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

Family economic empowerment and mental health among AIDS-affected children living in AIDS-impacted communities: evidence from a randomised evaluation in southwestern Uganda

OBJECTIVE

The authors examine whether an innovative family economic empowerment intervention addresses mental health functioning of AIDS-affected children in communities heavily impacted by HIV/AIDS in Uganda.

METHODS

A cluster randomised controlled trial consisting of two study arms, a treatment condition (n=179) and a control condition (n=118), was used to examine the impact of the family economic empowerment intervention on children's levels of hopelessness and depression. The intervention comprised matched children savings accounts, financial management workshops and mentorship. Data were collected at baseline and 12 months post-intervention.

RESULTS

Using multivariate analysis with several socioeconomic controls, the authors find that children in the treatment condition (receiving the intervention) report significant improvement in their mental health functioning. Specifically, the intervention reduces hopelessness and depression levels. On the other hand, children in the control condition (not receiving the intervention) report no changes on both measures.

CONCLUSIONS

The findings indicate that children with poor mental health functioning living in communities affected by HIV/AIDS may benefit from innovative family economic empowerment interventions. As measures of mental health functioning, both hopelessness and depression have long-term negative psychosocial and developmental impacts on children. These findings have implications for public health programmes intended for long-term care and support of children living in resource poor AIDS-impacted communities.

Depression among AIDS-orphaned children higher than among other orphaned children in southern India

Background

Systematic data on mental health issues among orphaned children are not readily available in India. This study explored depression and its associated risk factors among orphaned children in Hyderabad city in south India.

Methods

400 orphaned children drawn equally from AIDS and non-AIDS orphan groups aged 12–16 years residing in orphanages in and around Hyderabad city in southern India were recruited to assess depression and associated risk factors using the Center for Epidemiologic Studies-Depression Scale (CES-DC). Variation in the intensity of depression was assessed using multiple classification analysis (MCA).

Results

397 (99%) orphans provided complete interviews in the study of whom 306 (76.5%) were aged 12 to 14 years, and 206 (51.8%) were paternal orphans. Children orphaned by AIDS were significantly more likely to report being bullied by friends or relatives (50.3%) and report experiencing discrimination (12.6%) than those orphaned due to other reasons (p < 0.001). The overall prevalence of depression score >15 with CES-DC was 74.1% (95% CI 69.7-78.4) with this being significantly higher for children orphaned by AIDS (84.4%, 95% CI 79.4 – 89.5) than those due to other reasons (63.6%, 95% CI 56.9 – 70.4). Mean depression score was significantly higher for children orphaned by AIDS (34.6) than the other group (20.6; p < 0.001). Among the children orphaned by AIDS, the bulk of depression score was clustered in 12–14 years age groups whereas in the children orphaned by other reasons it was clustered in the 15–16 years age group (p = 0.001). MCA analysis showed being a child orphaned by AIDS had the highest effect on the intensity of depression (Beta = 0.473).

Conclusions

Children orphaned by AIDS had significantly higher depressive symptoms than the other orphaned children. These findings could be used for further planning of mental health interventions to meet the mental health needs of orphaned children, that could include preventive, diagnostic and treatment services.

Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges

Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.

The VUKA family program: piloting a family-based psychosocial intervention to promote health and mental health among HIV infected early adolescents in South Africa

An increasing number of adolescents born with HIV in South Africa are on antiretroviral treatment and have to confront complex issues related to coping with a chronic, stigmatizing and transmittable illness. Very few evidence-based mental health and health promotion programs for this population exist in South Africa. This study builds on a previous collaboratively designed and developmentally timed family-based intervention for early adolescents (CHAMP). The study uses community-based participatory approach as part of formative research to evaluate a pilot randomized control trial at two hospitals. The paper reports on the development, feasibility, and acceptability of the VUKA family-based program and its short-term impact on a range of psychosocial variables for HIV + preadolescents and their caregivers. A 10-session intervention of approximately 3-month duration was delivered to 65 preadolescents aged 10-13 years and their families. VUKA participants were noted to improve on all dimensions, including mental health, youth behavior, HIV treatment knowledge, stigma, communication, and adherence to medication. VUKA shows promise as a family-based mental and HIV prevention program for HIV + preadolescents and which could be delivered by trained lay staff.

One size does not fit all: psychometric properties of the Shona Symptom Questionnaire (SSQ) among adolescents and young adults in Zimbabwe

BACKGROUND

Depression is a major contributor to the global burden of disease. Onset commonly occurs during the adolescent period. Understanding how depression tools are functioning among adolescents has been relatively overlooked.

METHODS

Using cross-sectional survey data among a sample of 2768 adolescents (aged 15-19) and 2027 young adults (aged 20-24) living in Zimbabwe this paper calibrated the Shona Symptom Questionnaire (SSQ) against the Self Report Questionnaire (SRQ-20) and examined the performance indices of the SSQ based on various cut points for classification. Using a multivariate logistic regression model we isolated particular characteristics to test their association with the odds of being misclassified as non-depressed by the SSQ.

RESULTS

A modified cut point of five or more substantially increases the depression estimates for both age groups. The prevalence of depression increased from 3.5% to 13.2% among adolescents and from 5.1% to 16.2% among young adults based on these revisions. Adolescents who were orphaned or ever had sex had significantly a greater odd of being misclassified. When retested using the modified cut point of five or greater, associations with misclassification disappeared.

LIMITATIONS

Scales were not administered separately or in their entirety but rather overlapping items were only asked once, utilizing exclusively SRQ-20 phrasing rather than the culturally-emic language in the SSQ.

CONCLUSIONS

Not all depression scales are appropriate for use among adolescents given their unique developmental stage. An alternative cut point for depression classification could improve detection of depression among Zimbabwean adolescents.

Do children orphaned by AIDS experience distress over time? A latent growth curve analysis of depressive symptoms

This longitudinal study aimed to examine the enduring effects of parental HIV/AIDS on children's psychological well-being in Asia. A sample of 1625 children aged from 6 to 18 years old were assessed annually for their depressive symptoms over three years. Latent growth curve modeling (LGCM) was used to examine the trajectories of depressive symptoms among AIDS orphans and vulnerable children in comparison with children from HIV-free families. AIDS orphans demonstrated the highest initial level of depressive symptoms among the three groups. On average, children's depressive symptoms' scores can be expected to realize an approximate 25% decrease for AIDS orphans, 19% decrease for vulnerable children, and 15% decrease for comparison children over a three-year period. Individual differences within the groups showed that children with higher initial level of depressive symptoms can be expected to decrease slower over time. Multiple group LGCM showed that the three groups of children demonstrated significantly different trajectories of depressive symptoms. Among the key demographic factors, only age exerted an effect on the trajectory of depressive symptoms of vulnerable children, indicating that the younger children showed higher level of initial depressive symptoms and lower rate of decrease than the older children. The current study enriched our knowledge on the longitudinal effect of parental HIV/AIDS on children's emotional distress. Future psychological support might take the children's developmental stages and cultural appropriateness into consideration and deliver service for the most vulnerable group of children affected by HIV/AIDS.

Impact of parental HIV/AIDS on children's psychological well-being: a systematic review of global literature

This review examines the global literature regarding the impact of parental HIV/AIDS on children's psychological well-being. Fifty one articles reporting quantitative data from a total of 30 studies were retrieved and reviewed. Findings were mixed but tended to show that AIDS orphans and vulnerable children had poorer psychological well-being in comparison with children from HIV-free families or children orphaned by other causes. Limited longitudinal studies suggested a negative effect of parental HIV on children's psychological well-being in an early stage of parental HIV-related illness and such effects persisted through the course of parental illness and after parental death. HIV-related stressful life events, stigma, and poverty were risk factors that might aggravate the negative impact of parental HIV/AIDS on children. Individual coping skills, trusting relationship with caregivers and social support were suggested to protect children against the negative effects of parental HIV/AIDS. This review underlines the vulnerability of children affected by HIV/AIDS. Culturally and developmentally appropriate evidence-based interventions are urgently needed to promote the psychological well-being of children affected by HIV/AIDS.

Pathways to poor educational outcomes for HIV/AIDS-affected youth in South Africa

A recent systematic review of studies in the developing world has critically examined linkages from familial HIV/AIDS and associated factors such as poverty and child mental health to negative child educational outcomes. In line with several recommendations in the review, the current study modelled relationships between familial HIV/AIDS, poverty, child internalising problems, gender and four educational outcomes: non-enrolment at school, non-attendance, deficits in grade progression and concentration problems. Path analyses reveal no direct associations between familial HIV/AIDS and any of the educational outcomes. Instead, HIV/AIDS-orphanhood or caregiver HIV/AIDS-sickness impacted indirectly on educational outcomes via the poverty and internalising problems that they occasioned. This has implications for evidence-based policy inferences. For instance, by addressing such intervening variables generally, rather than by seeking to target families affected by HIV/AIDS, interventions could avoid exacerbating stigmatisation, while having a more direct and stronger impact on children's educational outcomes. This analytic approach also suggests that future research should seek to identify causal paths, and may include other intervening variables related to poverty (such as child housework and caring responsibilities) or to child mental health (such as stigma and abuse), that are linked to both familial HIV/AIDS and educational outcomes.

Pathways from parental AIDS to child psychological, educational and sexual risk: developing an empirically-based interactive theoretical model

Increasing evidence demonstrates negative psychological, health, and developmental outcomes for children associated with parental HIV/AIDS illness and death. However, little is known about how parental AIDS leads to negative child outcomes. This study used a structural equation modelling approach to develop an empirically-based theoretical model of interactive relationships between parental or primary caregiver AIDS-illness, AIDS-orphanhood and predicted intervening factors associated with children's psychological distress, educational access and sexual health. Cross-sectional data were collected in 2009-2011, from 6002 children aged 10-17 years in three provinces of South Africa using stratified random sampling. Comparison groups included children orphaned by AIDS, orphaned by other causes and non-orphans, and children whose parents or primary caregivers were unwell with AIDS, unwell with other causes or healthy. Participants reported on psychological symptoms, educational access, and sexual health risks, as well as hypothesized sociodemographic and intervening factors. In order to build an interactive theoretical model of multiple child outcomes, multivariate regression and structural equation models were developed for each individual outcome, and then combined into an overall model. Neither AIDS-orphanhood nor parental AIDS-illness were directly associated with psychological distress, educational access, or sexual health. Instead, significant indirect effects of AIDS-orphanhood and parental AIDS-illness were obtained on all measured outcomes. Child psychological, educational and sexual health risks share a common set of intervening variables including parental disability, poverty, community violence, stigma, and child abuse that together comprise chain effects. In all models, parental AIDS-illness had stronger effects and more risk pathways than AIDS-orphanhood, especially via poverty and parental disability. AIDS-orphanhood and parental AIDS-illness impact child outcomes through multiple, interlinked pathways. The interactive model developed in this study suggests key areas of focus for interventions with AIDS-affected children.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Domestic chores workload and depressive symptoms among children affected by HIV/AIDS in China

Limited data are available regarding the effects of domestic chores workload on psychological problems among children affected by HIV/AIDS in China. The current study aims to examine association between children's depressive symptoms and the domestic chores workload (i.e., the frequency and the amount of time doing domestic chores). Data were derived from the baseline survey of a longitudinal study which investigated the impact of parental HIV/AIDS on psychological problems of children. A total of 1449 children in family-based care were included in the analysis: 579 orphaned children who lost one or both parents due to AIDS, 466 vulnerable children living with one or both parents being infected with HIV, and 404 comparison children who did not have HIV/AIDS-infected family members in their families. Results showed differences on domestic chores workload between children affected by HIV/AIDS (orphans and vulnerable children) and the comparison children. Children affected by HIV/AIDS worked more frequently and worked longer time on domestic chores than the comparison children. Multivariate linear regression analysis showed that domestic chores workload was positively associated with depressive symptoms. The data suggest that children affected by HIV/AIDS may face increasing burden of domestic chores and it is necessary to reduce the excessive workload of domestic chores among children affected by HIV/AIDS through increasing community-based social support for children in the families affected by HIV/AIDS.

Longitudinal evaluation of the psychosocial wellbeing of recent orphans compared with non-orphans in a school-attending cohort in KwaZulu-Natal, South Africa

To assess differences in psychosocial wellbeing between recent orphans and non-orphans, we followed a cohort of 157 school-going orphans and 480 non-orphans ages 9-15 in a context of high HIV/AIDS mortality in South Africa from 2004 to 2007. Several findings were contrary to published evidence to date, as we found no difference between orphans and non-orphans in anxiety/depression symptoms, oppositional behavior, self-esteem, or resilience. Female gender, self-reported poor health, and food insecurity were the most important predictors of children's psychosocial wellbeing. Notably, girls had greater odds of reporting anxiety/depression symptoms than boys, and scored lower on self-esteem and resilience scales. Food insecurity predicted greater anxiety/depression symptoms and lower resilience. Perceived social support was a protective factor, as it was associated with lower odds of anxiety/depression symptoms, lower oppositional scores, and greater self-esteem and resilience. Our findings suggest a need to identify and strengthen psychosocial supports for girls, and for all children in contexts of AIDS-affected and economic adversity.

Risk and protective factors for depression symptoms among children affected by HIV/AIDS in rural China: a structural equation modeling analysis

Previous research has revealed a negative impact of orphanhood and HIV-related stigma on the psychological well-being of children affected by HIV/AIDS. Little is known about psychological protective factors that can mitigate the effect of orphanhood and HIV-related stigma on psychological well-being. This research examines the relationships among several risk and protective factors for depression symptoms using structural equation modeling. Cross-sectional data were collected from 755 AIDS orphans and 466 children of HIV-positive parents aged 6-18 years in 2006-2007 in rural central China. Participants reported their experiences of traumatic events, perceived HIV-related stigma, perceived social support, future orientation, trusting relationships with current caregivers, and depression symptoms. We found that the experience of traumatic events and HIV-related stigma had a direct contributory effect on depression among children affected by HIV/AIDS. Trusting relationships together with future orientation and perceived social support mediated the effects of traumatic events and HIV-related stigma on depression. The final model demonstrated a dynamic interplay among future orientation, perceived social support and trusting relationships. Trusting relationships was the most proximate protective factor for depression. Perceived social support and future orientation were positively related to trusting relationships. We conclude that perceived social support, trusting relationships, and future orientation offer multiple levels of protection that can mitigate the effect of traumatic events and HIV-related stigma on depression. Trusting relationships with caregivers provides the most immediate source of psychological support. Future prevention interventions seeking to improve psychological well-being among children affected by HIV/AIDS should attend to these factors.

Anxiety and Depression: Linkages with Viral Diseases

Anxiety and mood disorders are common in the general population in countries around the world. This article provides a review of the recent literature on anxiety and depressive disorders with a focus on linkages with several important viral diseases. Although the majority of studies have been conducted in developed countries such as the United States and Great Britain, some studies have been carried out in less developed nations where only a small percentage of persons with mental illness receive treatment for their condition. The studies summarized in this review indicate that there are important linkages between anxiety and depression and viral diseases such as influenza A (H1N1) and other influenza viruses, varicella-zoster virus, herpes simplex virus, human immunodeficiency virus/acquired immune deficiency syndrome, and hepatitis C. Additional studies are needed to further clarify the mechanisms for interactions between mental health and communicable diseases, in order to assist patients and further prevention and control efforts.