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

Body image, eating distress and emotional-behavioral difficulties among adolescents in Mbarara, Southwestern Uganda

BACKGROUND

Adolescents frequently have emotional and behavioral difficulties as they struggle with the challenges of transition from childhood to adulthood. Many struggle with issues of body image and eating distress as they deal with the difficult and frequently perplexing changes that occur with puberty. Yet there is surprisingly little research on the emotional and behavioral challenges, as well as body image and eating distress among this sizable population in Uganda. This study sought to assess attitudes and behaviors related to body image and eating distress, as well as emotional and behavioral difficulties among adolescents in Mbarara, Southwestern Uganda.

METHODS

This was a cross-sectional study among 788 adolescents aged 13 to 19 years in secondary schools in Mbarara city and Mbarara district in south-western Uganda. The study employed the Body Image and Eating Distress scale to assess attitudes and behaviors about dieting and body shape and the extended version of the Strengths and Difficulties Questionnaire (SDQ) to assess for perceived emotional and behavioral difficulties. Logistic regression was used to identify the association between body image and eating distress and perceived difficulties.

RESULTS

The prevalence of high body image and eating distress was 10.8% while that of perceived emotional and behavioral difficulties was 45.8%. Some of the adolescents (16.1%) were dissatisfied with their body shape, 24.6% exercised a lot to avoid gaining weight, 15.0% were terrified to gain even a little weight, and 12.1% could not control their eating. More males reported eating large amounts of food at one time (p =  < 0.001). Having emotional and behavioral difficulties (aOR: 1.89; 95% CI: 1.18 - 3.02; p = 0.019) and coming from a two-parent household (aOR: 1.79; 95% CI: 1.10 - 2.92; p = 0.019) increased the odds of high body image and eating distress.

CONCLUSION

High levels of body image and eating distress are linked to behavioral and emotional problems and adolescent's family structure. Clinicians who treat adolescents should use a holistic care strategy and be aware of the high prevalence and close association between emotional and behavioral difficulties, concerns about weight, and dieting. It is important to encourage parental involvement and support in providing information about mental health issues among adolescents.

Prevalence and factors associated with depression and anxiety among young school-going adolescents in the Western Cape Province of South Africa

INTRODUCTION

Between 10 and 20% of children and adolescents globally experience common mental health conditions such as depression or anxiety. Given the dearth of mental health services in low- and middle-income countries, most mental health conditions among adolescents remain undiagnosed and untreated. In South Africa, few studies have explored the prevalence of depression and anxiety among young adolescents aged 10-14 years. This study examined the prevalence of, and factors associated with depression and anxiety among young school-going adolescents in the Western Cape Province of South Africa.

METHODS

A cross-sectional study was conducted in 10 schools in the Western Cape Province from February to July 2022. Data were collected using a tablet-based survey and included sociodemographic items, the Generalized Anxiety Disorder 7-item scale (GAD-7), the Patient Health Questionnaire for Adolescents (PHQ-A) and other psychosocial measures. The prevalence of depression and anxiety was estimated based on cut-off scores for the GAD-7 and PHQ-A. Multivariable logistic regression models were used to investigate the associations between sociodemographic and psychosocial factors, and depression and anxiety.

RESULTS

Of the 621 adolescents, 33.5% (n = 208) reported experiencing symptoms of depression and 20.9% (n = 130) symptoms of anxiety potentially indicative of a diagnosis. The results of the multivariable logistic regression model indicate that being in a higher grade in school (AOR = 1.65, CI:1.43-1.92), any lifetime alcohol use (AOR = 1.62, CI:1.04-2.64), other drug use (AOR = 2.07, CI:1.06-4.04), and witnessing violence among adults at home (AOR = 2.12, CI:1.07-1.41) were significantly associated with experiencing depressive symptoms. Being in a higher grade in school (AOR = 1.69, CI: 1.42-2.01), poor emotional regulation skills (AOR = 1.03, CI: 1.00-1.07), and the use of cannabis (AOR = 1.03, CI: 1.00-1.07) were significantly associated with experiencing anxiety symptoms.

CONCLUSION

These findings add to our understanding of school-going adolescents' pressing mental health needs and suggest that mental health adolescent and caregiver interventions may be required to address mental health symptoms and associated risk factors.

Relationship between physical activity and behaviour challenges of adolescents in South Africa

Background

Four out of five adolescents worldwide are physically inactive based on recommended standards.

Aim

We determined whether physical activity is associated with lower behavioural challenges in adolescents to promote buy-in from stakeholders.

Setting

KwaZulu-Natal province, South Africa, from January 2020 to March 2020.

Methods

A cross-sectional study was conducted among 187 adolescent learners (12-18 years) from three government schools in KwaZulu-Natal Province, South Africa, from January to March 2020. We fitted linear regression models between the Strengths and Difficulties Questionnaire scores (total, internalising, externalising, and prosocial) and hours of physical activity exposure, adjusting for demographic covariates, and depression history.

Results

The median age was 14.4 years (interquartile range = 1.36) and 75.9% of the participants were females. Overall average and weekday physical activity were each associated with lower total and externalising but higher pro-social scores. Depression was associated with higher inactivity scores (total, internalising and externalising).

Conclusions

The article shows that physical activity can reduce the behavioural and emotional problems in adolescents.

Contribution

Physical activity is critical for a healthy adolescent hood and needs to be actively included in childhood development.

Impact of the Mediational Intervention for Sensitizing Caregivers on Mentalizing in Orphans and Vulnerable Children in South Africa

The Mediational Intervention for Sensitizing Caregivers (MISC) is a mentalization-based intervention which aims to enhance caregiver sensitivity and responsiveness. MISC has demonstrated treatment effects on mental health problems of Orphans and Vulnerable Children (OVC) in South Africa working with Community-Based Organization (CBO) careworkers as the point of intervention. Recent elaboration of mentalization-based theory points to alternate figures in a child's early environment as critical resources for enhancing children's mentalizing capacity. In this study we evaluated the treatment effect of MISC on children's mentalizing capacity at baseline and following 12-months of the intervention, controlling for the effects of age, gender, orphan status, socioeconomic status, quality of the home environment, and mental health difficulties at baseline. MISC and Treatment as Usual (TAU) groups were compared using a mixed model linear regression. Results demonstrated significant effects of MISC, time, and mental health difficulties on mentalizing capacity. To our knowledge, this study is the first mentalization-based caregiver intervention to demonstrate treatment effects on child mentalizing capacity, and MISC is the first mentalization-based caregiver intervention to focus on paraprofessionals as the point of intervention.

COVID-19 Pandemic Associated With Increased Self-reported Depressive Symptoms in Patients With Congenital Craniofacial Diagnoses

OBJECTIVE

The current study investigated the influence of the coronavirus (COVID-19) pandemic on patients with congenital craniofacial diagnoses.

METHODS

Patients (n = 66) with craniofacial diagnoses aged between 8 and 17 were prospectively evaluated with longitudinal psychosocial assessments using the anger, anxiety, depressive symptoms, and peer relationships instruments within the pediatric Patient-Reported Outcomes Measurement Information System (PROMIS). The COVID-19 cohort (n = 33) included patients with assessments within 2 years prior to the pandemic (t0) and during the pandemic (t1; March 2020 to March 2021). An age-matched comparison cohort (n = 33) with similar demographics and diagnoses included patients assessed twice over 3 years prior to the pandemic.

RESULTS

All PROMIS measures were in the average range clinically for both groups across time points. However, the COVID-19 group reported a significant increase in depressive symptoms during the pandemic (t1) compared to pre-pandemic (t0) scores (48.2 ± 10.1 vs 44.3 ± 9.4, P = .04, d = -0.37), while the comparison group did not demonstrate any differences in psychosocial functioning between t0 and t1. For the COVID-19 cohort, only the pandemic timeframe (r = 0.21, P = .03) was significantly associated with increased depressive symptom scores, and no other sociodemographic or medical variables were associated with depressive symptoms.

CONCLUSIONS

Self-reported depressive symptoms increased during the COVID-19 pandemic in patients with congenital craniofacial diagnoses. Longitudinal studies are needed to elucidate whether such changes will be persistent or compound known variables associated with psychosocial functioning.

Hope and mental health problems among orphans and vulnerable children in South Africa

ABSTRACTThere are over three million orphaned and vulnerable children (OVC) currently living in South Africa. OVC are at high risk for a number of negative outcomes, including poor mental health. Hope has been associated with well-being among youth, including youth in South Africa. However, the relationships between hope and mental health in high-adversity populations such as OVC has not been adequately described. The present study sought to address this research gap by evaluating the relationship between hope and mental health, controlling for gender, age, and orphan status, among OVC. This study includes 8- to 12-year-old OVC (N = 61) in Manguang, Free State, South Africa. Hope was assessed using the Children's Hope Scale (CHS) and mental health outcomes were assessed using the Strengths and Difficulties Questionnaire (SDQ). Hope was significantly, inversely associated with mental health outcomes after controlling for other variables in linear regression analysis. In contrast to previous research, this study found that increased hope scores were associated with adverse mental health outcomes among OVC in South Africa. Hope may be contextualized differently in this population due to resource scarcity and high rates of adversity including HIV-AIDS related stigma and poverty.

Evaluation of physical and mental health status of orphan children living in orphanages in Sonitpur district of Assam: a cross-sectional study

BACKGROUND

Orphan children living in orphanages are often neglected. These children's physical and mental health status is essential as they are highly prone to malnourishment and psychosocial distress. We aim to evaluate the orphan children's physical and psychosocial status living in orphanages.

METHODS

This study adopted a cross-sectional research design conducted with the children living in the orphanages using a pretested, predesigned schedule. A total of 83 children (aged 5 to 19 years) living in three different orphanages in the Sonitpur District of Assam were randomly selected for the study. Body Mass Index (BMI) for age and height were then determined using WHO standards. Thinness was defined as BMI for age below -2 SD (Standard Deviation) and thinness as height for age below -2 SD. The behavioural and mental status of children aged 10-19 years were evaluated using the Strengths and Difficulties Questionnaire (SDQ-21) with a cut-off value of SDQ score > 15 as the presence of emotional and behavioural distress.

RESULTS

Almost 50% of orphans were in the age group of 10-14 years, 62.7% were females, and 42.2% had a primary level of education. 52.5% of orphans exhibited severe thinness for < -3 SD. Observed severe thinness more among the 5-9 years and 10-14 years (p-value < 0.05) group and among the male orphans (p-value < 0.05). Of 65 children aged 10-19, 18.5% had behavioural and mental distress. Emotional (32.3%) and poor conduct problems (23%) were observed significantly among male adolescents.

CONCLUSIONS

Orphaned children, particularly those living in orphanages, are at risk of malnutrition and experience behavioural and psychosocial problems. Frequent assessments of their physical and mental health are advocated for early detection, prevention, and timely intervention.

Association of Major Disease Outbreaks With Adolescent and Youth Mental Health in Low- and Middle-Income Countries: A Systematic Scoping Review

IMPORTANCE

Adolescents and young people have been historically understudied populations, and previous studies indicate that during epidemics, these populations, especially in low- and middle-income countries (LMICs), are at high risk of developing mental disturbances.

OBJECTIVE

To identify the existing evidence regarding the association of mental health with outbreaks of the influenza A (H1N1), Zika, Ebola, and SARS-CoV-2 virus in exposed youth and adolescents in LMICs.

EVIDENCE REVIEW

Across 6 databases (Embase, Cochrane Library, PubMed, PsycINFO, Scopus, and Web of Science), the mental health outcomes of adolescents and youth (aged 10-24 years) associated with 4 major pandemic outbreaks from January 2009 to January 2021 in LMICs were reviewed. A group of 3 authors at each stage carried out the screening, selection, and quality assessment using Joanna Briggs Institute checklists. The social determinants of adolescent well-being framework was used as a guide to organizing the review.

FINDINGS

A total of 57 studies fulfilled the search criteria, 55 related to the SARS-CoV-2 (COVID-19) pandemic and 2 covered the H1N1 influenza epidemics. There were no studies associated with Zika or Ebola outbreaks that met screening criteria. The studies reported high rates of anxiety and depressive symptoms among adolescents, including posttraumatic stress disorder, general stress, and health-related anxiety. Potential risk factors associated with poor mental health outcomes included female sex; home residence in areas with strict lockdown limitations on social and physical movement; reduced physical activity; poor parental, family, or social support; previous exposure to COVID-19 infection; or being part of an already vulnerable group (eg, previous psychiatric conditions, childhood trauma, or HIV infection).

CONCLUSIONS AND RELEVANCE

Results of this systematic scoping review suggest that the COVID-19 pandemic and H1N1 epidemic were associated with adverse mental health among adolescents and youth from LMICs. Vulnerable youth and adolescents may be at higher risk of developing mental health-related complications, requiring more responsive interventions and further research. Geographically localized disease outbreaks such as Ebola, Zika, and H1N1 influenza are highly understudied and warrant future investigation.

Mediational Intervention for Sensitizing Caregivers to Improve Mental Health Outcomes in Orphaned and Vulnerable Children

OBJECTIVE

There is an urgent need to equip community-based careworkers with the skills to address the mental health needs of orphans and vulnerable children (OVC) as an essential response to shortages in human resources for mental health in Sub-Saharan Africa. We conducted a quasi-experimental feasibility trial in South Africa to adapt and evaluate an established year-long semi-structured, manualized video-feedback caregiver intervention (the Mediational Intervention for Sensitizing Caregivers; MISC) for community-based organizations (CBOs).

METHODS

Following a year-long iterative cross-cultural adaptation of MISC, we recruited 88 OVC (ages 7-11; 45.5% girls) and their CBO careworkers (N = 18; 94.4% female). Two CBOs (45 children; 9 CBO careworkers) received 12 months of MISC, and two CBOs (43 children; 9 CBO careworkers) received treatment as usual. Child mental health and quality of caregiving were assessed at 6 months into the intervention and at completion through multi-informant questionnaires and video-recordings of careworker-child interactions. Qualitative interviews were conducted to evaluate feasibility and acceptability.

RESULTS

MISC-CBO was acceptable and feasible in terms of attendance and post-intervention interviews. MISC improved child mental health, as well as the quality of careworker caregiving in terms of interactive effects for affective and cognitive (Expanding) components of MISC, and main effects for the cognitive components of Rewarding and Provision of meaning. MISC components did not mediate the effects of the intervention.

CONCLUSIONS

The current study shows that laypersons with no tertiary education and virtually no prior training who undergo MISC training can improve caregiving quality and the mental health of OVCs.

Psychometric properties of the ASEBA Child Behaviour Checklist and Youth Self-Report in sub-Saharan Africa - A systematic review

OBJECTIVE

Behavioural screening tools may be used to identify at-risk children in resource-limited settings in sub-Saharan Africa. The ASEBA forms (Child Behaviour Checklist and Youth Self-Report) are frequently translated and adapted for use in sub-Saharan African populations, but little is known about their measurement properties in these contexts.

METHODS

We conducted a systematic review of all published journal articles that used the ASEBA forms with sub-Saharan African samples. We evaluated the reported psychometric properties, as well as the methodological quality of the psychometric evaluations, using COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidelines.

RESULTS

Fifty-eight studies reported measurement properties of the ASEBA forms. Most studies came from Southern (n = 29, 50%) or East African (n = 25, 43%) countries. Forty-nine studies (84%) used translated versions of the tool, but details regarding the translation process, if available, were often sparse. Most studies (n = 47, 81%) only reported internal consistency (using coefficient alpha) for one or more subscale. The methodological quality of the psychometric evaluations ranged from 'very good' to 'inadequate' across all measurement properties, except for internal consistency.

CONCLUSIONS

There is limited good quality psychometric evidence available for the ASEBA forms in sub-Saharan Africa. We recommend (i) implementing a standardised procedure for conducting and reporting translation processes and (ii) conducting more comprehensive psychometric evaluations of the translated versions of the tools.

Screen Time and Mental Health Among Adolescents: Implications of the Rise in Digital Environment in South Africa

The rise in use of digital technology among adolescents is unquestionable, with few studies having explored the effect of screen time on mental or behavior challenges in sub-Saharan Africa. We investigated the extent of screen time and its associations with mental/behavior challenges in South Africa. A multisite study was conducted among adolescents aged 15 to 17 years from three government schools in KwaZulu-Natal Province, South Africa. Measures included depressive symptoms (using Patient Health Questionnaire-9), behavioral problems (using Strengths and Difficulties Questionnaire), and screen time (using Children's Leisure Activities Study Survey). The prevalence of severe depressive symptoms, conduct features, and negative prosocial behavior was 11.2% (n = 20), 13.6% (n = 25), and 4.9% (n = 9), respectively. The mean screen time was 2.1 h/d (SD = 2.4) during weekday and 4.7 h/d (SD = 5.5) during weekend. Weekend screen time was significantly associated with a greater likelihood of severe depression and conduct challenges, based on multivariable regression. We also found that greater weekend cell phone use was significantly associated with lower prosocial behavior. No role of weekday screen time was detected in this study. Parents or legal guardians need to be aware of their children's weekend screen time, including cell phones, as access to digital devices becomes more ubiquitous in resource-limited settings.

The potential impact of the COVID-19 pandemic on child growth and development: a systematic review

OBJECTIVE

This was a systematic review of studies that examined the impact of epidemics or social restriction on mental and developmental health in parents and children/adolescents.

SOURCE OF DATA

The PubMed, WHO COVID-19, and SciELO databases were searched on March 15, 2020, and on April 25, 2020, filtering for children (0-18 years) and humans.

SYNTHESIS OF DATA

The tools used to mitigate the threat of a pandemic such as COVID-19 may very well threaten child growth and development. These tools - such as social restrictions, shutdowns, and school closures - contribute to stress in parents and children and can become risk factors that threaten child growth and development and may compromise the Sustainable Development Goals. The studies reviewed suggest that epidemics can lead to high levels of stress in parents and children, which begin with concerns about children becoming infected. These studies describe several potential mental and emotional consequences of epidemics such as COVID-19, H1N1, AIDS, and Ebola: severe anxiety or depression among parents and acute stress disorder, post-traumatic stress, anxiety disorders, and depression among children. These data can be related to adverse childhood experiences and elevated risk of toxic stress. The more adverse experiences, the greater the risk of developmental delays and health problems in adulthood, such as cognitive impairment, substance abuse, depression, and non-communicable diseases.

CONCLUSION

Information about the impact of epidemics on parents and children is relevant to policy makers to aid them in developing strategies to help families cope with epidemic/pandemic-driven adversity and ensure their children's healthy development.

A Systematic Review of Some Reliability and Validity Issues regarding the Strengths and Difficulties Questionnaire Focusing on Its Use in Out-of-Home Care

PURPOSE

A systematic review was conducted to analyze the inter-rater reliability, cross-informant consistency, test-retest reliability, and temporal stability of the Strengths and Difficulties Questionnaire (SDQ), and its ability to discriminate.

METHOD

We searched three databases for articles about the SDQ (parent, teacher, and self-report version), used samples of children up to age 18 and reported inter-rater reliability, cross-informant reliability, test-retest reliability, temporal stability, specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Focusing on the TDS, inter-rater, and cross-informant reliability showed acceptable values, but respondent types (e.g., mothers and fathers) are not interchangeable. Test-retest reliability and temporal stability were also acceptable, and not excessively high. Specificity and NPV were acceptable but not sensitivity and PPV.

DISCUSSION AND CONCLUSION

Greater transparency is needed about who the respondent is when the term "parents" is used. The SDQ is an important supplement to service-as-usual assessments by social care professionals.

Measuring children's emotional and behavioural problems: are SDQ parent reports from native and immigrant parents comparable?

BACKGROUND

The number of immigrants worldwide is growing and migration might be a risk factor for the mental health of children. A reliable instrument is needed to measure immigrants' childrens mental health. The aim of the study was to test the measurement invariance of the parent version of the Strengths and Difficulties Questionnaire (SDQ) between German native, Turkish origin and Russian origin immigrant parents in Germany. The SDQ is one of the most frequently used screening instruments for mental health disorders in children.

METHODS

Differential Item Functioning (DIF) was tested in samples matched by socio-economic status, age and gender of the child. A logistic regression/item response theory hybrid method and a multiple indicators- multiple causes model (MIMIC) was used to test for DIF. Multi Group Confirmatory Factor analysis (MGCFA) was used to test for configural invariance. Parent reports of 10610 German native, 534 Russian origin and 668 Turkish origin parents of children aged 3-17 years were analysed.

RESULTS

DIF items were found in both groups and with both methods. We did not find an adequate fit of the original five factor model of the SDQ for the Turkish origin group, but for the Russian origin group. An analysis of functional equivalence indicated that the SDQ is equally useful for the screening of mental health disorders in all three groups.

CONCLUSION

Using the SDQ in order to compare the parent reports of native and immigrant parents should be done cautiously. Thus, the use of the SDQ in epidemiological studies and for prevention planning is questionable. However, the SDQ turns out to be a valid instrument for screening purposes in parents of native and immigrant children.

A qualitative study on teachers' perceptions of their learners' mental health problems in a disadvantaged community in South Africa

Background

The combination of extensive poverty, violence and HIV has potential mental health impacts on children in Southern Africa. This article is nested in a broader study to evaluate the strength and difficulties questionnaire (SDQ) among Sotho speakers, and assess the mental health status of children made orphans by AIDS.

Objectives

The aim of this study was to describe the mental health problems that the teachers perceive among learners in their classrooms, to understand what the teachers saw as causing these problems and to identify potential approaches to address these problems within the school setting.

Method

As part of the larger study, 10 teachers were purposively selected to write a report describing the mental health problems among learners in their class. These findings were discussed at two later meetings with a larger grouping of teachers to validate the findings and obtain additional input.

Results

The teachers were concerned about the emotional state of their pupils, especially in relation to depression, anxiety, substance abuse, scholastic problems and aggression. These problems were felt to arise from the children’s lived context; factors such as poverty, death of parents and caregivers from AIDS and trauma, parental substance abuse and child abuse. The teachers expressed a desire to assist the affected learners, but complained that they did not get support from the state services.

Conclusion

Many learners were evaluated by teachers as struggling with mental health issues, arising from their social context. The teachers felt that with support, schools could provide assistance to these learners.

Neurodevelopmental and behavioural outcomes of HIV-exposed uninfected and HIV-unexposed children at 2-3 years of age in Cape Town, South Africa

Successful vertical HIV transmission prevention programmes (VTP) have resulted in an expanding population of HIV-exposed uninfected (HEU) infants whose growth, health and neurodevelopmental outcomes could have consequences for future resource allocation. We compared neurodevelopmental and behavioural outcomes in a prospective cohort of 2-3 year old HEU and HIV-unexposed uninfected (HU) children.Women living with and without HIV and their infants were enrolled within three days of birth from a low-risk midwife obstetric unit in Cape Town, South Africa during 2012 and 2013, under WHO Option A VTP guidelines. HIV-uninfected children aged 30-42 months were assessed using the Bayley scales of Infant Development-Third edition (BSID) and Strengths and Difficulties questionnaire (SDQ).Thirty-two HEU and 27 HU children (mean birth weight 3048g vs 3096g) were assessed. HEU children performed as well as HU children on BSID cognitive, language and motor domains. Mean scores fell within the low average range. Mothers of HEU children reported fewer conduct problems but stunting was associated with increased total difficulties on the SDQ.HEU and HU children's performance on the BSID was similar. In this low-risk cohort, HIV exposure did not confer additional risk. Stunting was associated with increased behavioural problems irrespective of HIV exposure.

Building Laboratory-Based Arbovirus Sentinel Surveillance Capacity During an Ongoing Dengue Outbreak, Burkina Faso, 2017

In West Africa, identification of nonmalarial acute febrile illness (AFI) etiologic pathogens is challenging, given limited epidemiologic surveillance and laboratory testing, including for AFI caused by arboviruses. Consequently, public health action to prevent, detect, and respond to outbreaks is constrained, as experienced during dengue outbreaks in several African countries. We describe the successful implementation of laboratory-based arbovirus sentinel surveillance during a dengue outbreak in Burkina Faso during fall 2017. We describe implementation, surveillance methods, and associated costs of enhanced surveillance during an outbreak response as an effort to build capacity to better understand the burden of disease caused by arboviruses in Burkina Faso. The system improved on existing routine surveillance through an improved case report form, systematic testing of specimens, and linking patient information with laboratory results through a data management system. Lessons learned will improve arbovirus surveillance in Burkina Faso and will contribute to enhancing global health security in the region. Elements critical to the success of this intervention include responding to a specific and urgent request by the government of Burkina Faso and building on existing systems and infrastructure already supported by CDC's global health security program.

School connectedness as psychological resilience factor in children affected by HIV/AIDS

Children affected by HIV/AIDS are at high risk for poor mental health outcomes. Social and psychological connectedness to school has been identified as an important resilience factor for youth affected by adversity (Centers for Disease Control and Prevention. (2009). School connectedness: Strategies for increasing protective factors among youth. Atlanta, GA: U.S. Department of Health and Human Services). Defined as "the belief by students that adults in the school care about their learning as well as about them as individuals" (Centers for Disease Control and Prevention. (2009). School connectedness: Strategies for increasing protective factors among youth. Atlanta, GA: U.S. Department of Health and Human Services), school connectedness has been shown to be associated with higher academic performance, increased mental health, and quality of life. However, few studies have examined school connectedness in sub-Saharan Africa, and none have examined school connectedness in relation to mental health in children orphaned by HIV/AIDS. Further, existing studies have relied on self-report measures. Against this background, the aim of the current study was to examine orphan status, school connectedness, and their interaction in relation to child mental health by using a multimethod design. 750 children between the ages of 7-11, recruited through South African community-based organizations (224 AIDS/HIV orphans, 276 non-AIDS/HIV orphans, 250 non-orphans; 51.2% girls), completed measures of school connectedness; children, caregivers, and teachers reported on child well-being using the Strengths and Difficulties Questionnaire. AIDS/HIV and non-AIDS/HIV orphans reported lower school connectedness than non-orphans. However, results demonstrated significant relations between school connectedness and overall mental health regardless of group, suggesting that school connectedness buffers against negative mental health outcomes regardless of orphan status. This study identifies a strategic point of intervention to build resilience against the cascading effects of HIV/AIDS and poverty in children in sub-Saharan Africa.

A systematic review of tools used to screen and assess for externalising behaviour symptoms in low and middle income settings

BACKGROUND

Mental health issues, often manifested as behavioural difficulties, in children are estimated to be high in low and middle-income countries (LMIC) settings. There is a paucity of definitive data due to a lack of well-validated tools to use across settings. This review aims to provide evidence on what tools are used and which have been adapted and validated in LMIC settings.

METHODS

We performed a systematic review to identify tools used to assess or screen externalising behaviour problems in children and adolescents in LMIC and assess their cultural adaptations. We searched for studies measuring externalising behaviour in children from 0 to 19 years published up to September 2018. Articles were assessed to identify tools used and analysed using the Ecological Validity Framework.

RESULTS

We identified 82 articles from over 50 LMICs who had studied externalising behaviour in children. Twenty-seven tools were identified, with a predominance of studies using tools from the USA and Europe. Most studies did not describe an adaptation and evaluation process, with only one study following recommended criteria. New tools were identified which both screen and assess externalising behaviour which have not yet been utilised across settings.

CONCLUSIONS

Although tools from the USA and Europe are often utilised to screen and assess for externalising behaviour problems in children in LMICs, the conceptual frameworks behind the use of these tools in other cultural contexts are not always carefully examined. In order to have valid data across cultures, we should aim to adapt and validate tools before use. Provision of processes to validate tools across LMIC settings would be beneficial.

Validation of an HIV/AIDS Stigma Measure for Children Living with HIV and Their Families

BACKGROUND

There are few validated tools to measure stigma, particularly among children living with HIV and their families.

METHODS

This study was nested within a larger study that followed 240 child-caregiver dyads (children aged 10-15 years) at 8 clinics in western Kenya. The stigma instrument was administered to all child-caregiver dyads at 2 time points 6 months apart. The primary end point was to construct validity assessed by comparison to criterion constructs using generalized estimating equation models.

RESULTS

Mean age of child participants was 12.3 years and 52% were female. Generally, caregivers reported experiencing higher levels of HIV stigma compared to their children. Children (9%) and caregivers (14%) reported that HIV stigma made them feel stressed, anxious, and depressed. Child and caregiver stigma items showed high construct validity by emotional and behavioral outcomes.

CONCLUSIONS

The stigma instrument showed high validity when compared to emotional and behavioral outcomes.

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.

A Descriptive Study on Behavioral and Emotional Problems in Orphans and Other Vulnerable Children Staying in Institutional Homes

INTRODUCTION

Orphans and the other vulnerable children and adolescents (OVCA) living in institutional homes are more prone to behavioral and emotional problems than others as they are deprived of a family's love and care. There is a dearth of studies focusing on the psychological health of these children in India. Hence, we have conducted a cross-sectional descriptive study to explore the behavioral and emotional problems in these institutionalized children.

MATERIALS AND METHODS

The sample consisted of 292 orphans and OVCA in institutional homes of Visakhapatnam city. The sociodemographic data were collected using a semi-structured questionnaire. The Strengths and Difficulties Questionnaire (SDQ) with impact supplement was used to assess the behavioral and emotional problems in them.

RESULTS

In our study, 49 (16.78%) out of 292 children and adolescents were found to be having behavioral and emotional problems. Factors such as age, sex, reason for being in the institute, age of admission, and years of stay in the home were all seen to be significantly associated (P < 0.05) with emotional and behavioral problems. Conduct problems (34.90%) were found to be most prevalent followed by peer problems (15.80%), emotional problems (14.70%), hyperactivity (8.60%), and low prosocial behavior (3.40%).

CONCLUSION

The present study shows that the orphans and OVCA in institutional homes are vulnerable to behavioral and emotional problems. The screening for conduct problems, emotional problems, hyperactivity, and peer problems needs to be done at a regular basis for these children. Given the paucity of data in this regard, several multicenter studies also need to be done to get an overall comprehensive view of these problems.

The Strengths and Difficulties Questionnaire (SDQ) in Africa: a scoping review of its application and validation

BACKGROUND

Child and adolescent mental health in Africa remains largely neglected. Quick and cost-effective ways for early detection may aid early intervention. The Strengths and Difficulties Questionnaire (SDQ) is globally used to screen for mental health problems, but little is known about its use in Africa. We set out to perform a scoping review to examine existing studies that have used the SDQ in Africa.

METHODS

A comprehensive scoping review methodology was used to identify all peer-reviewed studies ever published that have used the SDQ in Africa. Data were extracted and analysed to assess the countries, languages and SDQ versions used, the purpose of the SDQ studies, psychometric properties of the SDQ, and to consider knowledge gaps for future in-country and cross-country studies.

RESULTS

Fifty-four studies from 12 African countries were identified, most from South Africa. Many different languages were used, but authorized SDQs in those languages were not always available on the SDQinfo website. Authors frequently commented on challenges in the translation and backtranslation of mental health terminology in African languages. The SDQ was typically used to investigate internalisation/externalization disorders in different clinical populations, and was most frequently used in the evaluation of children and adolescents affected by HIV/AIDS. Sixteen studies (29.6%) administered the SDQ to participants outside the intended age range, only 4 (7.4%) used triangulation of all versions to generate assessments, and eight studies (14.8%) used only subscales of the SDQ. Only one study conducted thorough psychometric validation of the SDQ, including examination of internal consistency and factor analysis. Where 'caseness' was defined in studies, UK cut-off scores were used in all but one of the studies.

CONCLUSIONS

The SDQ may be a very useful tool in an African setting, but the scoping review suggested that, where it was used in Africa researchers did not always follow instrument guidelines, and highlighted that very little is known about the psychometric properties of the SDQ in Africa. We recommend comprehensive evaluation of the psychometric properties of the SDQ in various African languages, including internal consistency, factor structure, need for local cut-off values and ensuring cultural equivalence of the instrument.

Cognitive and physical development in HIV-positive children in South Africa and Malawi: A community-based follow-up comparison study

BACKGROUND

Child development is negatively impacted by HIV with children that are infected and affected by HIV performing worse than their peers in cognitive assessments.

METHODS

We conducted a descriptive follow-up comparison study (n=989) in South Africa and Malawi. We tracked child development in 135 HIV-positive children compared to 854 uninfected children aged 4-13 years attending community-based organizations at baseline and again 12-15 months later.

RESULTS

Children with HIV were more often stunted (58.8% vs. 27.4%) and underweight (18.7% vs. 7.1%). They also had significantly poorer general physical functioning (M=93.37 vs. M=97.00). HIV-positive children scored significantly lower on digit span and the draw-a-person task.

CONCLUSIONS

These data clearly show that HIV infection poses a serious risk for child development and that there is a need for scaled up interventions. Community-based services may be ideally placed to accommodate such provision and deliver urgently needed support to these children.

Adjustment of a Population of South African Children of Mothers Living With/and Without HIV Through Three Years Post-Birth

Mothers living with HIV (MLH) and their children are typically studied to ensure that perinatal HIV transmission is blocked. Yet, HIV impacts MLH and their children lifelong. We examine child outcomes from pregnancy to 3 years post-birth among a peri-urban population of pregnant MLH and mothers without HIV (MWOH). Almost all pregnant women in 12 neighborhoods (98 %; N = 584) in Cape Town, South Africa were recruited and repeatedly assessed within 2 weeks of birth (92 %), at 6 months (88 %), 18 months (84 %), and 3 years post-birth (86 %). There were 186 MLH and 398 MWOH. Controlling for neighborhood and repeated measures, child and maternal outcomes were contrasted over time using longitudinal random effects regression analyses. For measures collected only at 3 years, outcomes were analyzed using multiple regressions. Compared to MWOH, MLH had less income, more informal housing and food insecurity, used alcohol more often during pregnancy, and were more depressed during pregnancy and over time. Only 4.8 % of MLH's children were seropositive; seropositive children were excluded from additional analyses. Children of MLH tended to have significantly lower weights (p < .10) over time (i.e., lower weight-for-age Z-scores) and were also hospitalized significantly more often than children of MWOH (p < .01). Children of MLH and MWOH died at similar rates (8.5 %) and were similar in social and behavioral adjustment, vocabulary, and executive functioning at 3 years post-birth. Despite living in households with fewer resources and having more depressed mothers, only the physical health of children of MLH is compromised, compared to children of MWOH. In township neighborhoods with extreme poverty, social, behavioral, language, and cognitive functioning appear similar over the first three years of life between children of MLH and MWOH.

Intimate Partner Violence and Child Behavioral Problems in South Africa

BACKGROUND

Research in high-income countries has repeatedly demonstrated that intimate partner violence (IPV) experienced by women negatively affects the health and behavior of children in their care. However, there is little research on the topic in lower- and middle-income countries. The population-based Asenze Study gathered data on children and their caregivers in KwaZulu-Natal, South Africa. This data analysis explores the association of caregiver IPV on child behavior outcomes in children <12 years old and is the first such study in Africa.

METHODS

This population-based study was set in 5 Zulu tribal areas characterized by poverty, food insecurity, unemployment, and a high HIV prevalence. The Asenze Study interviewed caregivers via validated measures of IPV, alcohol use, caregiver mental health difficulties, and child behavior disorders in their preschool children.

RESULTS

Among the 980 caregivers assessed, 37% had experienced IPV from their current partner. Experience of partner violence (any, physical, or sexual) remained strongly associated with overall child behavior problems (odds ratio range: 2.46-3.10) even after age, HIV status, cohabitation with the partner, alcohol use, and posttraumatic stress disorder were accounted for.

CONCLUSIONS

Childhood behavioral difficulties are associated with their caregiver's experience of IPV in this population, even after other expected causes of child behavior difficulties are adjusted for. There is a need to investigate the longer-term impact of caregiver partner violence, particularly sexual IPV, on the health and well-being of vulnerable children in lower- and middle-income countries. Studies should also investigate whether preventing IPV reduces the occurrence of childhood behavior difficulties.

Cognition, behavior, and the ILAE Classification of the Epilepsies: A view from Africa

Recent ILAE revisions to the definition and classification of the epilepsies have highlighted cognitive-behavioral comorbidities (CBCs). Integrating a CBC dimension within a formal classification scheme would more fully account for the burden of epilepsy. This would be technically challenging, because we use fundamentally different methods to conceptualize, define, and diagnose CBCs that require additional expertise. In low resource settings such as sub-Saharan Africa (SSA), CBC burden is high. Existing classification systems are inevitably simplified in practice, because complex classifications require training and technologies that rarely exist in these settings. This makes low-resource settings a good place to develop simple methods to integrate CBCs into existing classifications so that they ultimately will communicate the full burden of epilepsy. This article is part of a Special Issue entitled "The new approach to classification: Rethinking cognition and behavior in epilepsy".

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.

Evaluating mental health difficulties and associated outcomes among HIV-positive adolescents in Tanzania

AIDS-related mortality among HIV-positive adolescents has risen by 50% despite the scale up of antiretroviral therapy (ART). ART maladherence likely plays a role in the increase of AIDS-related deaths among adolescents and has shown to be associated with psychosocial and mental health difficulties. Addressing the specific mental health needs of HIV-positive adolescents is critical to ending the HIV epidemic. This cross-sectional study prospectively enrolled HIV-positive adolescents (12-24 years) in Moshi, Tanzania. A structured questionnaire was administered that included questions about home, school, adherence, and measures of stigma (Berger Stigma Scale) and mental health. Mental health measures included depression (Patient Health Questionnaire-9), emotional/behavioral difficulties (Strengths and Difficulties Questionnaire), and traumatic experiences/post-traumatic stress symptoms (The University of California Los Angeles-post-traumatic stress disorder-Reaction Index). Mental health difficulties were prevalent among HIV-positive adolescents and were associated with incomplete adherence and stigma. Resources are needed to reduce HIV stigma and address mental health among HIV-positive adolescents in low-resource settings. This will improve not only mental health, but may also improve ART adherence and virologic suppression, improving overall health of the individual and reducing the risk of HIV transmission to others.

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.

Socio-economic status and socio-emotional health of orphans in South Africa

This paper investigates the relationship between socio-economic status and emotional well-being of orphans in Mangaung, South Africa. Five hundred orphans aged 7-11 years participated in the cross-sectional study between 2009 and 2012. Data was collected by trained fieldworkers, who conducted face-to-face interviews and questionnaires with the orphans, their teachers and caregivers, and the heads of the households where the orphans resided. The caregivers, children and teachers all completed the Strengths and Difficulties Questionnaire in order to measure the orphans' mental health, while heads of household provided information about socio-economic indicators. STATA version 12 was used to perform multivariate data analyses to identify socio-economic factors associated with the mental health of orphans. Food security, access to medical services and a male caregiver were factors associated with better emotional well-being of orphans, whereas other variables such as household asset index and monthly household expenditure were not linked with the orphans' mental health. Two of the three variables (food security and access to medical services) associated with better emotional well-being of orphans are also government interventions to assist orphans. Further research is needed to determine whether other government programs also impact the emotional well-being of orphans.

Direct and Indirect Effects of Caregiver Social Support on Adolescent Psychological Outcomes in Two South African AIDS-Affected Communities

Caregiver social support has been shown to be protective for caregiver mental health, parenting and child psychosocial outcomes. This is the first known analysis to quantitatively investigate the relationship between caregiver social support and adolescent psychosocial outcomes in HIV-endemic, resource-scarce Southern African communities. A cross-sectional household survey was conducted over 2009-2010 with 2,477 South African adolescents aged 10-17 and their adult caregivers (18 years or older) in one urban and one rural community in South Africa's KwaZulu-Natal province. Adolescent adjustment was assessed using adult caregiver reports of the Strengths and Difficulties questionnaire (SDQ), which measures peer problems, hyperactivity, conduct problems, emotional symptoms and child prosocial behavior. Hierarchical linear regressions and multiple mediation analyses, using bootstrapping procedures, were conducted to assess for: (a) direct effects of more caregiver social support on better adolescent psychosocial wellbeing; and (b) indirect effects mediated by better parenting and caregiver mental health. Direct associations (p < .001), and indirect associations mediated through better parenting, were found for all adolescent outcomes. Findings reinforce the importance of social support components within parenting interventions but also point to scope for positive intervention on adolescent psychosocial wellbeing through the broader family social network.

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.