Persisting mental health problems among AIDS-orphaned children in South Africa

Parental Bereavement in Young Children Living in South Africa and Malawi: Understanding Mental Health Resilience

BACKGROUND

Parental loss is a major stressful event found to increase risk of mental health problems in childhood. Yet, some children show resilient adaptation in the face of adversity across time.

SETTING

This study explores predictors of mental health resilience among parentally bereaved children in South Africa and Malawi and their cumulative effect. The study also explores whether predictors of resilience differed between orphaned and nonorphaned children.

METHODS

Consecutive attenders of community-based organizations (children; 4-13 years, and their caregivers) were interviewed at baseline and 15- to 18-month follow-up (n = 833). Interviews comprising inventories on demographic information, family data, child mental health, bereavement experience, and community characteristics. Mental health screens were used to operationalize resilience as the absence of symptoms of depression, suicidality, trauma, emotional, and behavioral problems.

RESULTS

Almost 60% of children experienced parental loss. One-quarter of orphaned children showed no mental health problems at either wave and were classified as resilient. There were equal proportions of children classified as resilient within the orphaned (25%) versus nonorphaned group (22%). Being a quick learner, aiding ill family members, positive caregiving, household employment, higher community support, and lower exposure to domestic violence, physical punishment, or stigma at baseline predicted sustained resilience. There were cumulative influences of resilience predictors among orphaned children. Predictors of resilience did not vary by child age, sex, country of residence or between orphaned and nonorphaned children.

CONCLUSIONS

This study enhances understanding of resilience in younger children and identifies a number of potential environmental and psychosocial factors for bolstering resilience in orphaned children.

Measuring Symptoms of Psychopathology in Zambian Orphans and Vulnerable Children: Scale Validation and Psychometric Evaluation

There is a paucity of validated mental health measures for assessing psychological well-being among HIV-affected youth. We sought to explore the psychometric properties and validity of the Achenbach Youth Self-Report and Child Posttraumatic Stress Disorder Symptom Scale among orphans and vulnerable children (OVC) living in Lusaka, Zambia. These scales were administered to 210 OVC aged 13 to 17 years via audio computer-assisted self-interview. Confirmatory factor analysis was used to assess scale structure, Cronbach's alpha for internal consistency, and correlations between scales related to mental or psychosocial health for construct validity. A known-groups validation was conducted using local identifications of youth with and without significant psychosocial problems, and test-retest reliability was assessed. Scales exhibited good internal reliability (α > .80), adequate criterion validity (area under the curve > .70), and moderate test-retest reliability (.62-.68). Findings support the utility of these symptom scales for identifying OVC experiencing significant psychosocial problems in Zambia.

Building Resilience Among Orphaned and Vulnerable Children Through the Memory Book Intervention

Children who are orphaned and vulnerable due to poverty, war, or disease (HIV/AIDS) may experience childhood traumatic grief. A qualitative phenomenological approach was implemented to explore and compare the lived experiences of orphaned children, adolescents, and caregivers who had used the Memory Book intervention at six children's homes in India, Kenya, and South Africa. Study findings revealed similar themes between the countries, with primary themes of identity and relationships, and secondary themes of coping, hope, and emotion. Findings suggest the value of Memory Book resources to encourage the preservation of a child's story and grief recovery that can be used for any child facing recovery from difficult life events.

Can family-centered programing mitigate HIV risk factors among orphaned and vulnerable adolescents? Results from a pilot study in South Africa

Let's Talk is a structured, family-centered adolescent HIV prevention program developed for use in South Africa using key components adapted from programs successfully implemented in the US and South Africa. It is designed to address individual HIV transmission risk factors common among orphaned and vulnerable adolescents, including elevated risk for poor psychological health and sexual risk behavior. These efforts are accentuated through parallel programing to support caregivers' mental health and parenting skills. Twelve Let's Talk groups, each serving approximately 10 families, were piloted by two local community-based organizations in Gauteng and Kwa-Zulu Natal provinces, South Africa. Face-to-face interviews were conducted among participating caregivers and adolescents at baseline and three months post-intervention to explore the potential effects of the program on intermediate outcomes that may support HIV preventive behavior. Specifically, generalized estimation equations were used to estimate average change on HIV prevention knowledge and self-efficacy, caregiver and adolescent mental health, and family dynamics. Among the 105 adolescents and their 95 caregivers who participated in Let's Talk and completed both surveys, statistically significant improvements were found for adolescents' HIV and condom use knowledge as well as condom negotiation self-efficacy, but not sexual refusal self-efficacy. Both caregivers and adolescents demonstrated significantly better mental health at post-test. Adolescent/caregiver connection and communication about healthy sexuality also improved. These preliminary results highlight the potential of HIV prevention interventions that engage caregivers alongside the vulnerable adolescents in their care to mitigate adolescent HIV risk factors. A more rigorous evaluation is warranted to substantiate these effects and identify their impact on adolescents' risk behavior and HIV incidence.

Sexual and reproductive health behavior and unmet needs among a sample of adolescents living with HIV in Zambia: a cross-sectional study

BACKGROUND

Adolescents living with HIV face challenges, such as disclosure of HIV status, adherence to antiretroviral therapy, mental health, and sexual and reproductive health (SRH). These challenges affect their future quality of life. However, little evidence is available on their sexual behaviors and SRH needs in Zambia. This study aimed at assessing their sexual behaviors and SRH needs and identifying factors associated with marriage concerns and a desire to have children.

METHODS

This cross-sectional study was conducted at the University Teaching Hospital from April to July 2014. We recruited 200 adolescents aged 15-19 years who were aware of their HIV-positive status. We collected data on their first and recent sexual behavior, concerns about marriage, and desire to have children. We used the Generalized Linear Model to identify factors associated with having concerns about marriage and desire to have children. We performed thematic analysis with open-ended data to determine their perceptions about marriage and having children in the future.

RESULTS

Out of 175 studied adolescents, 20.6% had experienced sexual intercourse, and only 44.4% used condoms during the first intercourse. Forty-eight percent had concerns about marriage, and 87.4% desired to have children. Marriage-related concerns were high among those who desired to have children (adjusted relative risk [ARR] = 2.51, 95% CI = 1.02 to 6.14). Adolescents who had completed secondary school were more likely to desire to have children (ARR = 1.35, 95% CI = 1.07 to 1.71). Adolescents who had lost both parents were less likely to want children (ARR = 0.80, 95% CI = 0.68 to 0.95). Thematic analysis identified that major concerns about future marriage were fear of disclosing HIV status to partners and risk of infecting partners and/or children. The reasons for their willingness to have children were the desire to be a parent, having children as family assets, a human right, and a source of love and happiness.

CONCLUSIONS

Zambian adolescents living with HIV are at risk of engaging in risky sexual relationships and have difficulties in meeting needs of SRH. HIV care service must respond to a wide range of needs.

Mitigating depression among orphaned and vulnerable adolescents: a randomized controlled trial of interpersonal psychotherapy for groups in South Africa

BACKGROUND

Children and adolescents affected by HIV are at elevated risk of depression, yet research on related interventions in this population is scarce in sub-Saharan Africa. This study sought to examine the effects of interpersonal psychotherapy for groups (IPTG) on depressive symptomology among orphaned and vulnerable adolescents in South Africa.

METHOD

A cluster randomized controlled trial wherein adolescents ages 14-17 enrolled in community-based programming for HIV-affected and vulnerable families were randomly assigned by geographic cluster to participate in a 16-session IPTG intervention or the standard of care (n = 489). Baseline and postintervention surveys conducted with enrollees included standardized depression screening. Utilizing an intent-to-treat design, mixed effects models were performed to examine treatment effects for all participants and potential moderators including gender and baseline depression level (Clinical Trials registration: ClinicalTrials.gov NCT02386878).

RESULTS

While 23% of adolescents in the intervention group did not attend any IPTG sessions, average attendance was 12 out of 16 possible sessions among participants. The intervention was not associated with changes in depression symptomology.

CONCLUSIONS

Results underscore the importance of mitigating participation barriers prior to intervention roll-out and the need for increased evidence for psychological health interventions to mitigate depression among orphaned and vulnerable adolescents. This intervention and the study selectively targeted at-risk adolescents versus using diagnostic mental health criteria for enrollment; more research is needed to identify the potential benefits and disadvantages of these approaches.

Predictors of mental health problems in adolescents living with HIV in Namibia

BACKGROUND

Little research in sub-Saharan Africa has looked at factors that predict mental health problems in adolescents living with HIV (ALHIV). This study examines the psychological impact of HIV in adolescents in Namibia, including risk and protective factors associated with mental health.

METHODS

Ninety-nine fully disclosed ALHIV between the ages of 12 and 18 were interviewed at a State Hospital in Windhoek. A structured questionnaire assessed mental health, using the SDQ (Goodman, 1997), sociodemographic factors, poverty, social support, adherence and stigma.

RESULTS

Mean age was 14.3 years, 52.5% were female and most were healthy. Twelve percent scored in the clinical range for total mental health difficulties and 22% for emotional symptoms. Poverty was associated with more total mental health difficulties, t(96) = -2.63, p = .010, and more emotional symptoms, t(96) = -3.45, p = .001, whereas better social support was a protective factor, particularly caregiver support (r = -.337, p = .001). Adherence problems, HIV-related stigma and disclosing one's own HIV status to others were also associated with more total mental health difficulties. Poverty (β = -.231, p = .023) and stigma (β = .268, p = .009) were the best predictors for total mental health difficulties, whereas stigma (β = .314, p = .002) predicted emotional symptoms. Social support had a protective effect on peer problems (p = .001, β = -.349).

CONCLUSIONS

Several contextual factors associated with poorer mental health in ALHIV are identified.

Orphanhood and Self-Esteem: An 18-Year Longitudinal Study From an HIV-Affected Area in Tanzania

BACKGROUND

The HIV epidemic exacerbated the prevalence of prime-aged adult death in many parts of sub-Saharan Africa, resulting in increased rates of orphanhood. Little is known about whether this will coincide with adverse psychosocial well-being in adulthood for those who were orphaned at childhood.

METHODS

We studied a cohort of 1108 children from Kagera, a region of Tanzania that was heavily affected by HIV early in the epidemic. During the baseline data collection in 1991-1994, these children were aged 0-16 years and had both parents alive. We followed them roughly 16-19 years later in 2010, by which time 531 children (36%) had lost either one or both parents before their 19th birthday. We compared the 2010 10-item Rosenberg Self-Esteem Scale (RSES) score between children who lost a parent before the age of 19 and those who did not. We used the baseline data to control for preorphanhood confounders. This is important because we find that children who will lose their fathers in the future before age 19 came from somewhat lower socioeconomic backgrounds.

RESULTS

We found no correlation between maternal death and self-esteem measured through RSES. Paternal death was strongly correlated with lower levels of self-esteem (0.2 SDs lower RSES 95% confidence interval: 0.059 to 0.348), and the correlation was stronger when the death occurred during the child's teenage years. These effects are a net of socioeconomic differences that existed before the orphanhood event.

CONCLUSIONS

Our study supports the further development and piloting of programs that address psychosocial problems of orphans.

Orphans' perspectives on grief and loss in Botswana

This paper seeks to examine orphaned children's experiences on grief and loss in Botswana, and its impact on their well-being and make policy recommendations. A cross sectional design which utilized survey questionnaires was employed. Data were collected from 11 districts (3 urban and 8 rural) among orphan children aged 10-18 years. Chi-squared test was used to identify variables believed to be associated with loss and grief. Unadjusted (simple) and adjusted multiple logistic regression was used to investigate factors associated with loss. Of the 732 participants (53.1%) were females and mean age was 13.5 years (SD = 2.7); and 44.6% of these children had experienced death of a close family member in the past year which had been communicated. Children had access to education, lower primary (19.5%), upper primary (39.1%), junior secondary (32.5%), senior secondary school (6.6%), and (0.3%) in tertiary institutions. Most children (88.6%) had not experienced stigma and discrimination at school; 55.2% lived with grandparents, aunts (23.4%), siblings (11.8%), uncles (4.0%), other relatives (3.5%) and non-relatives (0.1%). Unadjusted logistic regression indicated that loss was significantly associated with having someone to talk to (OR = 0.72, 95% CI, 0.53-0.98, p = 0.03), change of residence (OR = 3.08, 95% CI, 1.94-4.90, p < 0.01), having siblings (OR = 2.06, 95% CI, 1.38-3.07, p < 0.01) and being from urban areas (OR = 0.56, 95% CI, 0.41-0.78, p < 0.01). In the adjusted model, loss was significantly associated with change of residence (OR = 2.72, 95% CI, 1.69-4.35, p < 0.01), having siblings (OR = 1.98, 95% CI, 1.30-3.01, p < 0.01) and being from urban areas (OR = 0.65, 95% CI, 0.46-0.93, p = 0.02). Age-specific interventions aimed at addressing the emotional, psychosocial and economic impacts of grief and loss are critical in preventing negative coping behaviors and improving the quality of life of orphans.

A randomized controlled trial of a resilience-based intervention on psychosocial well-being of children affected by HIV/AIDS: Effects at 6- and 12-month follow-up

BACKGROUND

Global literature suggests that resilience-based interventions may yield improvements in psychosocial well-being for vulnerable children, but limited data are available regarding the efficacy of such interventions among children affected by parental HIV/AIDS.

OBJECTIVE

To evaluate initial efficacy of a multi-level resilience-based intervention among children affected by parental HIV/AIDS in China in improving children's psychosocial well-being and resilience-related outcomes.

METHOD

Seven hundred-ninety children, 6-17 years of age, were recruited from rural China. Children were either AIDS orphans or were living with one or two parents infected with HIV/AIDS. Children and primary caregivers were randomly assigned to participate in a 4-arm trial to evaluate the Child-Caregiver-Advocacy Resilience (ChildCARE) intervention. This resilience-based psychosocial intervention provides programming at three levels (child, caregiver, community). Survey data were collected at baseline, 6-months, and 12-months in order to examine efficacy of the child-only and child + caregiver arms in improving children's psychological resilience.

RESULTS

Intervention groups displayed improvements in several resilience-related outcomes at 6- and 12-month follow-ups, including self-reported coping, hopefulness, emotional regulation, and self-control. The child-only intervention arm showed some fading of intervention effects by 12-months.

CONCLUSION

Preliminary findings suggest that the ChildCARE intervention is efficacious in promoting psychosocial well-being of children affected by parental HIV/AIDS in rural China. Targeting both children and caregivers for psychosocial intervention may be effective in improving children's resilience. Additional evaluation and modifications, including the inclusion of booster sessions, should be considered to further strengthen the program.

The power of siblings and caregivers: under-explored types of social support among children affected by HIV and AIDS

Children affected by HIV and AIDS have significantly higher rates of mental health problems than unaffected children. There is a need for research to examine how social support functions as a source of resiliency for children in high HIV-prevalence settings such as South Africa. The purpose of this research was to explore how family social support relates to depression, anxiety, and post-traumatic stress (PTS). Using the ecological model as a frame, data were drawn from a 2011 cross-sectional study of 1380 children classified as either orphaned by AIDS and/or living with an AIDS sick family member. The children were from high-poverty, high HIV-prevalent rural and urban communities in South Africa. Social support was analyzed in depth by examining the source (e.g. caregiver, sibling) and the type (e.g. emotional, instrumental, quality). These variables were entered into multiple regression analyses to estimate the most parsimonious regression models to show the relationships between social support and depression, anxiety, and PTS symptoms among the children. Siblings emerged as the most consistent source of social support on mental health. Overall caregiver and sibling support explained 13% variance in depression, 12% in anxiety, and 11% in PTS. Emotional support was the most frequent type of social support associated with mental health in all regression models, with higher levels of quality and instrumental support having the strongest relation to positive mental health outcomes. Although instrumental and quality support from siblings were related to positive mental health, unexpectedly, the higher the level of emotional support received from a sibling resulted in the child reporting more symptoms of depression, anxiety, and PTS. The opposite was true for emotional support provided via caregivers, higher levels of this support was related to lower levels of all mental health symptoms. Sex was significant in all regressions, indicating the presence of moderation.

Mental Health of Children Living in Foster Families in Rural Rwanda: The Role of HIV and the Family Environment

Fostering children is common in sub-Saharan Africa, but few studies examine these children's mental health needs. This study investigated the impact of living in a foster family on the mental health of HIV-positive, HIV-affected and HIV-unaffected children (n = 681 aged 10-17) in rural Rwanda. Regression analyses assessed the impact of living in a foster family on mental health, parenting, and daily hardships; multiple mediation analyses assessed whether family factors mediated the association between foster status and mental health. HIV-positive children were eight times more likely to live in foster families than HIV-unaffected children. Being HIV-affected was predictive of depression and irritability symptoms after controlling for family factors. Controlling for HIV-status, foster children had more symptoms of depression, anxiety, and irritability than non-fostered children. Positive parenting fully mediated the association between foster status and mental health. Mental health and parenting interventions for foster children and HIV-affected children may improve child outcomes.

Effectiveness of Mindfulness Intervention on Psychological Behaviors Among Adolescents With Parental HIV Infection: A Group-Randomized Controlled Trial

This study aims to identify the effectiveness of mindfulness intervention on the psychological behaviors of adolescents with parental HIV infection and its associated factors in Myanmar. A total of 80 adolescents from 2 intervention townships and 80 adolescents from 2 control townships were enrolled in a group randomized controlled trial with assessments at baseline and 6 months follow-up. The mindfulness intervention involved monthly group sessions for 3 consecutive months led by an experienced mindfulness trainer. Three domains of psychological behaviors-namely, emotional, conduct, and social behaviors-were assessed at baseline and compared after 6 months. Multilevel regression analysis was used to determine the effectiveness of the intervention and associated factors for psychological behaviors. The intervention significantly improved emotional and conduct behaviors at 6 months (P < .001) but had no effect on social behavior. The significant effect of the intervention existed after adjusting for gender, family type, child age, and orphan status.

Effect of a bereavement support group on female adolescents' psychological health: a randomised controlled trial in South Africa

BACKGROUND

Bereavement increases children's risk for psychological disorders, highlighting the need for effective interventions, especially in areas where orphanhood is common. We aimed to assess the effects of an eight-session support group intervention on the psychological health of bereaved female adolescents in South Africa.

METHODS

This randomised controlled trial enrolled female adolescents at 11 schools in three peri-urban towns of Free State province, South Africa. 453 bereaved ninth-grade students aged 13-17 years who had expressed interest in taking part in the group were randomly assigned (1:1) to receive the intervention or to be waitlisted for programme enrolment after the study period and serve as the control group. The intervention, Abangane ("friends" in isiZulu), is a locally derived, curriculum-based support group focused on coping with loss incorporating indigenous stories and cognitive behavioural therapy components. Weekly group sessions were facilitated by trained social workers or social auxiliary workers from a local non-profit organisation. The primary outcomes included indicators of grief and depression as reported by adolescents and behavioural problems reported by their caregivers. Grief was measured with three scales: the grief subscale of the Core Bereavement Items to assess normative grief; and the Intrusive Grief Thoughts Scale and the Inventory of Complicated Grief-Revised for Children to assess maladaptive grief symptoms in the past 4 weeks. Depression symptoms in the past 7 days were measured with the Center for Epidemiological Studies-Depression Scale for Children. Caregivers completed the Brief Problem Monitor-Parent Form to report on adolescent's behaviour in the previous 4 weeks. Analysis was intention to treat. This study is registered with ClinicalTrials.gov, number NCT02368808.

FINDINGS

Between Sept 30, 2014, and Feb 5, 2015, eligible female participants were identified, of whom 226 were assigned to the intervention, Abangane, and 227 were assigned to the waitlisted control group. Analysis included 382 adolescents who completed both surveys (193 participants assigned to Abangane and 189 assigned to waitlist). At follow up, the intervention group had significantly lower scores for primary outcomes, including intrusive grief (p=0·000, Cohen's d=-0·21), complicated grief (p=0·015, d=-0·14), and depression (p=0·009, d=-0·21) relative to the waitlisted group, while core bereavement scores were similar between groups (p=0·269). Caregivers in the intervention group reported lower levels of behavioural problems among adolescents (p=0·017, d=-0·31).

INTERPRETATION

Short-term, structured, theory-based support groups with contextually relevant content show promise in mitigating psychological and behavioural problems among bereaved adolescents. Abangane is replicable in resource limited settings, using freely available curriculum materials, existing programme structures, and appropriately trained personnel to implement it.

FUNDING

US Agency for International Development Southern Africa.

Identifying risks for mental health problems in HIV positive adolescents accessing HIV treatment in Johannesburg

BACKGROUND

Mental health problems of adolescents are underserved in low and middle-income countries where they account for a significant proportion of disease burden. Perinatally infected HIV-positive adolescents have a high prevalence of mental health disorders; however, little is known about those retained in care in South Africa.

METHODS

HIV-positive adolescents aged 13-19 years (n = 343) accessing five paediatric antiretroviral clinics in Johannesburg were assessed using standardized measures for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidality. Descriptive and bivariate analyses were conducted on all variables using Statistica v13.

RESULTS

Twenty-seven percent were symptomatic for depression, anxiety, or PTSD; 24% reported suicidality. Peer violence was significantly correlated to all mental health problems, as was hunger, being inappropriately touched, being hit, and being female. Those reporting sickness in the past year were more symptomatic. High exposure to violence was evident. Additionally, not feeling safe at home or in the community increased risk for all mental health disorders. Knowing one's HIV status was protective as was having dreams for the future.

CONCLUSION

HIV-positive adolescents accessing care demonstrated high levels of mental health problems that are largely unrecognized and could potentially be addressed within health systems. Mental health difficulties are driven by social challenges that require attention.

Parental HIV/AIDS and psychological health of younger children in South Africa

OBJECTIVE

We examined several indicators of psychological health in a sample of orphans and vulnerable children (OVC) to determine if there were significant differences between those orphaned by AIDS and those orphaned by other causes, and if there were gender differences.

METHOD

Our sample consisted of 119 young children (ages 6-10 years) who participated in a non-governmental organisation (NGO)-supported social services programme in a low-resource, non-urban community in South Africa. We collected data on three groups: non-orphans (OVC1; n = 45); orphans due to AIDS (OVC2; n = 43); and other orphans (OVC3; n = 31). Parents of non-orphans and legal guardians of orphans rated their children on a 112-item, age appropriate Child Behaviour Checklist (CBCL), South Africa version.

RESULTS

Children in the OVC2 group were significantly different from their peers on Internalising Problems and Somatic Complaints, while OVC3 group had a higher proportion of children in the at-risk range on Social Problems compared to OVC2. Females had elevated scores on the anxious/depressed, internalising problems, total problems, and sluggish cognitive tempo scales compared to males. There was an interaction between factors, such that boys in OVC2 had elevated mean scores on Somatic Complaints. These findings suggest increased vulnerability for girls on emotional issues and for boys on somatic problems.

Predictors of Mental Health Resilience in Children who Have Been Parentally Bereaved by AIDS in Urban South Africa

Children parentally bereaved by AIDS experience high rates of mental health problems. However, there is considerable variability in outcomes, and some show no mental health problems even when followed over time. Primary aims were to identify predictors of resilient adaptation at child, family and community levels within a group of AIDS-orphaned children, and to consider their cumulative influence. A secondary aim was to test whether predictors were of particular influence among children orphaned by AIDS relative to non-orphaned and other-orphaned children. AIDS-orphaned (n = 290), other-orphaned (n = 163) and non-orphaned (n = 202) adolescents living in informal settlements in Cape Town, South Africa were assessed on two occasions 4 years apart (mean age 13.5 years at Time 1, range = 10-19 years). Self-report mental health screens were used to operationalise resilience in AIDS-orphaned children as the absence of clinical-range symptoms of PTSD, anxiety, depression, conduct problems, and suicidality. A quarter of AIDS-orphaned children (24 %) showed no evidence of mental health problems at either wave. Child physical health, better caregiving quality, food security, better peer relationship quality, and lower exposure to community violence, bullying or stigma at baseline predicted sustained resilience. There were cumulative influences across predictors. Associations with mental health showed little variation by child age or gender, or between orphaned and non-orphaned children. Mental health resilience is associated with multiple processes across child, family and community levels of influence. Caution is needed in making causal inferences.

A Qualitative Exploration of the Mental Health and Psychosocial Contexts of HIV-Positive Adolescents in Tanzania

Although 85% of HIV-positive adolescents reside in sub-Saharan Africa, little is known about the psychosocial and mental health factors affecting their daily well-being. Identifying these contextual variables is key to development of culturally appropriate and effective interventions for this understudied and high-risk population. The purpose of this study was to identify salient psychosocial and mental health challenges confronted by HIV-positive youth in a resource-poor Tanzanian setting. A total of 24 qualitative interviews were conducted with a convenience sample of adolescents aged 12–24 receiving outpatient HIV care at a medical center in Moshi, Tanzania. All interviews were audio-recorded, transcribed, and coded using thematic analysis. Psychosocial challenges identified included loss of one or more parents, chronic domestic abuse, financial stressors restricting access to medical care and education, and high levels of internalized and community stigma among peers and other social contacts. Over half of youth (56%) reported difficulties coming to terms with their HIV diagnosis and espoused related feelings of self-blame. These findings highlight the urgent need to develop culturally proficient programs aimed at helping adolescents cope with these manifold challenges. Results from this study guided the development of Sauti ya Vijana (The Voice of Youth), a 10-session group mental health intervention designed to address the psychosocial and mental health needs of HIV-positive Tanzanian youth.

Prevalence and factors associated with depression symptoms among school-going adolescents in Central Uganda

BACKGROUND

Depression in adolescents constitutes a global public health concern. However, data on its prevalence and associated factors are limited in low income countries like Uganda.

METHODS

Using a cross-sectional descriptive study design, 519 adolescent students in 4 secondary schools in Mukono district, Uganda, were randomly selected after meeting study criteria. The 4 school types were: boarding mixed (boys and girls) school; day mixed school; girls' only boarding school; and, boys' only boarding school. The 519 participants filled out standardized questionnaires regarding their socio-demographic characteristics and health history. They were then screened for depression using the Children Depression Inventory (CDI) and those with a cut-off of 19 were administered the Mini International Neuro-Psychiatric Interview for Children and Adolescents 2.0 (MINI-KID), to ascertain the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM IV) diagnostic types of depression and any co morbidity. Logistic regression analyses were used to assess factors associated with significant depression symptoms (a score of 19 or more on the CDI).

RESULTS

There were 301 (58 %) boys and 218 (42 %) girls with age range 14-16 years and a mean age of 16 years (SD 2.18). Of 519 participants screened with the CDI, 109 (21 %) had significant depression symptoms. Of the 109 participants with significant depression symptoms, only 74 were evaluated with the MINI-KID and of these, 8 (11 %) met criteria for major depression and 6 (8 %) met criteria for dysthymia. Therefore, among participants that were assessed with both the CDI and the MINI-KID (n = 484), the prevalence of depressive disorders was 2.9 %. In this sample, 15 (3.1 %) reported current suicidal ideation. In the logistic regression analyses, significant depression symptoms were associated with single-sex schools, loss of parents and alcohol consumption.

LIMITATIONS

This is a cross-sectional study therefore, causal relationships are difficult to establish. Limited resources and the lack of collateral information precluded the assessment of a number of potential factors that could be associated with adolescent depression. The MINI-KID was administered to only 74 out of 109 students who scored ≥19 on the CDI since 35 students could not be traced again due to limited resources at the time.

CONCLUSIONS

Significant depression symptoms are prevalent among school-going adolescents and may progress to full-blown depressive disorders. Culturally sensitive psychological interventions to prevent and treat depression among school-going adolescents are urgently needed.

Caregiver alcohol use and mental health among children orphaned by HIV/AIDS in South Africa

Research in the developed world suggests that parental alcohol use negatively impacts child mental health. However, little research has examined these relations among children in the developing world and no studies to date have done so in the context of AIDS-orphanhood. Therefore, the present study tested the interactive effect of AIDS-orphan status with caregiver alcohol use on child mental health. The sample included 742 children (51.2% female; M_age= 9.18; age range: 7-11 years; 29.8 AIDS-orphans; 36.8% orphaned by causes other than AIDS; 33.4% non-orphaned) recruited from Mangaung in the Free State Province of South Africa. Child mental health was assessed via child self-report, caregiver, and teacher reports; and caregiver alcohol use via self-report. Path analyses, via structural equation modeling, revealed significant direct effects for AIDS-orphan status on caregiver-reported child mental health; and for caregiver alcohol-use problems on teacher-reported child mental health. However, the interaction effect of AIDS-orphan status with caregiver alcohol use did not reach significance on all three reports of child mental health problems. These results suggest that orphan status and caregiver alcohol use may independently relate to mental health problems in children and that the effects of both should be considered in the context of the mental health needs of children in AIDS-affected countries.

Multi-informant perspective on psychological distress among Ghanaian orphans and vulnerable children within the context of HIV/AIDS

BACKGROUND

There is little knowledge about the psychosocial distress of children affected by human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) in Ghana, to aid the planning of services. This study investigated mental health problems among children affected by HIV/AIDS, compared with control groups of children orphaned by other causes, and non-orphans.

METHOD

The study employed a cross-sectional survey that interviewed 291 children and their caregivers. Both children and caregivers completed the Strengths and Difficulties Questionnaire that measured children's psychosocial wellbeing. Verbal autopsy was used to identify whether children lost one or both parents from AIDS.

RESULTS

The results indicated that controlling for relevant sociodemographic factors, both children's self-reports and caregivers' reports indicate that both children living with HIV/AIDS-infected caregivers and children orphaned by AIDS were at heightened risk for mental health problems than both children orphaned by other causes and non-orphans. The findings further indicated that a significant proportion of orphaned and vulnerable children exhibited symptoms for depression and other psychiatric disorders (approximately 63%) compared with 7% among the non-orphaned group. Caregivers gave higher ratings for children on externalizing problems and lower on internalizing problems, and vice versa when the children's self-reports were analysed.

CONCLUSIONS

The findings suggest that both children and their informants have diverse yet complementary perspectives on psychological outcomes. The study discusses the theoretical and practical implications of these findings and urgently calls for necessary intervention programmes that target all children affected by HIV/AIDS to effectively alleviate psychological distress and enhance the mental health of these children.

Reducing HIV-related risk and mental health problems through a client-centred psychosocial intervention for vulnerable adolescents in Addis Ababa, Ethiopia

INTRODUCTION

Ethiopia is experiencing an increasingly urban HIV epidemic, alongside a rise in urban adolescent migration. Adolescent migrants are often confronted by unique social challenges, including living in a difficult environment, abuse and mental health problems. These issues can increase adolescents' vulnerability to HIV and compromise their capacity to protect themselves and others from HIV. We piloted and assessed the effects of a targeted psychosocial intervention to reduce mental health problems and improve HIV-related outcomes among migrant adolescents in Addis Ababa.

METHODS

A pre- and post-comparison design was used in a cohort of 576 female and 154 male migrant adolescents aged 15 to 18 years in Addis Ababa receiving services from two service delivery organizations, Biruh Tesfa and Retrak. We implemented a three-month client-centred, counsellor-delivered psychosocial intervention, based on findings from formative research among the same target population, to address participants' increased vulnerability to HIV. The intervention package comprised individual, group and creative arts therapy counselling sessions. Key outcome indicators included anxiety, depression, aggressive behaviour, attention problems, social problems, knowledge of HIV, safer sex practices and use of sexual health services. Longitudinal data analysis (McNemar test and random effects regression) was used to assess changes over time in key indicators by gender.

RESULTS

For females, aggressive behaviour decreased by 60% (adjusted odds ratio (AOR): 0.4 (0.25 to 0.65)) and any mental health problem decreased by 50% (AOR: 0.5 (0.36 to 0.81)) from baseline to end line. In addition, knowledge of HIV increased by 60% (AOR: 1.6 (1.08 to 2.47)), knowledge of a place to test for HIV increased by 70% (AOR: 1.7 (1.12 to 2.51)) and HIV testing increased by 80% (AOR: 1.8 (1.13 to 2.97)). For males, HIV knowledge increased by 110% (AOR: 2.1 (1.1 to 3.94)), knowledge of a place to test for HIV increased by 290% (AOR: 3.9 (1.02 to 14.9)), HIV testing increased by 630% (AOR: 7.3 (2.6 to 20.7)) and use of sexual health services increased by 220% (AOR: 3.2 (1.62 to 6.27)). We did not find any significant reduction in mental health problems among male adolescents.

CONCLUSIONS

Our findings suggest that a psychosocial intervention was associated with increased knowledge and uptake of HIV and sexual health services among both male and female migrant adolescents and with reduced mental health problems among female adolescents. Mental health problems varied significantly for male and female adolescents, suggesting that future interventions should be tailored to address their different needs and would benefit from intensive follow-up efforts.

Risk and protective factors for internalizing and externalizing outcomes among HIV-affected youth in Haiti

The present study aims to: (1) estimate the levels of internalizing symptoms and externalizing behaviors among youth affected by HIV in central Haiti; and (2) examine the risk and protective factors associated with these outcomes to identify potential areas of intervention for HIV-affected youth. Baseline data for 492 youth affected by HIV (ages 10-17) and their 330 caregivers were collected for a pilot study of a psychosocial support intervention. Participants were recruited from a list of HIV-positive patients receiving care at Partners In Health/Zanmi Lasante clinic sites. Internalizing and externalizing behaviors were assessed using the Strengths and Difficulties Questionnaire. Demographic, economic, and social indicators were collected using a structured questionnaire administered by trained social workers. Youth affected by HIV in central Haiti displayed high levels of internalizing and, to a lesser degree, externalizing symptoms. Multivariate regression analysis demonstrated risk factors most strongly associated with internalizing symptoms (socioeconomic status, parental depressive symptoms) and externalizing behaviors (household living arrangements, such as living with a stepparent). Social support had a protective effect on externalizing behaviors for both caregiver (β=-0.03, p=0.01) and self-report (β=-0.05, p<0.0001). High levels of psychological distress were observed in this population, especially with respect to internalizing outcomes. Interventions should address the economic security, mental health, and access to antiretroviral therapy for families affected by HIV, as well as emphasize the importance of building supportive caregiver-child relationships to decrease the psychological symptoms and impact of other life stressors experienced by youth affected by HIV in Haiti and similar resource-limited settings.

Orphanhood by AIDS-Related Causes and Child Mental Health: A Developmental Psychopathology Approach

While the number of new HIV infections has declined, the number of orphans as a result of AIDS-related deaths continues to increase. The aim of this paper was to systematically review empirical research on the mental health of children affected by HIV/AIDS in the developing world, specifically with an eye on developing a theoretical framework to guide intervention and research. Articles for review were gathered by following the Preferred Reporting Items for Systemic Reviews and Meta Analyses (PRISMA standards), reviewed and then organized and synthesized with a Developmental Psychopathology framework. Results showed that the immediate and longterm effects of AIDS orphanhood are moderated by a number of important risk and protective factors that may serve as strategic targets for intervention. Research and clinical implications are discussed.

Biomedical risk, psychosocial influences, and developmental outcomes: lessons from the pediatric HIV population in Africa

Sub-Saharan Africa is home to millions of HIV-affected children. These children are likely to experience multiple developmental delays. In this chapter, I present data highlighting compromised neurobehavioral, mental health, and scholastic outcomes for children affected by HIV. Furthermore, I discuss biomedical factors (e.g., disease severity and nutritional status) that may exacerbate the adverse effects of HIV on childhood outcomes. I also present evidence on how psychosocial risk factors such as poor maternal mental health, orphanhood, and poverty may aggravate the effects of HIV. The concluding section of the chapter highlights conceptual and methodological refinements in research on the impact of HIV on child development in Sub-Saharan Africa.

Risk and protective factors for suicidal ideation and behaviour in Rwandan children

BACKGROUND

Suicide is a leading cause of death for young people. Children living in sub-Saharan Africa, where HIV rates are disproportionately high, may be at increased risk.

AIMS

To identify predictors, including HIV status, of suicidal ideation and behaviour in Rwandan children aged 10-17.

METHOD

Matched case-control study of 683 HIV-positive, HIV-affected (seronegative children with an HIV-positive caregiver), and unaffected children and their caregivers.

RESULTS

Over 20% of HIV-positive and affected children engaged in suicidal behaviour in the previous 6 months, compared with 13% of unaffected children. Children were at increased risk if they met criteria for depression, were at high-risk for conduct disorder, reported poor parenting or had caregivers with mental health problems.

CONCLUSIONS

Policies and programmes that address mental health concerns and support positive parenting may prevent suicidal ideation and behaviour in children at increased risk related to HIV.

How later adolescents with adult responsibilities experience HIV bereavement in Nigeria: application of a bereavement model

Conceptual models assist in the better understanding of phenomena and also in the planning of effective responses. We applied the Dual Process Model (DPM) to examine how six later adolescents (ages 18-24 years) experienced the multiple stressors of bereavement, maturational tasks, and caregiving roles. Using a semi-structured interviewing approach, participants who were purposively recruited narrated how parental loss to HIV impacted their lives. In relation to the proposition of the DPM model, the study revealed that participants (a) anticipated grief before the death of their parents, (b) engaged in activities to return to normalcy after parental loss, and (c) neglected grief emotions in order to cope with the demands of caregiving. The application of a model to examine responses to bereavement can assist health care practitioners to appreciate and have a deeper understanding of how best to approach caring interventions for late adolescents with multiple stressors.

Bullying victimisation, internalising symptoms, and conduct problems in South African children and adolescents: a longitudinal investigation

Bullying victimisation has been prospectively linked with mental health problems among children and adolescents in longitudinal studies in the developed world. However, research from the developing world, where adolescents face multiple risks to social and emotional development, has been limited by cross-sectional designs. This is the first longitudinal study of the psychological impacts of bullying victimisation in South Africa. The primary aim was to examine prospective relationships between bullying victimisation and internalising and externalising symptoms in South African youth. Secondary aims were to examine gender and age-related differences in experiences of bullying victimisation. Children and adolescents (10-17 years, 57 % female, n = 3,515) from high HIV-prevalent (>30 %) communities in South Africa were interviewed and followed-up 1 year later (97 % retention). Census enumeration areas were randomly selected from urban and rural sites in two provinces and door-to-door sampling included all households with a resident child/adolescent. Exposure to multiple experiences of bullying victimisation at baseline predicted internalising symptoms and conduct problems 1 year later. Additionally, baseline mental health scores predicted later bullying victimisation, demonstrating bi-directionality of relationships between bullying victimisation and mental health outcomes in this sample. Expected gender differences in physical, verbal, and relational bullying victimisation were evident and predicted declines in bullying victimisation over time were observed. In the developed world, school-based anti-bullying programmes have been shown to be effective in reducing bullying and victimisation. Anti-bullying programmes should be implemented and rigorously evaluated in South Africa, as this may promote improved mental health among South African children and adolescents.

Relationship Between Family Economic Resources, Psychosocial Well-being, and Educational Preferences of AIDS-Orphaned Children in Southern Uganda: Baseline Findings

This study examines the relationship between economic resources, psychosocial well-being, and educational preferences of AIDS-orphaned children in southern Uganda. We use baseline data from a sample of 1410 AIDS-orphaned children (defined as children who have lost one or both biological parents to AIDS) enrolled in the Bridges to the Future study, a National Institute of Child Health and Human Development (NICHD) funded study. Analyses from both bivariate and multiple regression analyses indicate the following: 1) despite the well-documented economic and psychosocial challenges AIDS-orphaned children face, many of these children have high educational plans and aspirations; 2) educational aspirations differ by orphanhood status (double orphan vs. single orphan); 3) regardless of orphanhood status, children report similar levels of psychosocial well-being; 4) high levels of family cohesion, positive perceptions of the future, school satisfaction, and lower levels of hopelessness (hopefulness) are associated with high educational aspirations; and 5) reported family economic resources at baseline, all seem to play a role in predicting children's educational preferences and psychosocial well-being. These findings suggest that the focus for care and support of orphaned children should not be limited to addressing their psychosocial needs. Addressing the economic needs of the households in which orphaned children live is equally important. Indeed, in the context of extreme poverty-in which most of the children represented in this study live-addressing structural factors, including poverty, may be a key driver in addressing their psychosocial functioning.

The burden of disease on HIV-infected orphaned and non-orphaned children accessing primary health facilities in a rural district with poor resources in South Africa: a cross-sectional survey of primary caregivers of HIV-infected children aged 5-18 years

Background

Provider-initiated HIV testing and counseling (PITC) is offered as part of the normal standard of care to increase access to treatment for HIV-infected children. In practice, HIV diagnosis occurs in late childhood following recurrent and chronic infections. We investigated primary caregivers’ reported reasons for seeking HIV testing for children aged 5–18 years, determined the orphan status of the children, and compared the clinical profile and disease burden of orphans and non-orphans.

Methods

This was a cross-sectional survey of primary caregivers of HIV-infected children accessing antiretroviral treatment (ART) from two community hospitals and 34 primary healthcare facilities in a rural district in Mpumalanga province, South Africa.

Results

The sample consisted of 406 primary caregivers: 319 (78.6%) brought the child to the health facility for HIV testing because of chronic and recurrent infections. Almost half (n = 183, 45.1%) of the children were maternal orphans, 128 (31.5%) were paternal orphans, and 73 (39.9%) were double orphans. A univariate analysis showed that maternal orphans were significantly more likely to be older (OR = 2.57, p = 0.000, CI: 1.71–3.84), diagnosed late (OR = 2.48, p = 0.009, CI: 1.26–4.88), and to start ART later (OR = 2.5, p = 0.007, CI: 1.28–4.89) than non-orphans. There was a high burden of infection among the children prior to HIV diagnosis; 274 (69.4%) presented with multiple infections. Multiple logistic regression showed that ART start age (aOR = 1.19, p = 0.000, CI: 1.10–1.29) and time on ART (aOR = 2.30, p = 0.000, CI: 1.45–3.64) were significantly associated with orphanhood status. Half (n = 203, (50.2%) of the children were admitted to hospital prior to start of ART, and hospitalization was associated with multiple infections (OR = 1.27, p = 0.004, CI: 1.07–1.51).

Conclusions

The study found late presentation with undiagnosed perinatal HIV infection and high prevalence of orphanhood among the children. The health of maternal orphans was more compromised than non-orphans. Routine PICT should be strengthened to increase community awareness about undiagnosed HIV among older children and to encourage primary caregivers to accept HIV testing for children.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-015-0049-x) contains supplementary material, which is available to authorized users.

Assessing the value of and contextual and cultural acceptability of the Strength and Difficulties Questionnaire (SDQ) in evaluating mental health problems in HIV/AIDS affected children

BACKGROUND

The Strengths and Difficulties Questionnaire (SDQ) is a robust, powerful and internationally recognised diagnostic screening tool for emotional and behaviour problems among children, with the particular advantage that it can be used by non-health professionals. This makes it useful in a South African context characterized by shortages of professional mental health carers. However the cultural and contextual acceptability and potential uses of the SDQ have not yet been examined in the South African context.

METHODS

The aim of the current study was to evaluate the acceptability of the SDQ in a Sesotho speaking area of South Africa. As part of a larger study to standardise the SDQ for use among Sotho speakers, teachers were asked to use the tool to assess learners in their class. Ten teachers were then asked to write a report on their experience of the SDQ and how useful and applicable they found it for their school setting. These findings were discussed at two later meetings with larger groupings of teachers. Reports were analysed using a modified contextualised interpretative content analysis method.

RESULTS

Teachers found the SDQ very useful in the classroom and easy to administer and understand. They found it contextually relevant and particularly useful in gaining an understanding of the learners and the challenges that learners were facing. It further allowed them to differentiate between scholastic and emotional problems, assisting them in developing relationships with the pupils and facilitating accurate referrals. There were very few concerns raised, with the major problem being that it was difficult to assess items concerning contexts outside of the school setting. The teachers expressed interest in obtaining further training in the interpretation of the SDQ and a greater understanding of diagnostic labels so as to assist their learners.

CONCLUSION

The SDQ was found to be acceptable and useful in the context of this very disadvantaged community. The teachers felt it assisted them in their role as teachers by providing a greater understanding of emotional and behaviour problems among learners. However, lack of places for referral and their own lack of appropriate skills and time did generate frustration.

Links between teacher assessment and child self-assessment of mental health and behavior among children affected by HIV/AIDS

Teachers are considered to be one of the most important influences in the lives of students. Teachers' assessments of students may be a primary source of information on children's mental and behavioral health; however, this topic has received little attention in research. We examined this issue through linking teachers' ratings of students and mental and behavioral outcomes of children affected by HIV. The hypothesis is that teacher ratings will be predictive of specific child mental and behavioral health outcomes. A quantitative cross-sectional design with self-administered paper-and-pencil instruments was used. The sample included 1221 children (aged 6-18, grades 1-11) affected by HIV including 755 orphans who lost one or both parents to AIDS and 466 vulnerable children living with HIV-infected parents in a central province of China. The corresponding teacher sample included 185 participants. Each child completed an assessment inventory of demographic information and mental and behavioral health measures. Teachers completed a questionnaire about children's school performance. SEM analyses revealed a good model fit according to all fit indices: comparative fit index = 0.93, root mean square error of approximation = 0.07, and standardized root mean square residual = 0.04. Structural equation modeling revealed that problem ratings by teachers were positively associated with child loneliness and behavioral problems, social competence ratings by teachers were negatively related to child depression, and personal growth and social interaction ratings by teachers were negatively related to child loneliness, depression, and trauma. The current study represents a unique contribution to the field in that it recognizes that teachers can be a valuable source of information on children's psychological health. Results from this study have implications for health prevention and intervention for children and families suffering from HIV/AIDS.

Measuring child awareness for adult symptomatic HIV using a verbal assessment tool: concordance between adult-child dyads on adult HIV-associated symptoms and illnesses

OBJECTIVES

This study assessed children's awareness for adult HIV-associated symptoms and illnesses using a verbal assessment tool by analysing inter-rater reliability between adult-child dyads. This study also evaluated sociodemographic and household characteristics associated with child awareness of adult symptomatic HIV.

METHODS

A cross-sectional survey using a representative community sample of adult-child dyads (N=2477 dyads) was conducted in KwaZulu-Natal, South Africa. Analyses focused on a subsample (n=673 adult-child dyads) who completed verbal assessment interviews for symptomatic HIV. We used an existing validated verbal autopsy approach, originally designed to determine AIDS-related deaths by adult proxy reporters. We adapted this approach for use by child proxy reporters for reporting on HIV-associated symptoms and illnesses among living adults. Analyses assessed whether children could reliably report on adult HIV-associated symptoms and illnesses and adult provisional HIV status.

RESULTS

Adult-child pairs concurred above the 65th percentile for 9 of the 10 HIV-associated symptoms and illnesses with sensitivities ranging from 10% to 100% and specificities ranging from 20% to 100%. Concordant reporting between adult-child dyads for the adult's provisional HIV status was 72% (sensitivity=68%, specificity=73%). Children were more likely to reliably match adult's reports of provisional HIV status when they lived in households with more household members, and households with more robust socioeconomic indicators including access to potable water, food security and television.

CONCLUSIONS

Children demonstrate awareness of HIV-associated symptoms and illnesses experienced by adults in their household. Children in households with greater socioeconomic resources and more household members were more likely to reliably report on the adult's provisional HIV status.

Psychological Resilience among Children Affected by Parental HIV/AIDS: A Conceptual Framework

HIV-related parental illness and death have a profound and lasting impact on a child's psychosocial wellbeing, potentially compromising the child's future. In response to a paucity of theoretical and conceptual discussions regarding the development of resilience among children affected by parental HIV, we proposed a conceptual framework of psychological resilience among children affected by HIV based on critical reviews of the existing theoretical and empirical literature. Three interactive social ecological factors were proposed to promote the resilience processes and attenuate the negative impact of parental HIV on children's psychological development. Internal assets, such as cognitive capacity, motivation to adapt, coping skills, religion/spirituality, and personality, promote resilience processes. Family resources and community resources are two critical contextual factors that facilitate resilience process. Family resources contain smooth transition, functional caregivers, attachment relationship, parenting discipline. Community resources contain teacher support, peer support, adult mentors, and effective school. The implications of the conceptual framework for future research and interventions among children affected by parental HIV were discussed.

Three-year change in the wellbeing of orphaned and separated children in institutional and family-based care settings in five low- and middle-income countries

BACKGROUND

With more than 2 million children living in group homes, or "institutions", worldwide, the extent to which institution-based caregiving negatively affects development and wellbeing is a central question for international policymakers.

METHODS

A two-stage random sampling methodology identified community representative samples of 1,357 institution-dwelling orphaned and separated children (OSC) and 1,480 family-dwelling OSC aged 6-12 from 5 low and middle income countries. Data were collected from children and their primary caregivers. Survey-analytic techniques and linear mixed effects models describe child wellbeing collected at baseline and at 36 months, including physical and emotional health, growth, cognitive development and memory, and the variation in outcomes between children, care settings, and study sites.

FINDINGS

At 36-month follow-up, institution-dwelling OSC had statistically significantly higher height-for-age Z-scores and better caregiver-reported physical health; family-dwelling OSC had fewer caregiver-reported emotional difficulties. There were no statistically significant differences between the two groups on other measures. At both baseline and follow-up, the magnitude of the differences between the institution- and family-dwelling groups was small. Relatively little variation in outcomes was attributable to differences between sites (11-27% of total variation) or care settings within sites (8-14%), with most variation attributable to differences between children within settings (60-75%). The percent of variation in outcomes attributable to the care setting type, institution- versus family-based care, ranged from 0-4% at baseline, 0-3% at 36-month follow-up, and 0-4% for changes between baseline and 36 months.

INTERPRETATION

These findings contradict the hypothesis that group home placement universally adversely affects child wellbeing. Without substantial improvements in and support for family settings, the removal of institutions, broadly defined, would not significantly improve child wellbeing and could worsen outcomes of children who are moved from a setting where they are doing relatively well to a more deprived setting.

Relationships between familial HIV/AIDS and symptoms of anxiety and depression: the mediating effect of bullying victimization in a prospective sample of South African children and adolescents

South African children and adolescents living in HIV/AIDS-affected families are at elevated risk of both symptoms of anxiety and depressive symptoms. Poverty and HIV/AIDS-related stigma are additional risk factors for these negative mental health outcomes. Community level factors, such as poverty and stigma, are difficult to change in the short term and identifying additional potentially malleable mechanisms linking familial HIV/AIDS with mental health is important from an intervention perspective. HIV/AIDS-affected children are also at increased risk of bullying victimization. This longitudinal study aimed to determine whether prospective relationships between familial HIV/AIDS and both anxiety symptoms and depressive symptoms operate indirectly via bullying victimization. Adolescents (M = 13.45 years, 56.67 % female, n = 3,515) from high HIV-prevalent (>30 %) communities in South Africa were interviewed and followed-up one year later (n = 3,401, 96.70 % retention). Census enumeration areas were randomly selected from urban and rural sites in two provinces, and door-to-door sampling included all households with a resident child/adolescent. Familial HIV/AIDS at baseline assessment was not directly associated with mental health outcomes 1 year later. However, significant indirect effects operating via bullying victimization were obtained for both anxiety and depression scores. Importantly, these effects were independent of poverty, HIV/AIDS-related stigma, and baseline mental health, which highlight bullying victimization as a potential target for future intervention efforts. The implementation and rigorous evaluation of bullying prevention programs in South African communities may improve mental health outcomes for HIV/AIDS-affected children and adolescents and this should be a focus of future research and intervention.

Evaluation of a Memory Book intervention with orphaned children in South Africa

The purpose of this collaborative research study was to evaluate the use of the Memory Book intervention for orphaned children's grief and loss recovery. A qualitative phenomenological approach was implemented to evaluate the Memory Book intervention with orphaned children at two children's homes in South Africa. Study findings support the ability of children to work through loss and grief when they are assisted in preserving and telling their story. The Memory Book intervention assists children to chronicle their lives and demonstrates the potential to guide future interventions by care providers and nurses in this context.

Evidence of impact: health, psychological and social effects of adult HIV on children

There is a growing evidence base on the immediate and short-term effects of adult HIV on children. We provide an overview of this literature, highlighting the multiple risks and resultant negative consequences stemming from adult HIV infection on the children they care for on an individual and family basis. We trace these consequences from their origin in the health and wellbeing of adults on whom children depend, through multiple pathways to negative impacts for children. As effective treatment reduces vertical transmission, the needs of affected children will predominate. Pathways include exposure to HIV in utero, poor caregiver mental or physical health, the impact of illness, stigma and increased poverty. We summarize the evidence of negative consequences, including those affecting health, cognitive development, education, child mental health, exposure to abuse and adolescent risk behaviour, including sexual risk behaviour, which has obvious implications for HIV-prevention efforts. We also highlight the evidence of positive outcomes, despite adversity, considering the importance of recognizing and supporting the development of resilience. This study is the first in a series of three commissioned by President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID), the summary provided here was used to inform a second study which seeks to identify insights from the broader child development field which will help us predict what long-term negative consequences children affected by HIV and AIDS are likely to experience. The third study discusses the design of a model to estimate these consequences. Although comprehensive, the review is often hampered by poor-quality research, inadequate design, small sample sizes and single studies in some areas.

Family-based prevention of mental health problems in children affected by HIV and AIDS: an open trial

OBJECTIVE

The objective of this study is to assess the feasibility and acceptability of an intervention to reduce mental health problems and bolster resilience among children living in households affected by caregiver HIV in Rwanda.

DESIGN

Pre-post design, including 6-month follow-up.

METHODS

The Family Strengthening Intervention (FSI) aims to reduce mental health problems among HIV-affected children through improved child-caregiver relationships, family communication and parenting skills, HIV psychoeducation and connections to resources. Twenty families (N = 39 children) with at least one HIV-positive caregiver and one child 7-17 years old were enrolled in the FSI. Children and caregivers were administered locally adapted and validated measures of child mental health problems, as well as measures of protective processes and parenting. Assessments were administered at pre and postintervention, and 6-month follow-up. Multilevel models accounting for clustering by family tested changes in outcomes of interest. Qualitative interviews were completed to understand acceptability, feasibility and satisfaction with the FSI.

RESULTS

Families reported high satisfaction with the FSI. Caregiver-reported improvements in family connectedness, good parenting, social support and children's pro-social behaviour (P < 0.05) were sustained and strengthened from postintervention to 6-month follow-up. Additional improvements in caregiver-reported child perseverance/self-esteem, depression, anxiety and irritability were seen at follow-up (P < .05). Significant decreases in child-reported harsh punishment were observed at postintervention and follow-up, and decreases in caregiver reported harsh punishment were also recorded on follow-up (P < 0.05).

CONCLUSION

The FSI is a feasible and acceptable intervention that shows promise for improving mental health symptoms and strengthening protective factors among children and families affected by HIV in low-resource settings.

Children's psychosocial wellbeing in the context of HIV/AIDS and poverty: a comparative investigation of orphaned and non-orphaned children living in South Africa

Background

Recent studies have questioned whether orphanhood is primarily associated with key dimensions of psycho-social wellbeing in children living in circumstances of material deprivation and high prevalence of HIV and AIDS.

Methods

This study uses cross-sectional data from a longitudinal study conducted between 2004-2007 to examine the psychosocial well-being of orphans and non-orphans in the Amajuba District of KwaZulu-Natal, South Africa. Psychosocial wellbeing included an assessment of orphans’ and non orphans’ level of anxiety and depression, affability and resilience. Stratified cluster sampling, based on both school and age, was used to construct a cohort of recent orphans and non-orphans and their households, randomly selected from schools.

Results

Levels of anxiety and depression, affability and resilience did not differ significantly between orphans and non-orphans, nor did salient household, poverty and caregiver characteristics vary substantially amongst orphans and non-orphans. Multivariate analyses indicated that children’s psychosocial outcomes, when controlling for orphan status and related demographic variables were more strongly influenced by household composition/size, living above or below the poverty threshold and factors associated with the caregiver-child relationship and caregiver health.

Conclusions

The results muster additional evidence for moving beyond narrow definitions of vulnerability associated exclusively with orphanhood to consider the multitude of material, social and relational factors affecting the psycho-social well-being of children in general who are living in circumstances of poverty and HIV and AIDS.

First evaluation of a population-based screen to detect emotional-behavior disorders in orphaned children in Sub-Saharan Africa

Due to the HIV/AIDS pandemic which has left 12 million children orphaned in Sub-Saharan Africa, children are at increased risk for mental health problems. Currently, no validity data exist for any screening measure of emotional-behavior disorders in pre-adolescent children in Sub-Saharan Africa. The aims of the current study were to evaluate the construct validity of the caregiver-, teacher-, and self-report versions of the one-page Strengths and Difficulties Questionnaire (SDQ) in 466 orphans in South Africa between the ages of 7 and 11 (M age = 9.23 years, SD = 1.33, 51.93 % female) and to provide, for the first time, clinical cut-offs for this population. Findings demonstrated support for the caregiver SDQ, but not the teacher and self-report versions. We provide clinical cut-offs, but caution their use before further research is conducted. There remains a critical need for further psychometric studies of the SDQ in the developing world.

Does investment in home visitors lead to better psychological health for HIV-affected families? Results from a quasi-experimental evaluation in South Africa

Children and families affected by HIV are at considerable risk for psychological distress. Community-based home visiting is a common mechanism for providing basic counseling and other services to HIV-affected families. While programs emphasize home visitor training and compensation as means to promote high-quality service delivery, whether these efforts result in measurable gains in beneficiaries' well-being remains largely unanswered. This study employs a longitudinal quasi-experimental design to explore whether these kinds of investments yield concomitant gains in psychological outcomes among beneficiaries. Baseline and follow-up data were collected over a two-year period from children aged 10–17 at the time of program enrollment and their caregivers, with 80% retention. In this sample of 1487 children and 918 caregivers, the psychological health outcomes of those enrolled in programs with home visitors who receive intensive training, organizational support, and regular compensation (termed “paraprofessional”) were compared to those enrolled in programs offering limited home visiting services from lay volunteers. Applying multilevel logistic regression, no measurable improvements were found among paraprofessional enrollees, and three outcomes were significantly worse at follow-up regardless of program model. Children's behavior problems became more prevalent even after adjusting for other factors, increasing from 29% to 35% in girls and from 28% to 43% in boys. Nearly one-quarter of girl and boys reported high levels of depression at follow-up, and this was a significant rise over time for boys. Rates of poor family functioning also significantly worsened over time, rising from 30% to 59%. About one-third of caregivers reported high levels of negative feelings at follow-up, with no improvements observed in the paraprofessional group. Results highlight that children's and caregivers' psychological outcomes may be relatively impervious to change even in paraprofessional home visiting models. Findings underscore the need for programs serving HIV-affected families toadd focused evidence-based psychological interventions to supplement traditional home visiting.

Where lies the risk? An ecological approach to understanding child mental health risk and vulnerabilities in sub-saharan Africa

Efforts at improving child-health and development initiatives in sub-Saharan Africa had focused on the physical health of children due to the neglect of child and adolescent mental health (CAMH) policy initiatives. A thorough and broad-based understanding of the prevalent child mental-health risk and vulnerability factors is needed to successfully articulate CAMH policies. In this discourse, we present a narrative on the child mental-health risk and vulnerability factors in sub-Saharan Africa. Through an ecological point of view, we identified widespread family poverty, poor availability and uptake of childcare resources, inadequate community and institutional childcare systems, and inadequate framework for social protection for vulnerable children as among the risk and vulnerability factors for CAMH in the region. Others are poor workplace policy/practice that does not support work-family life balance, poor legislative framework for child protection, and some harmful traditional practices. We conclude that an ecological approach shows that child mental-health risks are diverse and cut across different layers of the care environment. The approach also provides a broad and holistic template from which appropriate CAMH policy direction in sub-Saharan Africa can be understood.