Effects of perinatal HIV infection and early institutional rearing on physical and cognitive development of children in Ukraine

The next 1000 days: building on early investments for the health and development of young children

Following the first 1000 days of life that span from conception to two years of age, the next 1000 days of a child's life from 2-5 years of age offer a window of opportunity to promote nurturing and caring environments, establish healthy behaviours, and build on early gains to sustain or improve trajectories of healthy development. This Series paper, the first of a two-paper Series on early childhood development and the next 1000 days, focuses on the transition to the next 1000 days of the life course, describes why this developmental period matters, identifies the environments of care, risks, and protective factors that shape children's development, estimates the number of children who receive adequate nurturing care, and examines whether current interventions are meeting children's needs. Paper 2 focuses on the cost of inaction and the implications of not investing in the next 1000 days. In low-income and middle-income countries (LMICs), only 62 million children aged 3 and 4 years (25·4%) currently receive adequate nurturing care during the next 1000 days, leaving 181·9 million children exposed to risks that jeopardise their healthy development. Inputs across nurturing care dimensions of health, nutrition, protection, responsive care, and learning vary substantially across countries. In LMICs, although 86·2% of children have a healthy weight in this period, less than one in three children have access to developmental stimulation or are protected from physical punishment, and only 38·8% have access to early childhood care and education services. Intervention research in LMICs in the next 1000 days is scarce. The continuity of developmentally appropriate nurturing care, coordination across health, education, and protection sectors, and the implementation of interventions to support caregivers and improve the quality of education and care remain top priorities in this period. These sectors play key roles in promoting quality early care and education for this age group, which will help maximise developmental potential and opportunities of children globally and help progress towards the achievement of the Sustainable Development Goals.

Prevalence of neurodevelopmental delays in infants with perinatal HIV infection in comparison with HIV exposure in rural South Africa

BACKGROUND

Assessing neurodevelopmental functioning in early infancy is essential as this is a critical period for infant development. Infants born to mothers with HIV are at a greater risk of developmental delays than those born to mothers without HIV. In this study, we analyzed differences in early neurodevelopmental functioning for infants with HIV exposure versus HIV infection to inform infant screening and early intervention.

METHODS

Participants were recruited from community health centers in Mpumalanga Province, South Africa. Prenatally, mothers completed baseline demographic assessment at 8 to 24-week gestation periods. Infant neurodevelopment was assessed using the Bayley Infant Neurodevelopmental Screener (BINS) 12 months postnatally. Five areas of development were assessed: cognition, receptive communication, expressive communication, fine motor ability, and gross motor ability.

FINDINGS

Postnatal infant assessment using the BINS revealed that infants were at risk for neurodevelopmental delays across all domains assessed. Notably, infants exposed to HIV, regardless of HIV status, were 'at emerging risk' or 'at clear risk' for cognitive (43.5%), receptive communication (38.2%), expressive communication (53.1%), fine motor (49.9%), and gross motor delays (55.6%). Differences were noted by HIV status in the cognition domain, such that HIV-exposed infants were more likely to be at emerging or clear risk than HIV-infected infants. There was a different trend with gross motor delays, such that HIV-infected infants were at a greater risk for motor delays than HIV-exposed, uninfected infants.

CONCLUSION

Screening tools for this vulnerable population provide valuable early life assessment to determine infant needs for intervention and treatment planning. Such interventions may mitigate the impact of HIV status on neurodevelopmental health generally and cognition.

Male Partner Involvement and Development of HIV-exposed Infants in Rural South Africa

Male partner involvement (MPI) during the prenatal and postnatal periods has been proven to have a beneficial effect on infant development. Infants born to HIV seropositive mothers with lacking or no prenatal and postnatal male partner support may be at a higher risk for adverse developmental outcomes. This study examined the effect of MPI on cognitive, communicative, fine, and gross motor development in 160 infants born to HIV seropositive mothers attending Prevention of Mother-to-Child Transmission of HIV (PMTCT) services in rural South Africa. Results of the bivariate logistic regression showed that both prenatal (OR 1.13; 95% CI 1.01, 1.26; p < 0.05) and postnatal MPI (at 12 months) (1.19; 1.07, 1.31; p < 0.005) were associated with risk for delayed gross motor development in HIV exposed infants. Decreased postnatal MPI (0.85; 0.75, 0.98; p < 0.05) was significantly associated with risk for delayed cognitive development. Not living together with a male partner (2.01; 1.06, 3.80; p < 0.05) was significantly associated with risk for delayed cognitive development. In the multivariate logistic regression analysis, decreased postnatal MPI (0.85; 0.75, 0.98; p < 0.05) was significantly associated with risk for delayed cognitive development. On the other hand, postnatal MPI (1.30; 1.12, 1.50; p < 0.005) was associated with risk for delayed gross motor development among HIV exposed infants. Increased MPI can have beneficial effects on infants’ cognitive development. Interventions in PMTCT programs should promote increased prenatal and postnatal MPI to improve cognitive development in HIV exposed infants.

Maternal pregnancy diet, postnatal home environment and executive function and behavior in 3- to 4-y-olds

BACKGROUND

Optimal maternal nutrition during pregnancy has been linked to better cognitive and behavioral development in children. However, its influence on the effects of suboptimal postnatal exposures like reduced stimulation and support in the home is not known.

OBJECTIVES

To examine the effect of maternal pregnancy diet on executive function and/or behavioral development in children raised in suboptimal home environments.

METHODS

Data were provided by 808 mother-infant dyads from the Canadian Maternal-Infant Research on Environmental Chemicals-Child Development study. Maternal pregnancy diet was self-reported using the Healthy Eating Index 2010 questionnaire. Stimulation and support in the home was assessed using the Home Observation for Measurement of the Environment (HOME) when children were 3-4 y old. Child executive function was reported by mothers at this age using the Behavior Rating Inventory of Executive Functioning-Preschool Edition, and child behavior was assessed using the Behavior Assessment System for Children-2nd Edition. We examined the interaction of maternal pregnancy diet and postnatal HOME scores on child executive function and behavior using linear regression adjusted for maternal education, postpartum depression, prepregnancy BMI, and smoking.

RESULTS

Maternal pregnancy diet was associated with an increasingly positive association with child working memory (β: 0.21; 95% CI: 0.82, 3.41; P = 0.001), planning (β: 0.17; 95% CI: 0.38, 2.84; P = 0.007), and adaptability (β: -0.13; 95% CI: -1.72, -0.08; P = 0.032) as levels of postnatal stimulation decreased.

CONCLUSIONS

The positive association of maternal pregnancy diet quality and executive function and adaptability in 3- to 4-y-olds appeared to increase with decreasing levels of postnatal stimulation and support. These results suggest that overall maternal pregnancy diet could be linked to better child neurodevelopment in families experiencing barriers to providing stimulation and support to children in their home.

Enhancing diurnal cortisol regulation among young children adopted internationally: A randomized controlled trial of a parenting-based intervention

Children who have been adopted internationally commonly experience institutional care and other forms of adversity prior to adoption that can alter the functioning of the hypothalamic-pituitary-adrenal (HPA) axis. In particular, internationally adopted children tend to have blunted diurnal declines compared to children raised in their birth families. The Attachment and Biobehavioral Catch-Up (ABC) intervention was developed to enhance young children's biological and behavioral regulation by promoting sensitive parenting. The current study used a randomized controlled trial to assess whether ABC improved the diurnal functioning of the HPA axis among 85 children who had been adopted internationally when they were between the ages of 4 and 33 months (M = 16.12). Prior to the intervention, there were no significant differences in diurnal cortisol production between children whose parents were randomly assigned to receive ABC and children whose parents were randomly assigned to receive a control intervention. After the intervention, children whose parents had received the ABC intervention exhibited steeper declines in cortisol levels throughout the day than children whose parents had received the control intervention. These results indicate that the ABC intervention is effective in enhancing a healthy pattern of diurnal HPA axis regulation for young children who have been adopted internationally.

The persistent associations between early institutional care and diurnal cortisol outcomes among children adopted internationally

Young children in institutional care experience conditions that are incompatible with their needs for attachment relationships. As a result, early institutionalization is expected to have lasting effects on the regulation of the hypothalamic-pituitary-adrenocortical (HPA) axis. The current study tested whether early institutionalization has persistent consequences for diurnal HPA axis outcomes among 130 children who had been adopted internationally between the ages of 6 and 48 months. Daily cortisol samples were collected from children at two time points: shortly after adoption (average of 5.3 months after adoption) and approximately 3 years later (average of 39.2 months after adoption). Shortly after adoption, children who had experienced a long duration of institutional care had lower morning cortisol levels and more blunted declines in cortisol across the day than children who experienced minimal or no institutional care. Three years later, children who had experienced a long duration of institutionalization continued to exhibit low morning cortisol levels and also exhibited low bedtime cortisol levels. Altogether, these results support the idea that early adversity results in the downregulation of the HPA axis and suggest that the effects of institutionalization on HPA axis functioning may persist several years after children are adopted into highly enriched families.

Prepared but unprepared: a qualitative study of provider perspectives on the preparation and adjustment of U.S. families who internationally adopt children with HIV

An increasing number of U.S. families are adopting children with HIV born outside the country. This exploratory qualitative study seeks to understand providers' perspectives on international adoptee and family preparation and adjustment to life in the U.S. Eleven psychosocial and five medical care providers participated in hour-long, semi-structured, recorded interviews focused on their experiences caring for internationally adopted children with HIV (IACH) and their adoptive parents. Transcribed interviews were analyzed to identify emergent themes. Providers described considerable variation among families who adopted children. Some had grown biological children and several adopted multiple children with special needs. Most were connected to communities of faith which served as an inspiration to adopt and offered support. Serious medical and HIV-related issues were minimal. Psychosocial concerns were more common and included attachment, adjustment, and behavioral issues. Participants noted that adoptive parents were well informed about HIV, but less prepared for cognitive delays and emotional challenges. Some providers experienced or expected to have challenges offering sexual and reproductive health education to adolescents due to their adoptive parents' religious beliefs on sexuality. Additional support managing behavioral and emotional challenges, as well as sexual education, may be needed especially as IACH transition into adolescence and young adulthood.

Early Deprivation Revisited: Contemporary Studies of the Impact on Young Children of Institutional Care

There is clear evidence that early deprivation in the form of early institutional care affects children both immediately and long after they are removed from the institution. This article reviews the modern literature on the impact of institutional care from animal models to longitudinal studies in humans. Importantly, we examine the current understanding of neuroendocrine regulation in the context of early deprivation. We discuss the opportunities and limitations of studying the effects of deprivation in previously institutionalized children, review behavioral findings and related neurobiological studies, and address the physical health ramifications of institutional care. Finally, we touch on future directions for both science and intervention.

Lower IQ and poorer cognitive profiles in treated perinatally HIV-infected children is irrespective of having a background of international adoption

Background

HIV-associated cognitive deficiency in perinatally HIV-infected (PHIV) children has been studied in Western countries in a population of which an increasing proportion has been internationally adopted. Studies often lack an appropriate internationally adopted HIV-uninfected control group, potentially confounding the relationship between HIV and cognitive functioning. This study aims to further elucidate the association between treated HIV infection and cognitive development by addressing the background of international adoption.

Methods

We cross-sectionally studied the impact of HIV on cognition by comparing PHIV children and HIV- uninfected controls, matched for age-, sex-, ethnicity-, socioeconomic status (SES)- and adoption status. We used a standardized neuropsychological test battery to measure intelligence (IQ), and the cognitive domains of processing speed, working memory, executive function, learning ability and visual-motor function and compared outcomes using lineair regression models, adjusted for IQ. We determined cognitive profiles and cognitive impairment by using multivariate normative comparison (MNC) and explored associations with HIV disease- and treatment-related factors.

Results

We enrolled fourteen PHIV children (mean age 10.45 years [1.73 SD], 93% adopted from sub-Saharan Africa at a median age of 3.3 years [IQR 2.1–4.2]) and fifteen HIV- uninfected controls. Groups did not clinically nor statistically differ in age, sex, ethnicity, SES, region of birth, adoption status and age at adoption. PHIV scored consistently lower on all cognitive domains and MNC outcomes. Compared to controls, PHIV children had a significant lower IQ (mean 81 [SD 11] versus mean 97 [SD 15], p = 0.005), and a poorer cognitive profile by MNC (Hotelling’s T² mean -4.36 [SD 5.6] versus mean 0.16 [SD 4.5], p = 0.021), not associated with HIV disease- and treatment-related factors. Two PHIV (14%) and one control (7%) were classified as cognitively impaired (p = 0.598).

Conclusions

Findings indicate treated HIV-infection to be independently associated with lower IQ and poorer cognitive profiles in PHIV children, irrespective of a background of international adoption.

Attachment disorder and attachment theory - Two sides of one medal or two different coins?

INTRODUCTION

Currently, attachment quality and attachment disorder exist in parallel, but the mutual association is still insufficiently clarified. For policy makers and clinical experts, it can be difficult to differentiate between these constructs, but the distinction is crucial to develop mental-health services and effective treatment concepts. We aimed to investigate the association between attachment representations (AR) and attachment disorders (AD), including Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) in children aged between 5 and 9.

METHODS

A total of 135 children aged between 5 and 9 years (M=7.17 years, SD=1.40, 63% male) and their primary caregivers participated in the study. Children were interviewed with the story stem method to assess AR, and the primary caregiver completed diagnostic interviews and questionnaires on mental disorders, AD, emotional and behavioral problems, and intelligence and development.

RESULTS

The prevalence of AR in children with AD was 28.6% for the 'secure' form of AR, 17.1% for the 'insecure-avoidant' form, 25.7% for the 'insecure-ambivalent' form, and 28.6% for the 'disorganized' form. Prevalences of the various AR forms did not differ statistically significantly, indicating that AR is conceptionally distinct from AD. Children with disorganized attachment scored significantly lower on language and intelligence skills than children with secure attachment. AD was significantly associated with a higher number of comorbidities, emotional and behavioral problems, and lower language skills.

CONCLUSIONS

Longitudinal studies using standardized assessment instruments are needed to systematically provide comparable and reliable empirical findings to improve current understanding of AR and AD as well as their etiological models.

Effects of institutional rearing on children's diurnal cortisol production

Young children living in institutional settings often show a range of deficits in social, physical, and cognitive functioning. Whereas the diurnal production of cortisol has been examined among post-institutionalized children in a number of investigations, studies of children continuing to live in institutions are limited. In this study, we assessed wake-up and bedtime cortisol among 73 children living in Russia, with 52 institutionally-reared (n = 31 at time 2), and 21 family-reared (n = 18 at time 2). Institutionally-reared children showed a blunter wake-up to bedtime slope than family-reared children at both time 1 and time 2, with significantly higher cortisol levels at bedtime. These findings highlight the deleterious effects of institutional care on children's developing neuroendocrine regulation.

How Early Experience Shapes Human Development: The Case of Psychosocial Deprivation

Experience plays an essential role in building brain architecture after birth. The question we address in this paper is what happens to brain and behavior when a young child is deprived of key experiences during critical periods of brain development. We focus in particular on the consequences of institutional rearing, with implication for the tens of millions of children around the world who from an early age experience profound psychosocial deprivation. Evidence is clear that deprivation can lead to a host of both short- and long-term consequences, including perturbations in brain structure and function, changes at cellular and molecular levels, and a plethora of psychological and behavioral impairments.

Working Memory Structure in Atypical Development: HIV-infected and HIV-exposed, Uninfected School Beginners

Not much is known about the structure of working memory in atypical development. We undertook a detailed comparison of the functional organization of working memory in HIV-infected (n = 95; M_age = 7.42 years), and HIV-exposed (n = 86; M_age = 7.36 years) children, together with an uninfected, unexposed typically developing comparison group (n = 92; M_age = 7.05 years). Participants were in their first year of formal education. Within-group comparisons of five models showed that a four-factor model with separate verbal and visuospatial storage and processing accounted for the typically developing group, while working memory was structurally undifferentiated in the HIV-affected groups.

The role of the home environment in neurocognitive development of children living in extreme poverty and with frequent illnesses: a cross-sectional study

Background: The home environment is reported to contribute significantly to children’s developing cognitive skills. However, it is not yet evident whether this role prevails in the context of extreme poverty and frequent ill-health. We therefore investigated the role of the home environment in Ugandan children taking into account the frequent infections and extreme poverty in which they lived.

Methods: Cognitive abilities of 163 5-year-old children were assessed. Home environments of these children, their health status and family socioeconomic status (SES) were assessed respectively using the EC-HOME, anthropometry and illnesses, and traditional SES measures. Structural equation analyses compared five models on the influence of the home environment, SES, and child health on the cognitive scores.

Results: The model in which the home environment mediates the combined influence of SES and child health on cognitive performance showed a particularly good fit to the data compared with the four alternative models, i.e. those in which the HOME, SES and health independently influence cognitive performance.

Conclusions: Home environments providing cognitive stimulation can enable children to overcome effects of major adverse life experiences on cognitive development.

Pre- and postnatal exposure to intimate partner violence among South African HIV-infected mothers and infant developmental functioning at 12 months of age

In rural South Africa, pregnant HIV-infected women report high rates of psychological (55%) and physical (20%) intimate partner violence (IPV). IPV increases the risk of infant developmental delays. Such delays may have negative socioemotional and cognitive outcomes throughout the lifespan. This paper assesses the relationship between IPV and infant development in rural South Africa. The present investigation was a cross-sectional add-on follow-up designed retrospectively. A randomly selected sub-sample of mothers from the main randomized controlled trial (n = 72) were asked to participate with their infants at 12 months of age; all women invited agreed to participate. Women were 18.35 ± 5.47 weeks pregnant; demographics, HIV disclosure status, and pre- and postnatal IPV measured via the Conflict Tactics Scale during pregnancy at baseline and 12 months post-partum were assessed. Infant HIV serostatus and developmental functioning at 12 months of age were assessed. Women were a mean age of 29 ± 2 years. One third had completed at least 12 years of education and had a monthly income of ~ US$76. At 12 months post-partum, 6% of infants tested HIV seropositive. Postnatal physical IPV was associated with delays in cognitive and receptive language development p < 0.05, but only in unadjusted analyses. This study identified an association between early IPV exposure and infant cognitive and receptive communication delays. Given the small sample size, findings support replication. Longitudinal studies are needed to confirm temporal order and identify appropriate timing for interventions in HIV-exposed infants.

Infant Development and Pre- and Post-partum Depression in Rural South African HIV-Infected Women

HIV-exposed infants born to depressed women may be at risk for adverse developmental outcomes. Half of HIV-infected women in rural South Africa (SA) may suffer from pregnancy-related depression. This pilot study examined the impact of depression in HIV-infected women in rural SA on infant development. Mother-infant dyads (N = 69) were recruited in rural SA. Demographics, HIV disclosure, depression, male involvement, and alcohol use at baseline (18.35 ± 5.47 weeks gestation) were assessed. Male involvement, depression, infant HIV serostatus and development were assessed 12 months postnatally. Half of the women (age = 29 ± 5) reported depression prenatally and one-third reported depression postnatally. In multivariable logistic regression, not cohabiting with their male partner, nondisclosure of HIV status, and postnatal depression predicted cognitive delay; decreased prenatal male involvement predicted delayed gross motor development (ps < 0.05). Assessing pregnancy-related depression among HIV-infected women and infant development and increasing male involvement may reduce negative developmental outcomes among HIV-exposed or infected infants.

Impact of care at foster homes on the health-related quality of life of HIV-infected children and adolescents: a cross-sectional study from India

PURPOSE

To assess the impact of care at foster homes on the health-related quality of life (HRQOL) of children living with HIV (CLHIV), attending a referral ART Centre, and to compare their HRQOL with children living in their own homes.

METHODS

A cross-sectional study was conducted in 144 CLHIV between 5 and 18 years of age, attending a referral ART Centre in South India to assess their HRQOL using the standard PedsQL™ 4.0 questionnaire. Data were then analysed to compare the HRQOL of children living in foster homes to those children living in their own homes. The child report and the parent proxy-report on the child's HRQOL were also compared to see for any differences in their perspectives.

RESULTS

56.25% CLHIV were brought up in different foster homes. In the child's self-report, the mean HRQOL was higher for children living in foster homes [physical score (76.54 ± 12.40), psychosocial score (71.41 ± 12.40) and total score (73.20 ± 11.13)] when compared to children living in their own homes [physical score (75.09 ± 14.76), psychosocial score (70.60 ± 13.48) and total score (72.17 ± 12.00)]. There was no statistically significant difference in the HRQOL between these two groups (p > 0.05). In the parent proxy-report also, there was no statistically significant difference in the HRQOL in all the three scores. The child self-report depicted a significantly higher HRQOL in all the domains compared to the parent proxy-report (p < 0.05).

CONCLUSIONS

HRQOL of children living in foster homes is at par with the quality of life enjoyed by children living in their own homes. Foster care manages to provide a reasonable HRQOL in CLHIV, and has become an inseparable component of quality health care delivery for these children.

Working Memory Profiles in HIV-Exposed, Uninfected and HIV-Infected Children: A Comparison with Neurotypical Controls

This study compared the working memory profiles of three groups of children, namely HIV-infected (HIV-I; n = 95), HIV-exposed, uninfected (HIV-EU; n = 86) and an HIV-unexposed, uninfected, (HIV-UU; n = 92) neurotypical control group. Working memory, an executive function, plays an important role in frontal lobe-controlled behaviors, such as motivation, planning, decision making, and social interaction, and is a strong predictor of academic success in school children. Memory impairments have been identified in HIV-I children, particularly in visuospatial processing. Verbal working memory has not been commonly investigated in this population, while it is unknown how the working memory profiles of HIV-EU children compare to their HIV-I and HIV-UU peers. Of interest was whether the working memory profiles of the HIV-EU children would be more similar to the HIV-I group or to the uninfected control group. The results revealed no significant differences in working memory performance between the HIV-I and HIV-EU groups. However, this does not mean that the etiology of the working memory deficits is the same in the two groups, as these groups showed important differences when compared to the control group. In comparison to the controls, the HIV-I group experienced difficulties with processing tasks irrespective of whether they drew on a verbal or visuospatial modality. This appears to stem from a generalized executive function deficit that also interferes with working memory. In the HIV-EU group, difficulties occurred with verbally based tasks, irrespective of whether they required storage or processing. For this group, the dual demands of complex processing and using a second language seem to result in demand exceeding capacity on verbal tasks. Both groups experienced the greatest difficulties with verbal processing tasks for these different reasons. Thus, disruption of different cognitive abilities could result in similar working memory profiles, as evidenced in this study. This has implications for the underlying developmental neurobiology of HIV-I and HIV-EU children, as well the choice of appropriate measures to assist affected children.

Auditory Alterations in Children Infected by Human Immunodeficiency Virus Verified Through Auditory Processing Test

Introduction The auditory system of HIV-positive children may have deficits at various levels, such as the high incidence of problems in the middle ear that can cause hearing loss. Objective The objective of this study is to characterize the development of children infected by the Human Immunodeficiency Virus (HIV) in the Simplified Auditory Processing Test (SAPT) and the Staggered Spondaic Word Test. Methods We performed behavioral tests composed of the Simplified Auditory Processing Test and the Portuguese version of the Staggered Spondaic Word Test (SSW). The participants were 15 children infected by HIV, all using antiretroviral medication. Results The children had abnormal auditory processing verified by Simplified Auditory Processing Test and the Portuguese version of SSW. In the Simplified Auditory Processing Test, 60% of the children presented hearing impairment. In the SAPT, the memory test for verbal sounds showed more errors (53.33%); whereas in SSW, 86.67% of the children showed deficiencies indicating deficit in figure-ground, attention, and memory auditory skills. Furthermore, there are more errors in conditions of background noise in both age groups, where most errors were in the left ear in the Group of 8-year-olds, with similar results for the group aged 9 years. Conclusion The high incidence of hearing loss in children with HIV and comorbidity with several biological and environmental factors indicate the need for: 1) familiar and professional awareness of the impact on auditory alteration on the developing and learning of the children with HIV, and 2) access to educational plans and follow-up with multidisciplinary teams as early as possible to minimize the damage caused by auditory deficits.

Culturally sensitive adaptation of the concept of relational communication therapy as a support to language development: An exploratory study in collaboration with a Tanzanian orphanage

BACKGROUND

Orphans and other vulnerable children (OVC) who grow up in institutional care often show communication and language problems. The caregivers lack training, and there are few language didactics programmes aimed at supporting communication and language development in OVC in institutional care in Tanzania.

OBJECTIVES

The purpose of the study was to adapt the German concept of relational communication therapy (RCT) as a support to language development in a Tanzanian early childhood education context in a culturally sensitive way. Following the adaptation of the concept, a training programme for Tanzanian caregiver students was developed to compare their competencies in language didactics before and after training.

METHODS

A convergent mixed methods design was used to examine changes following training in 12 participating caregiver students in a Tanzanian orphanage. The competencies in relational language didactics were assessed by a self-developed test and video recordings before and after intervention. Based on the results, we drew conclusions regarding necessary modifications to the training modules and to the concept of RCT.

RESULTS

The relational didactics competencies of the caregiver students improved significantly following their training. A detailed analysis of the four training modules showed that the improvement in relational didactics competencies varied depending on the topic and the teacher.

CONCLUSION

The results provide essential hints for the professionalisation of caregivers and for using the concept of RCT for OVC in institutional care in Tanzania. Training programmes and concepts should not just be transferred across different cultures, disciplines and settings; they must be adapted to the specific cultural setting.

"When am I going to stop taking the drug?" Enablers, barriers and processes of disclosure of HIV status by caregivers to adolescents in a rural district in Zambia

Background

Disclosure of adolescents’ own HIV status by caregivers is not only challenging but low. The reasons for this remain unclear despite efforts to examine and seek to understand disclosure patterns or factors that may either facilitate or inhibit this disclosure. This study explored the enablers, barriers and processes of disclosure of HIV status to adolescents by their caregivers in Kafue district of Zambia.

Methods

A case study method was used to understand factors that facilitate or inhibit caregiver’s ability to disclose the HIV status of adolescents aged 10–15 years. Data collected through in-depth interviews with 30 caregivers as well as 6 key informants were analysed using thematic analysis.

Results

Overall, 17 out of 30 (56.7 %) caregivers had informed the adolescents about their HIV status. Reasons for disclosing of the HIV status included inquiries by adolescents as to why they were taking medication, threats by adolescents not to take HIV medication, desire to promote treatment self-efficacy amongst adolescents as well as facilitating adoption of safe sexual behaviour among adolescents. The disclosure processes were conducted either at the home or at the clinic. Enabling factors for HIV disclosure were adolescents’ knowledge of HIV and caregivers’ knowledge of and experience with HIV programs. Barriers to disclosure of HIV status included fear of psychological trauma for the adolescents, perceived inability of adolescents to keep their HIV status confidential which could attract HIV stigmatisation for the family, and caregivers’, fear of being blamed by the adolescents for the infection, limited disclosure skills by caregivers as well as negative attitude by some HIV counsellors.

Conclusions

Despite challenges associated with disclosure of adolescents’ own HIV status by caregivers, environments that facilitate this process exist and can be strengthened. Promoting HIV disclosure requires in-depth and context-specific understanding of the factors that enable and undermine this process. Limitations in this understanding may have played critical roles in past strategic implementation of locally driven and relevant interventions to improve disclosure of HIV status by caregivers to adolescents in Zambia.

Research on Institutionalized Children: Implications for International Child Welfare Practitioners and Policymakers

This paper reviews the empirical literature on the effects of institutionalization on young children’s development from the perspective of global child welfare practice and policy. It considers the characteristics of typical institutions, how to assess the quality of care in institutions, the level of physical and behavioral/mental development of infants and young children while residing in institutions, the crucial role of caregiver–child interactions in children’s development, the potential of children to developmentally improve when institutional caregiver–child interactions improve or children are transferred to families, and the influence of the quality of care on children’s development regardless of context. Several controversies are considered in a balanced fashion and from the standpoint of the nature of the evidence, such as care as typically practiced versus more ideal care, intercountry adoptions, improving institutions, and volunteers in institutions. Implications for practice and policy are identified throughout, especially factors that characterize successful large-scale attempts to transition from institutionalization to a system of family alternatives.

Predicting long-term outcomes for children affected by HIV and AIDS: perspectives from the scientific study of children's development

The immediate and short-term consequences of adult HIV for affected children are well documented. Little research has examined the long-term implications of childhood adversity stemming from caregiver HIV infection. Through overviews provided by experts in the field, together with an iterative process of consultation and refinement, we have extracted insights from the broader field of child development of relevance to predicting the long-term consequences to children affected by HIV and AIDS. We focus on what is known about the impact of adversities similar to those experienced by HIV-affected children, and for which there is longitudinal evidence. Cautioning that findings are not directly transferable across children or contexts, we examine findings from the study of parental death, divorce, poor parental mental health, institutionalization, undernutrition, and exposure to violence. Regardless of the type of adversity, the majority of children manifest resilience and do not experience any long-term negative consequences. However, a significant minority do and these children experience not one, but multiple problems, which frequently endure over time in the absence of support and opportunities for recovery. As a result, they are highly likely to suffer numerous and enduring impacts. These insights suggest a new strategic approach to interventions for children affected by HIV and AIDS, one that effectively combines a universal lattice of protection with intensive intervention targeted to selected children and families.

Adoption policy and evidence-based domestic adoption practice: a comparison of Romania, Ukraine, India, Guatemala, and Ethiopia

The United Nations Convention on the Rights of the Child (1989), The Hague Convention on the Protection of Children and Co-operation in Respect of Intercountry Adoption (The Hague Permanent Bureau, 1993), and the Guidelines for the Alternative Care of Children (2009) have provided a comprehensive, rights-based framework and guidance for developing domestic adoption and alternative, family based care programs. Domestic adoption is a critical component of any child-protection system and a core part of the range of alternative care options that the United Nations and other international organizations recommend be developed, resourced, and made accessible to children without parental care. This article uses data collected from adoptive parents' postadoption and governmental data in Romania, Ukraine, India, Guatemala, and Ethiopia to focus on domestic adoption in each of these countries. The article highlights both promising practices in domestic adoption as well as policies and practices that require additional research.

Beyond allostatic load: Rethinking the role of stress in regulating human development

How do exposures to stress affect biobehavioral development and, through it, psychiatric and biomedical disorder? In the health sciences, the allostatic load model provides a widely accepted answer to this question: stress responses, while essential for survival, have negative long-term effects that promote illness. Thus, the benefits of mounting repeated biological responses to threat are traded off against costs to mental and physical health. The adaptive calibration model, an evolutionary–developmental theory of stress–health relations, extends this logic by conceptualizing these trade-offs as decision nodes in allocation of resources. Each decision node influences the next in a chain of resource allocations that become instantiated in the regulatory parameters of stress response systems. Over development, these parameters filter and embed information about key dimensions of environmental stress and support, mediating the organism's openness to environmental inputs, and function to regulate life history strategies to match those dimensions. Drawing on the adaptive calibration model, we propose that consideration of biological fitness trade-offs, as delineated by life history theory, is needed to more fully explain the complex relations between developmental exposures to stress, stress responsivity, behavioral strategies, and health. We conclude that the adaptive calibration model and allostatic load model are only partially complementary and, in some cases, support different approaches to intervention. In the long run, the field may be better served by a model informed by life history theory that addresses the adaptive role of stress response systems in regulating alternative developmental pathways.

The consequences of early institutionalization: can institutions be improved? - should they?

BACKGROUND AND SCOPE

The focus of this review is on institutionalized children, one of the most inequitably and severely treated groups of children. Although institutions vary, many share some common characteristics, including large groups, high children: caregiver ratios, many and changing caregivers, and caregiver-child interactions that lack warm, sensitive, contingently-responsive, and child-directed behaviors. Resident children develop poorly physically, mentally, and social-emotionally, but those adopted from institutions display substantial catch-up growth in many domains of development. If they are adopted at an early age, there have been no long-term consequences of institutionalization yet measured; but if institutionalization is prolonged, they display higher rates of long-term deficiencies and problems in many domains.

METHODS

This review is based on a database search of the literature, focusing on the development of children while residents, and the development of post-institutionalized children who have been transitioned from institutions to family care. It also draws on the reports and findings of the St. Petersburg-USA Orphanage Intervention.

FINDINGS

A combination of theories pertaining to attachment (especially caregiver attachment to the infant/toddler), chronic stress, and genetics may explain these outcomes. It appears that caregiver-child interactions are a major contributor to children's outcomes, and interventions in institutions that improve such interactions produce substantial increases in children's physical, mental, and social-emotional development, including for children with disabilities.

CONCLUSIONS

Deinstitutionalization and the creation of comprehensive professional child welfare systems emphasizing family care alternatives is a preferred goal, but this is likely to take many low-resource countries decades to develop. If substantial numbers of children remain in institutions despite best efforts to find families for them, improving the institutions might help to provide all the children with the best care possible under the circumstances.

Structure, Caregiver–Child Interactions, and Children’s General Physical and Behavioral Development in Three Central American Institutions

This article describes structural characteristics and caregiver–child interactions ( N = 34) in three Central American institutions for infants and young children ( N = 79) and relates differences in these characteristics to differences in children’s physical, behavioral, and cognitive development. Generally, the institution with the smallest group size, fewest children per caregiver, and a few consistent caregivers had children with the best physical, behavioral, and cognitive development; this institution also had many temporary volunteers who played with the children. Differences in the quality of caregiver–child interactions were not directly related to children’s development, but the potential benefit of high-quality interactions may have been minimized by a high children:caregiver ratio in one institution, and the presence of volunteers to play with children may have compensated for and/or minimized the display of higher-quality interactions by staff caregivers in another institution.

Triagem auditiva neonatal em recém-nascidos de mães soropositivas para o HIV

OBJETIVO: Analisar as emissões otoacústicas de crianças nascidas de mães soropositivas para o HIV na triagem auditiva neonatal. MÉTODOS: Realizou-se a pesquisa das Emissões Otoacústicas Evocadas por Transiente (EOAT) e do reflexo cócleo-palpebral (RCP) em 247 neonatos, todos nascidos a termo e sem fatores de risco para a audição. O Grupo Controle (GC) foi composto por 167 neonatos e o Grupo Pesquisa (GP) por 80 neonatos expostos ao HIV durante a gestação. Considerou-se "falha" quando o neonato apresentava ausência de EOAT em pelo menos uma das orelhas. Os dados foram analisados estatisticamente. RESULTADOS: No Grupo Pesquisa, oito (10%) neonatos falharam na triagem auditiva neonatal e no Grupo Controle este número foi de sete (4,2%) (p=0,09). No reteste dos neonatos que falharam, houve a persistência da ausência das emissões otoacústicas em um neonato do Grupo Pesquisa (12,5%) e em dois neonatos (28,6%) do Grupo Controle (p=0,6). Em todos os neonatos houve a presença do RCP. CONCLUSÃO: Não houve associação entre ausência de EOA por transiente e a exposição do neonato ao HIV durante a gestação.

Research, Practice, and Policy Perspectives on Issues of Children without Permanent Parental Care

This chapter presents conclusions, trends, conceptual analyses, hypotheses, and speculations regarding some fundamental issues of research, practice, and policy that are largely unsettled or controversial. As such, the chapter is not a summary of Chapters 1-8, but rather contains interpretations and opinions of the author intended to elevate the priority of certain issues, suggest hypotheses to be studied, and propose practice and policy steps to be considered.

Research, Practice, and Policy Perspectives on Issues of Children without Permanent Parental Care

This chapter presents conclusions, trends, conceptual analyses, hypotheses, and speculations regarding some fundamental issues of research, practice, and policy that are largely unsettled or controversial. As such, the chapter is not a summary of Chapters 1-8, but rather contains interpretations and opinions of the author intended to elevate the priority of certain issues, suggest hypotheses to be studied, and propose practice and policy steps to be considered.

Vigilância do desenvolvimento neuropsicomotor de crianças de um programa DST/AIDS

A terapia anti-retroviral de alta potência (TARV) é uma forma eficaz de prevenção da transmissão do vírus HIV de mãe para filho. No entanto, os estudos ainda investigam os efeitos da exposição intraútero à TARV, dentre eles o atraso no desenvolvimento neuropsicomotor (DNPM). O presente estudo apresenta o relato de um projeto de extensão, cujos objetivos foram verificar o DNPM de crianças de um programa DST/AIDS, orientar as famílias considerando seu contexto socioeconômico e realizar encaminhamentos para serviços de saúde específicos. A vigilância do DNPM foi feita em três etapas: (1) avaliação em ambulatório; (2) avaliação e orientações em domicílio; (3) elaboração de relatórios aos gestores de saúde. Foram utilizados os testes DENVER II e o PEDI, além de um questionário socioeconômico. Participam do programa DST/AIDS 15 crianças, sendo 12 soro-revertidas, 1 soropositiva e 2 indefinidas. Doze crianças foram avaliadas, e os domínios mais comprometidos foram linguagem, pessoal-social e motor fino, respectivamente. Quanto ao nível econômico, 73,3% pertenciam ao nível E, e 58,3% das mães eram analfabetas ou cursaram apenas o primário. Crianças filhas de mães HIV positivo, além de fatores biológicos, geralmente estão expostas a fatores de risco ambientais que contribuem para alterações do DNPM. Desta forma, o acompanhamento por uma equipe de profissionais de saúde, em parceria com a família da criança, torna-se uma importante ferramenta para a identificação e intervenção precoce.

Implementing Changes in Institutions to Improve Young Children's Development

An estimated 8 million children, mostly birth to approximately 6-8 years of age, live in institutions worldwide. While institutional environments vary, certain characteristics are common, including relatively large groups; high children:caregiver ratios; many and frequently changing caregivers; homogeneous grouping by age and disability status; periodic graduations to new groups of peers and caregivers; and an "institutional style of caregiving" that minimizes talking, provides rather dispassionate perfunctory care, and offers little warm, sensitive, contingently-responsive caregiver-child interactions. The development of children in residence is usually delayed, sometimes extremely so, in every physical and behavioral domain. Although efforts are being made in many countries to care for children without permanent parents in family environments (e.g., domestic adoption, foster and kinship care, reunification with biological parents), it is not likely that transitions to family alternatives will be completed in all countries in the near future; thus, institutions are likely to exist for many years if not decades. But institutions need not operate in the current manner; they can be modified to be substantially more family-like in structure and in the behavior of caregivers. Research indicates that when such changes are made the development of children, both typically developing and those with special needs, is improved substantially. Based on the available literature and the authors' experience, this paper describes steps that can be taken to implement such changes in residential institutions for infants and young children.

Impact of institutional care on attachment disorganization and insecurity of Ukrainian preschoolers

Institutional care has been shown to lead to insecure and disorganized attachments and indiscriminate friendliness. Some children, however, are surprisingly resilient to the adverse environment. Here the protective role of the long variant of the serotonin receptor gene (5HTT) is explored in a small hypothesis-generating study of 37 Ukrainian preschoolers reared in institutional settings or in their biological families. Attachment was observed with the Strange Situation Procedure, and indiscriminate social behavior was assessed in a semistructured interview with the caregiver. We found a moderating role of 5HTT for the association between adverse environment and attachment disorganization. Children with the ss or sl genotyope showed more attachment disorganization and less attachment security when they grew up in an institution compared to children who lived in a family, but children who were homozygous for the l allele appeared to be protected against the adverse institutional environment on attachment. We conclude that not all children may be equally vulnerable to extremely adverse rearing experiences.

Differential susceptibility to the environment: an evolutionary--neurodevelopmental theory

Two extant evolutionary models, biological sensitivity to context theory (BSCT) and differential susceptibility theory (DST), converge on the hypothesis that some individuals are more susceptible than others to both negative (risk-promoting) and positive (development-enhancing) environmental conditions. These models contrast with the currently dominant perspective on personal vulnerability and environmental risk: diathesis stress/dual risk. We review challenges to this perspective based on emerging theory and data from the evolutionary, developmental, and health sciences. These challenges signify the need for a paradigm shift in conceptualizing Person x Environment interactions in development. In this context we advance an evolutionary--neurodevelopmental theory, based on DST and BSCT, of the role of neurobiological susceptibility to the environment in regulating environmental effects on adaptation, development, and health. We then outline current thinking about neurogenomic and endophenotypic mechanisms that may underpin neurobiological susceptibility, summarize extant empirical research on differential susceptibility, and evaluate the evolutionary bases and implications of BSCT and DST. Finally, we discuss applied issues including methodological and statistical considerations in conducting differential susceptibility research; issues of ecological, cultural, and racial--ethnic variation in neurobiological susceptibility; and implications of differential susceptibility for designing social programs. We conclude that the differential susceptibility paradigm has far-reaching implications for understanding whether and how much child and adult development responds, for better and for worse, to the gamut of species-typical environmental conditions.

Characteristics of environments, caregivers, and children in three Central American orphanages

This study provides descriptive empirical information on the environments, organizational structure, caregivers, caregiver-child interactions, and children's general behavioral development and problem behaviors from three institutions for young children in Central America. While the institutions were clean, they were physically sparse and had Infant-Toddler Environmental Rating Scale (ITERS; T. Harms, D. Cryer, & R. Clifford, 2006) and Early Childhood Environmental Rating Scale (ECERS; T. Harms, R. Clifford, & D. Cryer, 2005) scores that averaged 1.62 (7 = highest). Caregivers provided routine caregiving with limited emotion, responsiveness, support, empathy, or guidance. Caregivers tended to work long hours and then were off 2 to 3 days, and children periodically graduated to new wards, so there was little stability of caregivers in children's lives. Children's average Battelle Developmental Inventory Total Developmental Quotient = 58 to 63, which would be considered mildly-moderately retarded in noninstitutional U.S. populations; no child scored >90, 80% scored <70, and nearly half scored <60. Children displayed high frequencies of indiscriminate friendliness, noncompliance, and provocative and aggressive/violent behaviors. These data and that of a few other studies represent the only comprehensive, empirical description of institutions for young children, which constitutes the independent variable (institutionalization) for a burgeoning literature on postinstitutional adopted children. Results are consistent with the hypothesis that a lack of warm, sensitive, contingently responsive interactions with relatively few consistently available caregivers may be a major contributor to delayed contemporary development and persistent deficits and problems observed in some postinstitutional adopted children and adolescents.

The motor development of orphaned children with and without HIV: Pilot exploration of foster care and residential placement

Background

The AIDS epidemic has lead to an increase in orphaned children who need residential care. It is known that HIV leads to delayed motor development. However, the impact of place of residence on motor function has not been investigated in the South African context. The aim of the study was therefore to establish if children in institutionalised settings performed better or worse in terms of gross motor function than their counterparts in foster care. A secondary objective was to compare the performance of children with HIV in these two settings with those of children who were HIV negative.

Methods

Forty-four children both with and without HIV, were recruited from institutions and foster care families in Cape Town. The Peabody Development Motor Scale (PDMS II) was used to calculate the total motor quotient (TMQ) at baseline and six months later. Comparisons of TMQ were made between residential settings and between children with and without HIV.

Results

Twenty-one children were infected with HIV and were significantly delayed compared to their healthy counterparts. Antiretroviral therapy was well managed among the group but did not appear to result in restoration of TMQ to normal over the study period. HIV status and place of residence emerged as a predictor of TMQ with children in residential care performing better than their counterparts in foster care. All children showed improvement over the six months of study.

Conclusions

Foster parents were well supported administratively in the community by social welfare services but their children might have lacked stimulation in comparison to those in institutional settings. This could have been due to a lack of resources and knowledge regarding child development. The assumption that foster homes provide a better alternative to institutions may not be correct in a resource poor community and needs to be examined further.

The importance of quality of care: effects of perinatal HIV infection and early institutional rearing on preschoolers' attachment and indiscriminate friendliness

BACKGROUND

The rearing environment of human immunodeficiency virus (HIV)-infected children is often compromised, putting these children at additional risks. Positive caregiving may ameliorate the impact of adverse circumstances and promote attachment security. The goal of the present study was to examine the attachment relationships of HIV-infected children in biological families and institutions; to examine the effects of HIV infection and institutional rearing on attachment security and indiscriminate friendliness; and to assess the role of caregiving in the face of HIV-related adversities.

METHODS

We studied 64 Ukrainian uninfected and HIV-infected children reared in families and institutions (mean age 50.9 months). Physical and cognitive development of children as well as attachment-related domains and indiscriminate friendliness were assessed.

RESULTS

Institutional care but not the presence of HIV was associated with lower levels of attachment security and higher levels of indiscriminate friendliness. On average, the level of indiscriminate friendliness among institution-reared children was more than twice as high as among family-reared children. Only 24% of institution-reared children had clearly developed attachment patterns, as opposed to 97% among family-reared children. Controlling for physical and cognitive development, type of care (institution or family), and HIV status, positive caregiving was associated with higher levels of attachment security. Indiscriminate friendliness was associated with lower levels of attachment security among family-reared children, but with higher levels of positive caregiving among institution-reared children.

CONCLUSIONS

Etiology and function of indiscriminate friendliness may differ for family-reared versus institution-reared children. The findings of this study suggest the necessity of early interventions improving the quality of care for HIV-infected children.