be such an arduous task and hope to speak more about that in the future. This is quite exciting area of research for me. For others as we are wanting to potentially trace the biological mechanisms by which intergenerational trauma may manifest.
I’ve also been starting new research as a result of the COVID 19 pandemic. So, I was writing all of this work before and during the COVID 19 pandemic. We had to shift our research, to a degree, to provide emergency mental health resources for our participants who are deeply affected by the pandemic, and we’re living in contexts where mental health support is just really not available. So, through public health response, we were also able to conduct data collection to try to understand the mental health impacts of the COVID 19 pandemic. So, I have ongoing research there. And finally, a new set of collaborators to try to understand the mental health pathways that are affecting patients with these lingering effects of COVID, also known as long COVID. So, what are these psychiatric sequelae of long COVID among adults living in Johannesburg?
[00:25:52.913] Jo Carlowe: Brilliant. Andrew, thank you so much. For more details on Dr. Andrew Wooyoung Kim, please visit the ACAMH website www.acamh.org and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review, and do you share with friends and colleagues.