Psychiatric morbidity in HIV-infected children

Patterns of emotional and behavioural challenges in children living with HIV: results from a hyperendemic South African setting

This study examined the patterns of emotional and behavioural problems in children from an HIV hyperendemic sub-Saharan Africa setting. A cross-sectional questionnaire survey was administered to 198 parents/caregivers of children living with HIV aged 2-12 years, attending a paediatric HIV out-patient service at a public sector hospital in KwaZulu-Natal Province, South Africa. The parent version of the Strengths and Difficulties Questionnaire (SDQ) which consists of five sub-scales (i.e. emotional difficulties, conduct problems, hyperactivity/inattention symptoms, peer problems and prosocial behaviours) were used to capture data on emotional and behavioural problems in children. The results indicated that over half of sampled children (n = 115, 58.1%) had abnormal levels of problems in at least one sub-scale, with adjusted regression indicating that academic difficulties and delayed milestones were significantly associated (i.e. greater total SDQ score as a continuous measure). Lower parental/caregiver educational attainment (i.e. not having tertiary education) was the only parent/caregiver characteristic associated with greater emotional and behavioural problems. Given the high prevalence of emotional and behavioural problems and its link to academic difficulties and delayed milestones, the need for screening and developmental support for children living with HIV may be warranted.

Psychiatric Morbidity in Children with HIV/AIDS at a Tertiary Health Institution in North-central Nigeria

INTRODUCTION

Children with human immunodeficiency virus (HIV) infection are living longer with the infection and are at risk of different complications. We assessed for the prevalence of and associated factors for psychiatric morbidity among HIV-infected children in a tertiary facility in Ilorin, Nigeria.

METHODS

A descriptive cross-sectional, two-staged study involving 196 HIV-positive children (6-17 years). A semi-structured questionnaire and psychological instruments were used for the study.

RESULTS

Thirty-eight (19.4%) children had psychiatric disorders: attention-deficit hyperactivity disorder and enuresis. Single parenthood, HIV clinical stages and complications were associated with psychiatric morbidity. Linear combination of the risk factors was not related to the psychiatric disorder. Bivariate correlation analysis showed the tendency to develop psychiatric disorder among the children was positively correlated with complications in the child and the person the child resides with.

CONCLUSIONS

Complicated HIV infection and adverse life events result in elevated risk of having psychiatric morbidity.

A comparative study of the psychological problems of HIV-infected and HIV-uninfected children in a South African sample

According to research children living with HIV experience elevated levels of depression, anxiety, ADHD and disruptive behavioural disorders. Although South Africa's paediatric population that is infected with the human immunodeficiency virus (HIV) is the largest worldwide, little research has been conducted on their mental health challenges. However, attributing high levels of mental health problems solely to their HIV status can be problematic as there may be other contributory factors. This research explored the mental health problems of HIV-infected children and compared these to the mental health problems of their HIV-unaffected peers from similar backgrounds. Data was gathered from two samples of child and caregiver pairs. HIV-infected children (aged 6-12 years) and their caregivers/mothers (n = 54) were recruited from the Kalafong paediatric clinic where they received medical treatment and routine ART. A comparison group of 113 HIV-uninfected children and their uninfected mothers were recruited from primary care clinics in the same community. Caregivers completed the Child Behaviour Checklist (CBCL) to assess children's mental health. Children completed the Self-Description Questionnaire (SDQ-I) and the Revised Children's Manifest Anxiety Scale (RCMAS). The scores of the psychometric sub-scales of the two groups were compared using parametric and non-parametric statistics. HIV-infected children experienced more somatic and affective problems, physiological anxiety, less ADHD and lower self-esteem than HIV-uninfected children in the comparison group, while controlling for age differences. The high levels of mental health problems of both groups of children may be attributed to similar difficult socio-economic circumstances. The fact that most infected children were not aware of their HIV-status could have influenced the results. Mental health services should not be limited to HIV-infected children but should form part of all health care services.

Prevalence and correlates for ADHD and relation with social and academic functioning among children and adolescents with HIV/AIDS in Uganda

BACKGROUND

Aim of this study was to determine the prevalence of attention-deficit/hyperactivity disorder (ADHD), its associated correlates and relations with clinical and behavioural problems among children and adolescents with HIV/AIDS (CA-HIV) attending five HIV clinics in central and South Western Uganda.

METHODS

This study used a quantitative design that involved a random sample of 1339 children and adolescents with HIV and their caregivers. The Participants completed an extensive battery of measures including a standardized DSM-5 referenced rating scale, the parent version (5-18 years) of the Child and Adolescent Symptom Inventory-5 (CASI-5). Using logistic regression, we estimated the prevalence of ADHD and presentations, correlates and its impact on negative clinical and behavioural factors.

RESULTS

The overall prevalence of ADHD was 6% (n = 81; 95%CI, 4.8-7.5%). The predominantly inattentive presentation was the most common (3.7%) whereas the combined presentation was the least prevalent (0.7%). Several correlates were associated with ADHD: socio-demographic (age, sex and socio-economic status); caregiver (caregiver psychological distress and marginally, caregiver educational attainment); child's psychosocial environment (quality of child-caregiver relationship, history of physical abuse and marginally, orphanhood); and HIV illness parameters (marginally, CD4 counts). ADHD was associated with poor academic performance, school disciplinary problems and early onset of sexual intercourse.

CONCLUSIONS

ADHD impacts the lives of many CA-HIV and is associated with poorer academic performance and earlier onset of sexual intercourse. There is an urgent need to integrate the delivery of mental health services into routine clinical care for CA-HIV in Sub-Saharan Africa.

A comparative assessment of generalized anxiety, conduct and peer relationship problems among AIDS and other orphaned children in India

BACKGROUND

Data on mental health among orphaned children in India are scanty. We compared the generalized anxiety, conduct and peer relationship problems and their associated risk factors among children orphaned by HIV/AIDS and those due to other reasons in the Indian city of Hyderabad.

METHODS

Four hundred orphaned children aged 12 to 16 years residing in orphanages in Hyderabad were sampled, half being AIDS orphans (COA) and the rest orphaned due to other reasons (COO). Interviews were done using standardized scales to assess generalized anxiety, conduct and peer relationship problems. A score >8, >4, and >5 was considered as indicator of generalized anxiety, conduct problem and peer relationship problem, respectively. Variations in the intensity of these three conditions due to possible factors including co-existing depression were assessed using multiple classification analysis (MCA).

RESULTS

A total of 396 (99.3 %) orphans participated of whom 199 (50.3 %) were COA. The mean generalized anxiety, conduct and peer relationship problem scores were 11.1 (SD 5.2), 3.8 (SD 2.5) and 3.8 (SD 2.5) for COA; and 7.6 (SD 4), 2.6 (SD 2) and 2.3 (SD 1.8) for COO, respectively. Among COA, the prevalence of generalized anxiety score of >8 was 74.4 % (95 % CI 67.8-80.0 %), of conduct problem score of >4 was 33.2 % (95 % CI 26.9-40.1 %), and of peer relationship problem score of >5 was 27.6 %, (95 % CI 21.8-34.3 %), with these being significantly lower in COO. In MCA, a higher mean depression score had the highest effect on the intensity of generalized anxiety, conduct and peer relationship problem (Beta 0.477; 0.379 and 0.453 respectively); being COA and a girl had the most impact on generalized anxiety (0.100 and 0.115, respectively).

CONCLUSIONS

A significantly high proportion of AIDS orphans deal with generalized anxiety, conduct and peer relationship problem as compared with other orphans highlighting the need to address the poor mental health of orphans in India.

Validating the Children's Depression Inventory in the context of Rwanda

BACKGROUND

Depression is often co-morbid with chronic conditions, and when combined with HIV it can increase progression and reduce survival. A brief and accurate screening tool for depression among children living with HIV is necessary to increase access to mental health care and improve HIV-related outcomes in the long-term.

METHODS

A validation study was conducted, comparing the Children's Depression Inventory (CDI) with a structured clinical assessment as the gold standard among children living with HIV ages 7-14 years in Rwanda. The response rate was 87 % and the analysis was performed among 100 study participants.

RESULTS

Twenty-five percent of children had a diagnosis of depression based on the clinical interview. Sensitivity of the CDI ranged from 44 to 76 % and specificity was 92 to 100 % for cut-off scores from 5 to 9. The area under the curve (AUC) for receiver operating characteristic analysis, an estimate of overall accuracy, was 0.87 (95 % confidence interval: 0.77 - 0.97).

CONCLUSIONS

The significant prevalence of depression among children living with HIV in Rwanda reflects a critical need to advance mental health care in this population. Although overall accuracy of the CDI is reasonable in this context, further research needs to be done to develop a more sensitive measure of depression in this vulnerable population. Development of a highly sensitive screening measure will be a fundamental step towards improving access to mental health care among children living with HIV, potentially improving health outcomes and quality of life in the long-term as this vulnerable population transitions into adulthood.

Child and adolescent mental health in South Africa

Mental health problems in childhood and adolescence pose a major threat to public health. Epidemiological studies in high, middle and low income countries indicate that approximately one in five children and adolescents suffer from a mental disorder. In many instances these persist into adulthood. In South Africa, HIV infection, substance use, and exposure to violence increase vulnerability to mental disorders. Child and adolescent mental health services play a key role in reducing the burden of mental disorders in childhood and later in adulthood. This paper focuses on service needs for children and adolescents in South Africa. It commences with a discussion of the prevalence of child and adolescent psychiatric disorders after which the legal and policy context of child and adolescent psychiatric services is described. A framework for child and adolescent mental health service provision is presented, following which steps for reducing the extent of unmet service need are considered. The paper concludes with a call to scale up child and adolescent mental health services in South Africa, based on the stark realities of unmet need and the constitutional rights of children and adolescents to appropriate mental health care.

Longitudinal study of emerging mental health concerns in youth perinatally infected with HIV and peer comparisons

OBJECTIVE

Cross-sectional research indicates high rates of mental health concerns among youth with perinatal HIV infection (PHIV), but few studies have examined emerging psychiatric symptoms over time.

METHODS

Youth with PHIV and peer comparisons who were HIV-exposed but uninfected or living in households with HIV-infected family members (HIV-affected) and primary caregivers participated in a prospective, multisite, longitudinal cohort study. Groups were compared for differences in the incidence of emerging psychiatric symptoms during 2 years of follow-up and for differences in psychotropic drug therapy. Logistic regression models were used to evaluate the association of emerging symptoms with HIV status and psychosocial risk factors.

RESULTS

Of 573 youth with study entry assessments, 92% attended at least 1 annual follow-up visit (PHIV: 296; comparisons: 229). A substantial percentage of youth who did not meet symptom criteria for a psychiatric disorder at study entry did so during follow-up (PHIV = 36%; comparisons = 42%). In addition, those who met criteria at study entry often met criteria during follow-up (PHIV = 41%; comparisons = 43%). Asymptomatic youth with PHIV were significantly more likely to receive psychotropic medication during follow-up than comparisons. Youth with greater HIV disease severity (entry CD4% <25% vs 25% or more) had higher probability of depression symptoms (19% vs 8%, respectively).

CONCLUSIONS

Many youth in families affected by HIV are at risk for development of psychiatric symptoms.

Validation of the Pediatric Symptom Checklist in HIV-infected Batswana

OBJECTIVE: To determine the validity of the Pediatric Symptom Checklist (PSC), a brief measure of psychosocial health, for screening HIV+ Batswana children. METHOD: Setswana versions of the parent and child PSC were administered to 509 HIV+ Batswana children (age 8-16) and their parents/guardians. Test properties were evaluated and cut-off scores were derived using receiver operating characteristic curve analysis. Scores on the parent-completed PSC and the child-completed PSC-Y were compared to parental and clinic staff reports of concern about the child's psychosocial health and to scores on the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scale. RESULTS: The Setswana PSC has high internal consistency (Cronbach's alpha 0.87 for the parent-completed version). Comparing PSC scores to parental reports of concern and child-reported depression symptoms, a cut-off score of 20 on the PSC and PSC-Y maximised the sensitivity and specificity. CONCLUSIONS: The PSC performed well in Setswana-speaking children and is a promising screening tool for paediatric psychosocial problems in busy clinical settings. Screening with the PSC may allow for early detection and treatment of psychosocial problems. This is likely to be of particular value for HIV+ children for whom HIV treatment non-adherence may result from untreated psychosocial dysfunction.

Behavioral deficits and progressive neuropathology in progranulin-deficient mice: a mouse model of frontotemporal dementia

Progranulin haploinsufficiency causes frontotemporal dementia with tau-negative, ubiquitin-positive neuronal inclusion pathology. In this study, we showed that progranulin-deficient mice displayed increased depression- and disinhibition-like behavior, as well as deficits in social recognition from a relatively young age. These mice did not have any deficit in locomotion or exploration. Eighteen-month-old progranulin-deficient mice demonstrated impaired spatial learning and memory in the Morris water maze. In addition to behavioral deficits, progranulin-deficient mice showed a progressive development of neuropathology from 12 mo of age, including enhanced activation of microglia and astrocytes and ubiquitination and cytoplasmic accumulation of phosphorylated TDP-43. Thus, progranulin deficiency induced FTD-like behavioral and neuropathological deficits. These mice may serve as an important tool for deciphering underlying mechanisms in frontotemporal dementia.

Decisional Capacity among Minors with HIV: A Model for Balancing Autonomy Rights with the Need for Protection

The purpose of this paper is threefold: (1) to describe the relevant ethical and legal issues associated with decisional capacity among minors and to discuss the importance of these concepts for children and adolescents living with HIV; (2) to provide a framework for assessing the decisional capacity of children and adolescents with HIV; and (3) to present a model for thinking about how to use this assessment data to guide action along the protection-autonomy continuum.

Depressive symptoms among HIV-positive pregnant women in Thailand

PURPOSE

To examine predictors of depressive symptoms among human immunodeficiency virus (HIV)-positive, pregnant women in Thailand.

DESIGN

Correlational, cross-sectional study.

METHODS

Data were collected at prenatal clinics in five hospitals in Thailand from January 2004 to January 2006. One hundred twenty-seven HIV-positive pregnant women completed questionnaires in Thai on depressive symptoms, self-esteem, emotional support, physical symptoms, and demographics. Simultaneous multiple regression was used to analyze predictors of depressive symptoms.

FINDINGS

Seventy-eight percent of the 127 participants reported depressive symptoms to some degree. Physical symptoms (beta= .192, p<.05) were positively associated with depressive symptoms, but self-esteem (beta=-.442, p<.001), emotional support (beta=-.193, p<.01), and financial status (beta=-.209, p<.01) were negatively correlated with depressive symptoms.

CONCLUSIONS

The study results have added new knowledge about depressive symptoms and their predictors in HIV-positive pregnant women in Thailand.

CLINICAL RELEVANCE

Depressive symptoms have been associated with faster progression to acquired immunodeficiency syndrome among HIV-positive individuals. The high rate of depression in our study suggests that HIV-positive pregnant women in Thailand should all be screened for depressive symptoms. Causes of physical symptoms should be identified and treated. Emotional support and self-esteem should be strengthened for HIV-positive pregnant Thai women.

HIV and mental health: An overview of research from India

HIV/AIDS has gained prominence in India as a growing public health issue. There is a complex but significant interaction between mental health and HIV/AIDS. HIV affects mental health by its direct neurobiological action, the impact of having the illness, by its treatment including that for opportunistic infections and by its impact on the family. In addition, substance use and mental illness as vulnerability factors add to the complexity of assessment, differential diagnosis and management. This paper reviews literature published in India on the topic.