A preliminary study of factors associated with psychological adjustment and disease course in school-age children infected with the human immunodeficiency virus

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.

DSM-IV mental disorders and neurological complications in children and adolescents with human immunodeficiency virus type 1 infection (HIV-1)

Aim

To study the types of psychiatric problem encountered in children infected with the human immunodeficiency virus (HIV) and their relationship to central nervous system disorder and the severity of infection.

Methods

17 HIV-infected children presenting with psychiatric problems were included. Mental disorders were evaluated according to DSM-IV criteria. Neurological disorders and progressive encephalopathy (presence or absence) diagnosis were evaluated by clinical and radiological examination. The severity of infection was assessed by the percentage of CD4 lymphocytes.

Results

The most frequent diagnoses were major depression (MDD: 47%) and attention deficit hyperactivity disorder (ADHD: 29%). Major depression diagnosis was significantly associated with neuroimaging or clinical neurological abnormalities (p < 0.01). In contrast, no association was found between hyperactivity diagnosed according to DSM-IV criteria and central nervous system disorder. Percentage of CD4 lymphocytes were close to 0 for more than 80% of children presenting with psychiatric complications.

Conclusion

The very low % of CD4 lymphocytes of these children suggest that the appearance of a psychiatric complication should be regarded as a factor indicating severe HIV infection. Depressive disorders may be a clinical form of encephalopathy.

An assessment of WISC-IIIUK on children with HIV infection

The Wechsler Intelligence Scale for Children - Third Edition UK test was administered to groups of children between the ages of 6 and 12 years with vertically transmitted HIV infection (n = 70) and a control group who were not infected by the virus (n = 70). The study was conducted in India. The two groups were matched for general verbal abilities, age and gender. The children were assessed for Verbal IQ, Performance IQ and Full-Scale IQ. The Verbal Comprehension Index, Perceptual Organization Index and Freedom from Distractibility Index were also obtained. A three-factor analysis of variance disclosed that school-age children with vertically transmitted HIV infection notched below in the areas of Verbal IQ, Performance IQ, Full-Scale IQ, Verbal Comprehension Index, Perceptual Organization Index and Freedom from Distractibility Index when collated with normal uninfected cohorts. Findings are discussed in the light of both theoretical and clinical implications.

Neurodevelopment in perinatally HIV-infected children: a concern for adolescence

Globally, an estimated 3.4 million children are living with HIV, yet little is known about the effects of HIV and antiretroviral treatment (ART) on the developing brain, and the neurodevelopmental and behavioural outcomes of perinatally HIV-infected (PHIV+) adolescents. We reviewed the literature on neurodevelopmental outcomes in PHIV+ children and adolescents, and summarized the current evidence on behaviour, general cognition, specific domains, hearing and language, school performance and physical disabilities due to neurological problems. Evidence suggests that PHIV+ children do not perform as well as controls on general cognitive tests, processing speed and visual-spatial tasks, and are at much higher risk for psychiatric and mental health problems. Children with AIDS-defining diagnoses are particularly at risk for poorer outcomes. A striking finding is the lack of published data specific to the adolescent age group (10-25 years), particularly from resource-constrained countries, which have the highest HIV prevalence. In addition, extreme heterogeneity in terms of timing and source of infection, and antiretroviral experience limits our ability to summarize findings of studies and generalize results to other settings. Due to the complex nature of the developing adolescent brain, environmental influences and variation in access to ART, there is an urgent need for research on the longitudinal trajectory of neurodevelopment among children and adolescents perinatally infected with HIV, especially in high burden resource-constrained settings.

Annual Research Review: Mental health and resilience in HIV/AIDS-affected children-- a review of the literature and recommendations for future research

BACKGROUND

To date, research on mental health in HIV-affected children (children who have an HIV-positive caregiver or live with the virus themselves) has focused on risk factors associated with the disease. However, simultaneous identification of factors that contribute to resilience in the face of risks is also needed. A greater understanding of modifiable protective processes that contribute to resilience in the mental health of children affected by HIV can inform the design of interventions that bolster naturally occurring supports and contribute to early prevention or better management of risks.

METHODS

We reviewed the recent literature on mental health and resilience in children and adolescents affected by HIV/AIDS. Literature searches of PsycInfo and PubMed were conducted during July-December 2011 consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Qualitative and quantitative studies were included for review if primary research questions pertained to mental health and coping or protective processes in children and families affected by HIV/AIDS. All studies subject to full review were evaluated for quality using a modified Systematic Assessment of Quality in Observational Research (SAQOR) rating system.

RESULTS

One hundred and seventy one unique studies were returned from online searches of the literature and bibliography mining. Of these, 29 were evaluated as pertaining directly to mental health and resilience in families and children living with HIV/AIDS. Eight studies presented qualitative analyses. Ten quantitative studies examined individual resources contributing to child resilience and four quantitative studies looked at family-level resources. Ten studies also investigated community level interactions. Four presented findings from resilience-focused interventions.

CONCLUSIONS

There is a clear need for rigorous research on mental health and resilience in HIV-affected children and adolescents. The evidence base would greatly benefit from more standardized and robust approaches to thinking about resilience from an ecological perspective inclusive of resources at multiple levels and their interactions.

Social-emotional functioning of children and adolescents with neurofibromatosis type 1 and plexiform neurofibromas: relationships with cognitive, disease, and environmental variables

OBJECTIVE

This descriptive cross-sectional study aimed to determine how cognitive, disease, and environmental variables relate to social-emotional functioning in youth with NF1 and plexiform neurofibromas.

METHODS

Psychological assessments were administered to 53 children (mean age 12.4 years); parents and teachers completed the behavior assessment system for children-second edition (BASC-2). Disease severity was quantified by nurse-practitioner ratings and tumor burden, and parents completed a life events checklist to indicate environmental stressors.

RESULTS

Notable proportions of children scored in the at-risk/clinically significant ranges on several parent and teacher BASC-2 subscales including somatization, attention problems, depression, and withdrawal. Combinations of cognitive, disease, and environmental variables predicted scores on parent BASC-2 internalizing problems, behavior symptoms index, and Adaptive Skills composites.

CONCLUSIONS

Cognitive, disease, and environmental variables relate to social-emotional outcomes in children with NF1. These youth may benefit from interventions targeting social skills, cognitive functioning, and adaptive ways of coping with NF1-related pain.

Behavioral and emotional problems among children aged 6-14 years on highly active antiretroviral therapy in Addis Ababa: a cross-sectional study

Children infected with human immunodeficiency virus (HIV) are at particular risk for psychological disturbance. Little is known about the mental health status of children on highly active antiretroviral therapy (HAART). A hospital-based cross-sectional study of 318 children aged 6-14 on HAART in Addis Ababa was conducted. Behavioral and emotional problem was assessed using the child behavior check list (CBCL/6-18). Logistic regression analysis was done to select the best subset of predictor variables and determine their association with behavioral and emotional problems. Of the 318 caregivers of children aged 6-14 on HAART, 39.3% of the children had behavioral and emotional problems. Low family monthly income (AOR, 3.44, 95% CI, 1.89-6.25), older age (AOR, 2.27, 95% CI, 1.34-3.83), and parental loss (AOR, 1.89, 95% CI, 1.10-3.25) were found to be determinants of behavioral and emotional problems in the multivariate logistic regression. There is high prevalence of behavioral and emotional problems in children on HAART in Addis Ababa. More support is needed to children from families of low income and those who lost their parents. Further research should be carried out to enhance better understanding and appropriate response to behavioral and emotional problems.

Co-occuring psychiatric symptoms in children perinatally infected with HIV and peer comparison sample

OBJECTIVE

To compare the rates of psychopathology in youths perinatally infected with HIV (N = 319) with a comparison sample of peers (N = 256) either HIV-exposed or living in households with HIV-infected family members.

METHOD

Participants were randomly recruited from 29 sites in the United States and Puerto Rico and completed an extensive battery of measures including standardized DSM-IV-referenced ratings scales.

RESULTS

The HIV+ group was relatively healthy (73% with CD4% >25%), and 92% were actively receiving antiretroviral therapy. Youths with HIV (17%) met symptom and impairment criteria for the following disorders: attention-deficit/hyperactivity disorder (12%), oppositional defiant disorder (5%), conduct disorder (1%), generalized anxiety disorder (2%), separation anxiety disorder (1%), depressive disorder (2%), or manic episode (1%). Many youths with HIV (27%) and peers (26%) were rated (either self- or caregiver report) as having psychiatric problems that interfered with academic or social functioning. With the exception of somatization disorder, the HIV+ group did not evidence higher rates or severity of psychopathology than peers, although rates for both groups were higher than the general population. Nevertheless, self-awareness of HIV infection in younger children was associated with more severe symptomatology, and youths with HIV had higher lifetime rates of special education (44 vs 32%), psychopharmacological (23 vs 12%), or behavioral (27 vs 17%) interventions. Youth-caregiver agreement was modest, and youths reported more impairment.

CONCLUSION

HIV infection was not associated with differentially greater levels of current psychopathology; nevertheless, investigation of relations with developmental changes and specific illness parameters and treatments are ongoing.

Stressful life events and their relationship to psychological and medical functioning in children and adolescents with HIV infection

OBJECTIVES

To assess the relationship between number and type of stressful life events (SLEs) and psychological and medical functioning in HIV-infected children.

METHODS

For this cross-sectional study, caregivers of 55 vertically infected children aged 8-17 years completed a measure assessing SLEs occurring in the past 6 months. Children and caregivers both completed a questionnaire assessing the child's level of depression and anxiety. Concurrent demographic and medical data were gathered from chart review.

RESULTS

School-related SLEs were the most common type of event and predicted child-reported depressive symptoms. Children who had disclosed their diagnosis in the past 6 months were rated as more anxious by their caregivers than nondisclosers. Also, disclosers had lower CD4 percentages and absolute counts and higher viral load levels and were more likely to have been hospitalized recently. The total number of loss-related SLEs predicted viral load levels. Finally, children who experienced at least 1 financially related SLE had lower CD4 counts and were more likely to have been hospitalized than those experiencing no financial SLEs. Overall, children and caregivers reported nonsignificant levels of child depression and anxiety.

CONCLUSIONS

Both the total number and type of SLEs experienced have important implications for psychological and medical functioning in HIV-infected youth.

The role of cognitive functioning in medication adherence of children and adolescents with HIV infection

OBJECTIVE

To evaluate the relationship between cognitive functioning and medication adherence in children and adolescents with perinatally acquired HIV infection.

METHODS

Children and adolescents, ages 3-18 (N = 1,429), received a cognitive evaluation and adherence assessment. Multiple logistic regression models were used to identify associations between adherence and cognitive status, adjusting for potential confounding factors.

RESULTS

Children's average cognitive performance was within the low-average range; 16% of children were cognitively impaired (MDI/FSIQ <70). Cognitive status was not associated with adherence to full medication regimens; however, children with borderline/low average cognitive functioning (IQ 70-84) had increased odds of nonadherence to the protease inhibitor class of antiretroviral therapy. Recent stressful life events and child health characteristics, such as HIV RNA detectability, were significantly associated with nonadherence.

CONCLUSION

Cognitive status plays a limited role in medication adherence. Child and caregiver psychosocial and health characteristics should inform interventions to support adherence.

Psychosocial stress predicts future symptom severities in children and adolescents with Tourette syndrome and/or obsessive-compulsive disorder

BACKGROUND

The goals of this prospective longitudinal study were to monitor levels of psychosocial stress in children and adolescents with Tourette syndrome (TS) and/or obsessive-compulsive disorder (OCD) compared to healthy control subjects and to examine the relationship between measures of psychosocial stress and fluctuations in tic, obsessive-compulsive (OC), and depressive symptom severity.

METHODS

Consecutive ratings of tic, OC and depressive symptom severity were obtained for 45 cases and 41 matched healthy control subjects over a two-year period. Measures of psychosocial stress included youth self-report, parental report, and clinician ratings of long-term contextual threat. Structural equation modeling for unbalanced repeated measures was used to assess the temporal sequence of psychosocial stress with the severity of tic, OC and depressive symptoms.

RESULTS

Subjects with TS and OCD experienced significantly more psychosocial stress than did the controls. Estimates of psychosocial stress were predictive of future depressive symptoms. Current levels of psychosocial stress were also a significant predictor of future OC symptom severity, but not vice versa. Current OC symptom severity was a predictor of future depressive symptom severity, but not vice versa. Current levels of psychosocial stress and depression were independent predictors of future tic severity, even after controlling for the effect of advancing chronological age.

CONCLUSIONS

The impact of antecedent psychosocial adversity is greater on future depressive symptoms than for tic and/or OC symptoms. Worsening OC symptoms are also a predictor of future depressive symptoms. Advancing chronological age is robustly associated with reductions in tic severity.

Neurocognitive outcomes in pediatric HIV

Cognitive impairment has long been associated with the natural history of HIV among vertically infected children. In children, HIV may have a direct or indirect impact on the developing brain, may lead to global or highly specific consequences, and may be responsible for minor cognitive consequences or, conversely, long-term and severe disability. This differential impact is related to multiple factors that influence the individual expression of the virus in any given child. This review provides an overview of the relevant literature on neurocognitive outcomes for infants, children, and youth vertically infected with HIV, with attention to those factors impacting neurocognitive outcome within a developmental framework. Research findings in both the era preceding and following the introduction of combined therapies are reviewed, since many of the issues identified prior to state-of-the-art treatment currently available in the United States and other developed countries still apply in much of the developing world. Intervention issues and directions for future research are also discussed.

Evaluation of a peer support group therapy for HIV-infected adolescents

OBJECTIVE

To assess the effects of a peer support group therapy on HIV-infected adolescents.

DESIGN

A prospective study of a cohort of HIV-infected adolescents participating or not participating in a psychodynamic oriented, emotional support group.

METHODS

From a group of 30 perinatally HIV-infected adolescents who attended an outpatient clinic, 10 agreed to participate in the peer support group (group 1), 10 declined (group 2) and 10 others who lived too far from the clinic were not invited to participate (group 3). The three groups were compared at baseline and 2 years later using the outcome measures: perceived illness experience scale, perceived treatment inventory, self-esteem inventory.

RESULTS

At baseline, the three groups had similar characteristics overall. The adolescents' self-esteem was in the normal range. After 2 years, worries about illness had decreased in group 1, whereas the scores had increased or remained the same for the other adolescents (P = 0.026). The adolescents in group 1 had less negative perception of treatment at 2 years than those in groups 2 and 3 (P = 0.030). After intervention, the percentage of adolescents with an undetectable viral load had increased in group 1 from 30 to 80% (P = 0.063) but was unchanged in groups 2 and 3. Considering the three groups altogether, the decrease in the viral load correlated with improvement of the perceived treatment inventory (Spearman R = 0.482 P = 0.015).

CONCLUSIONS

: This pilot study suggests that a peer support group intervention is associated with an improvement in adolescents' emotional well being, and that this can have a positive influence on medical outcomes.

Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry

The present report meta-analyzes more than 300 empirical articles describing a relationship between psychological stress and parameters of the immune system in human participants. Acute stressors (lasting minutes) were associated with potentially adaptive upregulation of some parameters of natural immunity and downregulation of some functions of specific immunity. Brief naturalistic stressors (such as exams) tended to suppress cellular immunity while preserving humoral immunity. Chronic stressors were associated with suppression of both cellular and humoral measures. Effects of event sequences varied according to the kind of event (trauma vs. loss). Subjective reports of stress generally did not associate with immune change. In some cases, physical vulnerability as a function of age or disease also increased vulnerability to immune change during stressors.

Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry

The present report meta-analyzes more than 300 empirical articles describing a relationship between psychological stress and parameters of the immune system in human participants. Acute stressors (lasting minutes) were associated with potentially adaptive upregulation of some parameters of natural immunity and downregulation of some functions of specific immunity. Brief naturalistic stressors (such as exams) tended to suppress cellular immunity while preserving humoral immunity. Chronic stressors were associated with suppression of both cellular and humoral measures. Effects of event sequences varied according to the kind of event (trauma vs. loss). Subjective reports of stress generally did not associate with immune change. In some cases, physical vulnerability as a function of age or disease also increased vulnerability to immune change during stressors.

Psychiatric hospitalizations among children and youths with human immunodeficiency virus infection

OBJECTIVE

Psychiatric manifestations of pediatric human immunodeficiency virus (HIV) infection have been described. However, data on severe sequelae requiring hospitalization among this population have not been reported.

METHODS

The Pediatric Acquired Immunodeficiency Syndrome (AIDS) Clinical Trials Group (PACTG) 219C is a prospective cohort study designed to examine long-term outcomes among HIV-infected children and HIV-uninfected infants born to HIV-infected women. Children with HIV infection who have enrolled in PACTG 219C are examined quarterly, with collection of clinical and laboratory data. Hospitalizations and diagnoses for all participants between September 2000 (when enrollment into PACTG 219C was started) and December 2002 were reviewed.

RESULTS

Among 1808 HIV-infected participants who were <15 years of age at the last visit date, 25 children had been hospitalized for psychiatric manifestations, 8 before enrollment into PACTG 219C. Seventeen children were hospitalized during 2757 person-years of follow-up monitoring after entry into PACTG 219C, which represents an incidence of 6.17 cases per 1000 person-years (95% confidence interval: 3.59-9.87 cases per 1000 person-years). This was significantly higher than the incidence of 1.70 cases per 1000 person-years (95% confidence interval: 1.67-1.72 cases per 1000 person-years) in the general pediatric population <15 years of age, as reported in the 2000 National Hospital Discharge Survey, yielding a relative rate of 3.62 (95% confidence interval: 2.11-5.80). A total of 32 HIV-infected children, regardless of age, were hospitalized because of psychiatric illnesses. The majority of patients were admitted because of depression (n = 16) or behavioral disorders (n = 8). Fifteen (47%) underwent multiple psychiatric hospitalizations. The median age at the first psychiatric hospitalization was 11 years (range: 4-17 years); all patients had been perinatally infected. Knowledge of HIV seropositivity status and having experienced a significant life event were both significantly associated with an increased risk of psychiatric hospitalization (hazard ratios of 6.13 and 3.04, respectively). No psychiatric hospitalizations were observed among the 1021 HIV-uninfected members of the cohort.

CONCLUSIONS

Children with HIV/AIDS are at increased risk for psychiatric hospitalizations during childhood and early adolescence, compared with the general pediatric population. Knowledge of HIV seropositivity status and recent significant life events were significantly associated with increased risks of admission in this population.

Development of the Yale Children's Global Stress Index (YCGSI) and its application in children and adolescents ith Tourette's syndrome and obsessive-compulsive disorder

OBJECTIVE

The Yale Children's Global Stress Index (YCGSI) is a new clinical rating instrument designed to provide objective global clinician ratings of psychosocial stress in studies of children and adolescents. This study was designed to evaluate the psychometric properties of the YCGSI.

METHOD

Independent ratings of clinical severity and psychosocial stress were obtained at two time points separated by 4 months from 33 subjects with Tourette's syndrome (TS) and/or early-onset obsessive-compulsive disorder (OCD), aged 7 to 17 years, and 25 age-matched control subjects. Parents and children were interviewed separately. Multiple measures of stress were obtained including the YCGSI and the Daily Life Stressors Scale (DLSS).

RESULTS

Data support the interrater reliability and convergent and divergent validity of the YCGSI. At both time points, children and adolescents with TS and OCD had, on average, experienced significantly more psychosocial stress than did the controls. Cross-sectional ratings of tic and obsessive-compulsive symptom severity did not correlate with the YCGSI, but did correlate with self-report ratings of stress on the DLSS. In contrast, ratings on the YCGSI were associated with clinician ratings of depression.

CONCLUSIONS

The YCGSI has acceptable psychometric properties. Children and adolescents with TS and OCD appear to be at increased risk of experiencing higher levels of psychosocial stress and adversities compared with their peers in the community. Future studies need to examine the possible differential contributions of distinctive forms of stress on the intramorbid course of these disorders.

High rates of behavioral problems in perinatally HIV-infected children are not linked to HIV disease

OBJECTIVE

Descriptive studies and clinical reports have suggested that human immunodeficiency virus (HIV)-positive children are at risk for behavioral problems. Inadequate control groups and sample sizes have limited the ability of investigators to consider multiple influences that place HIV-positive children at risk for poor behavioral outcomes. We examined the unique and combined influences of HIV, prenatal drug exposure, and environmental factors on behavior in children who were perinatally exposed to HIV.

METHODS

Participants included 307 children who were born to HIV-positive mothers (96 HIV infected and 211 seroreverters) and enrolled in a natural history, longitudinal study of women to infant HIV transmission. Caregivers completed parent behavioral rating scales, beginning when the children were 3 years old. Data were also collected on prenatal drug exposure; child age, gender, and ethnicity; caregiver relationship to child; and birth complications.

RESULTS

Multivariate analyses comparing the HIV-infected children with perinatally exposed but uninfected children from similar backgrounds failed to find an association between either HIV status or prenatal drug exposure and poor behavioral outcomes. The strongest correlates of increased behavioral symptoms were demographic characteristics.

CONCLUSIONS

This study suggests that although a high prevalence of behavioral problems does exist among HIV-infected children, neither HIV infection nor prenatal drug exposure is the underlying cause. Rather, other biological and environmental factors are likely contributors toward poor behavioral outcomes.