Lifetime incidences of traumatic events and mental health among children affected by HIV/AIDS in rural China

The Relationship Between Negative Self-Concept, Trauma, and Maltreatment in Children and Adolescents: A Meta-Analysis

Experiencing trauma in childhood is a global public health issue linked to worse physical and mental health outcomes, including Post-Traumatic Stress Disorder (PTSD). Self-concept is a transdiagnostic concept linked to various psychopathologies and understanding its unique relationship to trauma is important. This meta-analysis aimed to understand the size of the effect between trauma and maltreatment and self-concept in children and adolescents. The current meta-analysis searched PubMed, PILOTS, PsycINFO, and Web of Science databases. Inclusion criteria involved studies with defined trauma exposure, valid measures of self-concept, and participants' mean age under 18 years old. One-hundred-and-thirty-four studies were included in the meta-analysis (N = 255,334). A random-effects meta-analysis was performed. A small negative relationship was observed between trauma exposure and self-concept (r = - 0.20, 95% CI - 0.22, - 0.18). This relationship was significantly moderated by some variables (type and nature of trauma exposure) but not others (participant gender, type of self-concept measure, quality of studies, country economic status). A small relationship between trauma exposure and negative self-concept in children and adolescents was detected, with repeated trauma exposure and type of trauma exposure moderating this relationship. This provides important directions for clinical practice around providing support for those exposed or most vulnerable to experiencing trauma.

Identifying the Mental Health Effects of Cumulative Traumatic Exposure in HIV-Affected Youth: A Longitudinal Assessment

INTRODUCTION

Traumatic events (TEs) in early life can precede adult psychopathology. Limited research exists on this relationship in young adults with perinatally acquired HIV-infection (PHIV) or perinatal HIV-exposure without infection (PHEU), who often experience social and health disparities. This study examined TEs experienced in childhood/adolescence and their association with psychiatric and substance use disorders in young adults with PHIV and PHEU.

METHODS

Participants in a New York City-based longitudinal cohort study were assessed for TE exposure at enrollment (mean age = 12 years) and the first 2 follow-up interviews. Past-year psychiatric and substance use disorders were evaluated via psychiatric interview (DISC-IV) at the fifth follow-up interview (mean age = 22 years). Unadjusted and adjusted logistic regression models assessed associations between cumulative childhood/adolescence TEs and young adult psychiatric and substance use outcomes. Group differences were tested for PHIV and PHEU subgroups.

RESULTS

Among 236 participants (60% Black, 51% Latinx), mean cumulative traumatic event count was 3.09 (SD = 1.77); 26% had a past-year psychiatric diagnosis, and 28% had a past-year substance use diagnosis. Increased TEs were associated with past-year psychiatric diagnoses in young adulthood [average marginal effects (AME) 4.21, 95% confidence interval (CI): 0.83 to 7.58]; for PHEU participants, increased TEs were associated with a past-year substance use disorder (AME 15.67, 95% CI: 8.08 to 23.25).

CONCLUSIONS

High levels of TEs in childhood/adolescence may contribute to psychiatric and substance use disorders in young adults with PHIV or PHEU. Research exploring relationships between TE exposure and later psychiatric problems is needed to inform interventions for HIV-affected youth.

Enacted Stigma Influences Bereavement Coping Among Children Orphaned by Parental AIDS: A Longitudinal Study with Network Analysis

Purpose

The study aims to understand how enacted stigma influences bereavement coping at the style (scale) level and the specific pathways at the strategy (item) level.

Methods

The longitudinal data of 755 children orphaned by parental Acquired Immune Deficiency Syndrome (AIDS) in rural China were used. Grief processing and deliberate grief avoidance were measured at wave 1 (baseline) and wave 2 (one-year follow-up) to reflect bereavement coping in the contexts of being with family members, being with friends, being with community members, and being alone. Enacted stigma that measured at wave 1 was used to assess the experienced stigma of these AIDS-orphaned children. Network analyses were run following regressions.

Results

Controlling for demographics and baseline-level bereavement coping, multivariate regressions revealed that enacted stigma at wave 1 significantly predicted grief processing and deliberate grief avoidance at wave 2. Network analyses showed that, for grief processing, stigma increased searching for meaning alone and with friends and expressing feelings to community members, which then provoked the same strategy across contexts. Meanwhile, stigma triggered the deliberate grief avoidance network by initially suppressing the expression of feelings to community members.

Conclusion

Enacted stigma contributes to bereavement coping. Stigma stirs up complex feelings but forces AIDS-orphaned children to suppress expressions, and it increases needs to process grief through meaning making but cuts supporting forces by promoting avoidance. Interventions are imperative to reduce stigma, improve emotion regulation, and facilitate meaning making for people bereaved by stigmatized deaths.

The role of social-psychological factors of victimity on victimization of online fraud in China

Introduction

The high incidence of online fraud in China poses a great threat to the social stability and property security of society. Victimity is the state or mindset of victims, referring to the various conditions related to being victims of crimes. Examining the association between the inherent and extrinsic factors of victimity and victimization of online fraud is of great importance for revealing the psychological mechanism of victimization and drawing up preventative measures.

Methods

Through the questionnaire survey of 504 online fraud victims and 523 non-victims, univariate analysis and logistic regression analysis were used to investigate the risk factors correlated with victimization.

Results

Age, education, and social support are positively correlated with fraud victimization, while impulsiveness, trust tendency, smartphone usage, and negative life experiences are negatively correlated with fraud victimization. Subsequent regression analyses showed that all the factors above, except for smartphone usage, are significant predictors for online fraud victimization.

Discussion

Our conceptual model and empirical results demonstrate the important role of victimity in making an individual become a victim and help clarify the mixed findings of previous studies on the risk factors for online fraud.

Future Orientation Among Children Affected by Parental HIV in China: An Exploratory Analysis of Complex Interactions

We utilized an exploratory analytic approach to examine predictors of children's future beliefs, an internal asset associated with resilience among children affected by HIV, with emphasis on complex interactions among multisystem factors. Children (N = 1221) affected by parental HIV in China reported on psychosocial functioning, as well as internal, familial, and community resilience assets. Exploratory data analysis was conducted using a binary segmentation program. Six binary splits on predictors accounted for 22.78% of the variance in future expectation, suggesting interactions between children's perceived control of their future, loneliness, caregiver trust, and social support. Four binary splits accounted for 23.15% of the variance in future orientation, suggesting multiway interactions between control of the future, loneliness, social support, and perceived stigma. Findings suggest combinations of resilience factors are associated with children's positive future beliefs. Implications for screening, prevention, and intervention among Chinese children affected by parental HIV are discussed.

Does HIV-Related Stigma Depress Social Well-Being of Youths Affected by Parental HIV/AIDS?

Parental illness or death due to HIV/AIDS has long-term impacts on children's social well-being, potentially challenging the children's basic developmental needs and future. Based on the theoretical model of social well-being, the present study tested a moderated mediation model that HIV-related stigma moderated the mediating role of social trust on the relationship between perceived social support (PSS) and social well-being. A sample of 297 youths aged 20-30 years affected by parental HIV/AIDS (57.2% male), including 129 (43.40%) AIDS orphans and 168 vulnerable youths (56.60%) completed questionnaires of perceived social support, social well-being, social trust, and HIV-related stigma. IBM SPSS 25.0 was used to conduct descriptive statistics and multiple regressions. Results showed that the mean score of PSS was 61.34 (SD = 13.99), social well-being was 57.33 (SD = 10.15), social trust was 56.21 (SD = 11.55), perceived stigma was 64.44 (SD = 16.72), and enacted stigma was 21.91 (SD = 9.73) among youths affected by parental HIV/AIDS and the PSS could predict increasing social well-being via increasing social trust. Moreover, the positive influence of PSS on social trust was moderated by the enacted stigma (p = 0.03), in which the positive influence was stronger among youths affected by parental HIV/AIDS who perceived or experienced low enacted stigma than those who perceived or experienced high enacted stigma. The positive impact of social trust on social well-being was moderated by perceived stigma (p = 0.04), in which the positive impact was more significant among youths affected by parental HIV/AIDS who perceived or experienced high perceived stigma than those who perceived or experienced low perceived stigma. These findings explained how and when the PSS affected social well-being and contributed toward an understanding of the experiences and perceptions of HIV-related stigma among youths affected by parental HIV/AIDS. This understanding may inform future research and policies toward improving the social well-being of youths affected by parental HIV/AIDS. The study also highlighted the importance of strengthening interventions on social relations and reducing HIV-related stigma for them.

Effects of a Multilevel Resilience-Based Intervention on Mental Health for Children Affected by Parental HIV: A Cluster Randomized Controlled Trial

The present study aimed to examine the efficacy of the Child-Caregiver-Advocacy Resilience (ChildCARE) intervention, a multilevel resilience-based psychosocial intervention, on mental health outcomes, including depressive symptoms, school anxiety, and loneliness, among children affected by parental HIV in central China. Seven hundred and ninety children (51.6% boys, 6-17 years of age) affected by parental HIV were randomly assigned by cluster to a control group or one of three intervention groups designed to test the three conditions of the ChildCARE intervention (child-only, child + caregiver, child + caregiver + community). Linear mixed-effects modeling was performed to test the intervention effect at 6, 12, and 18 months. The intervention did not yield significant changes in mental health outcomes in the child-only group at any follow-ups, whereas significant reductions in depressive symptoms and loneliness were observed in the child + caregiver group at 12 months. The observed intervention effects were not sustained at 18 months. Also, children who received the additional community component that, was implemented after 12 months did not show larger improvements in mental health outcomes than the control group at 18 months. Lastly, older children (i.e., ≥12 years) were found to benefit more from the intervention than their younger counterparts (i.e., <12 years). Overall, the findings provide some support for the promise of multilevel resilience-based interventions in improving mental health of children affected by parental HIV, but more research is needed to further determine whether multilevel resilience-based interventions can yield sustained effects on mental health.

Long-Term Trajectories of Depressive Symptoms Among Children Affected by Parental HIV: A 12-Year Follow-Up Study

The present study explored the trajectories of depressive symptoms over 12 years spanning from childhood to emerging adulthood and the between-trajectory differences in psychosocial adjustment among Chinese children (N = 492, 52.8% boys, aged 6 to 18 years at baseline) affected by parental HIV. Rebounding (12.6%), resilient (64.8%), and improving  (22.6%) trajectories were identified. Individuals in the rebounding trajectory reported the highest levels of psychological distress and the lowest levels of subjective well-being, positive self-regard, and personal strengths in adulthood. Individuals in the resilient trajectory reported lower levels of psychological distress and negative affect than those in the improving trajectory. The findings support the development of programs by policymakers and practitioners to improve the psychosocial adjustment of children who have been affected by parental HIV while considering individual differences in the trajectories of depressive symptoms.

The Effect of Social Exclusion on Trust Among Youth Orphaned by HIV/AIDS: Evidence From an Event-Related Potentials Study

Grounded in a follow-up study among children who lost one or both parents to HIV in central China in the early 2000s, we conducted an event-related potentials (ERPs) experiment to explore the effect of social exclusion on trust and the corresponding neurophysiological mechanism among youth orphaned by HIV/AIDS ("AIDS orphans"). A sample of 31 AIDS orphans (26.16 ± 3.34 years old; 15 female) and 32 age and development status matched controls (25.02 ± 3.45 years old; 14 female) participated in the study. They were all assigned to play Cyberball, a virtual ball-tossing game that reliably induced social exclusion (15 orphans, 16 controls) and inclusion (16 orphans, 16 controls). Then, they played the Trust Game by taking the role of trustor with their electroencephalograms (EEGs) being recorded during the game. In the Trust Game, each participant was required to decide whether to trust their partners in over 150 trials (decision-making stage). The partner's reciprocation strategies were pre-programmed by the experimenter (with an overall reciprocating rate of 50%). All participants were provided with post-decision feedback about the outcome of their decisions (gain or loss of game points) in each trial (outcome evaluation stage). We analyzed their behavioral responses at the decision-making stage and ERP components at the outcome evaluation stage. Behavioral results showed that the proportion of orphans choosing trust was significantly higher than the controls, and the trust ratio of the orphan exclusion (OE) group was significantly higher than that of the orphan inclusion (OI) group, control exclusion (CE) group, and control inclusion (CI) group. Furthermore, the response time of the OE group was significantly shorter than that of other groups. ERP results indicated that the amplitude of the feedback-related negativity (FRN) in the OI group was significantly more negative than that in the CI group with loss feedback, while there was no significant difference between the OE and OI groups. Similarly, the P300 amplitudes following outcome feedback were larger in the CI group than that in the OI group with gain feedback and had no significant difference between OE and OI.

Psychosocial factors of stigma and relationship to healthcare services among adolescents living with HIV/AIDS in Kano state, Nigeria

Background

Stigma associated with HIV shapes all aspect of prevention and treatment, yet there are limited data on how HIV-infected adolescents are affected by stigma. Stigma increases risk of psychological problems among HIV-infected individuals which can affect access to treatment and social support services. This study aimed at identifying psychosocial factors of stigma and relationship to healthcare services among adolescents on antiretroviral therapy (ART) in Gwale Local Government Area (LGA) of Kano state, Nigeria.

Methods

A facility-based cross-sectional survey was carried out from January 26 to February 28, 2020 across six health facilities providing ART service in Gwale local government. A structured interviewer-administered questionnaire was used to collect the data. ART clients attending clinics were interviewed following an informed consent. Descriptive statistics was used to summarize the data and results are presented using simple frequency tables and percentages. Upon completion of univariate analysis, the data was analyzed at the bivariate level using chi-square test to determine associations between different variables.

Results

One hundred and eight (108) clients voluntarily participated in the study of which 54 (50%) are male respondents and 54 (50%) are female respondents. Under the internalized stigma item, 67% of HIV-infected adolescents who have lost their father or mother to AIDS reported feeling less valuable than other children who are not infected with HIV. Under the perceived stigma items, 86% of participants who have lost their father or mother to AIDS reported to have excluded themselves from health services and social activities in the last twelve months due to fear of being insulted. Under the experienced stigma items, 62% of participants who have lost their father or mother to AIDS reported to have been avoided by friends and colleagues in the last twelve months.

Conclusion

The study revealed that loss of intimate relation (father or mother) to AIDS and equal treatment with other HIV negative siblings were found to be significantly associated with the three forms of stigma (internalized stigma, perceived stigma, and experienced stigma) including access to healthcare services. There is a need for social and psychological support programs among HIV-infected adolescents.

Impact of Adverse Childhood Events on the Psychosocial Functioning of Children Affected by Parental HIV in Rural China

Introduction: Children affected by parental HIV are more likely than unaffected peers to experience trauma and are at-risk for negative psychological and social outcomes. This study aimed to examine the relationship between adverse childhood events and psychosocial functioning among children affected by parental HIV. Methods: A total of 790 children ages 6-17 from Henan, China were enrolled in a longitudinal, randomized controlled trial of a resilience-based psychosocial intervention. At baseline, children reported on numerous psychosocial factors, including trauma exposure, symptoms of anxiety and depression, and peer social functioning. We used linear regression analysis to test the direct effect of trauma exposure on peer social functioning. We then tested whether depression and anxiety symptoms served as two potential parallel mediators in the association between trauma exposure and peer social functioning. Results: Trauma exposure was significantly associated with poor peer social functioning (β = -0.10, p = 0.005) when controlling for key covariates. When depression and anxiety symptoms were added to the model, the association between trauma exposure and peer social functioning became nonsignificant. Instead, there were significant indirect effects from trauma exposure to peer social functioning via depression (β = -0.06, 95%CI[-0.09, -0.03]) and anxiety (β = -0.02, 95%CI[-0.04, -0.00]). Conclusion: This study is among the first to link trauma exposure to peer social functioning deficits for children affected by parental HIV and demonstrates that symptoms of anxiety and depression mediate this relationship. Findings underscore the need for comprehensive psychosocial support for children affected by HIV, including screening for trauma exposure and mental health disorders.

Validation of the Lifetime Incidence of Traumatic Events (LITE-S/P) Questionnaires in Children and Adolescents in Slovenia

Introduction: A traumatic event is an extremely threatening and frightening experience in an individual's life. Children who are exposed to traumatic events are twice as likely to develop a mental disorder. Screening can provide insight into the traumatic experience of children, identifying those eligible for further evaluation, and support. With this aim, we evaluated the psychometric properties of the Lifetime Incidence of Traumatic Events questionnaire (LITE) in Slovene by calculating retest reliabilty, construct validity (cross-informant agreement) and external validity, where we calculated the correlation of the number of differenet traumatic events with psychopathological symptoms. Methods: 280 child-parent pairs (children aged 11.3 ± 2.2 years) from various Slovenian primary schools participated in the study. They were divided into two groups: 180 healthy primary school students and 100 children with Type 1 Diabetes (our study was a part of a larger study The Influence of Psychobiological Adversity on Children and Adolescents with Type 1 Diabetes Study). Two versions of the LITE questionnaire were used. Children completed the child report (LITE-S) and parents the parent report (LITE-P) version. After 4 weeks, 117 children, and 114 parents filled out the LITEs again. External validity was assessed using the Youth Self Report and Child Behaviour Checklist syndrome-oriented scales. Results: Retest reliability for individual scales was r = 0.469-0.639 (ρ = 0.443-0.636; p < 0.001), but higher for individual items (κ = 0.263-0.821; p < 0.001). Correlations between reports from parents and children were r = 0.313-0.345 (ρ = 0.317-0.348; p < 0.001). The number of different events experienced by children correlated significantly with the measured depressive-anxiety, and posttraumatic stress disorder symptoms. Conclusions: Based on our results, the LITE-S and LITE-P "All events" scale have acceptable psychometric properties for use in research and in clinical practise screening. We recommend looking at single items, taking into consideration the responses from both the child and the parent for more precise information. To improve the precision of the psychodiagnostic capacity of the questionnaire, further research on various populations should be performed.

EEG oscillation evidences of altered resting-state brain activity in children orphaned by parental HIV/AIDS

Early life adverse events in children orphaned by parental HIV/AIDS can have long-lasting effects on brain function. However, data are limited regarding the brain activation during resting state in these children. The current study aims to investigate the brain oscillation at rest in children orphaned by HIV/AIDS using resting-state EEG data. Data were derived from a larger neurodevelopmental study in which 90 children aged 9-17 years orphaned by AIDS and 66 matched controls were recruited through the local communities and school system. Children (63 orphans and 65 controls) who had resting-state EEG data and completed the Teacher-Child Rating Scale (T-CRS) were included in the current analysis. EEG results showed that children orphaned by HIV/AIDS had increased theta activity in the midline region, decreased beta activity in left hemisphere and overall increased theta/beta power ratio. Furthermore, the theta/beta ratio is positively correlated with learning problem and acting out scores, and negatively correlated with task orientation and peer social skill activities. Findings support that children orphaned by HIV/AIDS demonstrate different brain activity compared to non-orphan controls and also suggest that the EEG activities in resting state may serve as useful indicators of children's behavioral problems.

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.

Stigma and psychosocial wellbeing among children affected by parental HIV in China

OBJECTIVES

Parental HIV infection presents unique psychosocial challenges for families. Affected children are vulnerable to stigma-related distress from a parent's HIV status and are more likely to experience symptoms of depression and low self-esteem than unaffected peers. This study examined whether HIV-related stigma predicted poorer mental health among children affected by parental HIV and whether psychosocial assets mediated this relationship.

METHODS

A sample of 790 children (ages 6-17) affected by parental HIV in Henan, China reported on HIV-related stigma, social support, emotional regulation, future outlook, and mental health symptoms. Structural equation modeling was used to examine the direct and indirect effects of stigma on mental health.

RESULTS

Results indicated that stigma was associated with psychosocial resources, which in turn were associated with mental health symptoms. The indirect pathways from stigma to mental health symptoms through psychosocial resources were consistent across age and gender.

CONCLUSION

The experience of HIV-related stigma was associated with poorer overall mental health among children affected by parental HIV in China. Children's psychosocial resources, including social support, emotional regulation, and future outlook, mediated the relationship between HIV-related stigma and mental health symptoms. Future interventions may wish to target these modifiable aspects of wellbeing to improve social and behavioral outcomes in this vulnerable population.

Psychosocial correlates of health-related quality of life among people living with HIV in China: the mediating role of resilience

OBJECTIVES

The current study aims to examine associations between psychosocial factors and health-related quality of life (HRQoL) and the role of psychological resilience in mediating the relationship between perceived social support (PSS) and HRQoL.

DESIGN

A cross-sectional study was conducted among people living with HIV (PLHIV) in Guangxi, China. A sample of 2987 PLHIV (1876 men and 1111 women) was included in the current analysis.

METHODS

Hierarchical multiple regression models were employed to assess the association of HRQoL with stigma, three types of PSS (informational, emotional and tangible), and resilience as well as to identify the possible role of resilience in mediating the effect of PSS on HRQoL RESULTS:: HRQoL was negatively associated with stigma (β = -0.27, P < 0.001), but positively associated with emotional PSS (β = 0.13, P < 0.001). After resilience was added to the model, HRQoL remained negatively associated with stigma (β = -0.20, P < 0.001), but positively associated with resilience (β = 0.38, P < 0.001). A mediating effect of resilience was found between emotional PSS and HRQoL (Sobel's Z = 16.87, P < 0.001).

CONCLUSION

Interventions that consider enhancing resilience through building social support, especially emotional social support, will likely improve HRQoL among PLHIV.

A cluster randomized controlled trial to evaluate a resilience-based intervention for caregivers of HIV-affected children in China

OBJECTIVES

The Child-Caregiver-Advocacy Resilience (ChildCARE) intervention aims to enhance the psychosocial wellbeing of children affected by parental HIV by providing programing at three levels: child, caregiver, and community. The objective of the current study was to evaluate the intervention's efficacy in improving mental health and parenting outcomes for participating caregivers.

DESIGN

A cluster randomized controlled trial was used to evaluate initial efficacy of the intervention.

METHODS

A total of 790 caregivers of children affected by parental HIV were recruited from Henan, China. Caregivers and their children were randomly assigned to one-of-four intervention arms (control, child-only, child + caregiver, child + caregiver + community) to evaluate the multiple components of ChildCARE. Those assigned to receive the caregiver intervention participated in five 2-h intervention sessions designed to improve their parenting skills and enhance their ability to cope with daily stressors. Caregivers reported on their mental health and parenting behaviors at baseline, 12, 24, and 36 months, with mixed effect modeling used to examine intervention effects.

RESULTS

Caregivers who participated in the intervention reported decreased anxiety and parental stress at 12 months (P < 0.05). Participants also reported increased use of structured parenting skills (i.e., parental demandingness) at 12 and 24 months (P < 0.05). However, by 36 months, they reported significantly lower levels of parental competence (P < 0.01) than those assigned to the control condition.

CONCLUSION

Preliminary findings suggest that the caregiving component of ChildCARE yields initial improvements in some key parenting and mental health outcomes. However, the challenges of caring for children affected by HIV are complex and may require more intensive intervention to yield marked, positive changes across key caregiver outcomes.

A physical symptom-based measure of quality of care for children affected by HIV/AIDS

Based on cross-sectional data of 1,625 children aged 6-18 years who were affected by parental HIV/AIDS in central rural China, we evaluated a physical symptom based measure of quality of care (QOC_PS) for these children. The QOC_PS has acceptable reliability estimates for children of both genders, at different age, and by orphanhood status. Known-group validation and construct validity analysis demonstrated a good validity of QOC_PS indicator. The QOC_PS score was significantly associated with psychosocial well-being measures among children. The physical symptom based measure provides a psychometrically appropriate indicator of quality of care for children affected by HIV/AIDS in China. It could be used as an alternative measure to assess quality of care in resource-poor settings where other objective measurements are not available or feasible. Future research is needed to further validate the scale among children in different living environments across various cultural settings.

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.

Behavioral Problems Reported by Adolescents and Parents from HIV Affected Families in China

This study examined the influence of various factors on the behavioral problems of adolescents affected by HIV while considering the agreement between adolescent and parent reports on problem behaviors. A total of 136 families each with one parent living with HIV (PLH) and one child aged 13-18 were included. Structural equation modeling was used to explore relationships between selected family measures and adolescent's problem behaviors. The correlation between the PLH and adolescent-reported behavioral problem measures was low (β = 0.11). PLH-reported adolescent problem behaviors were negatively related to PLH-reported parental bonding (β = -0.39), family routines (β = -0.26), and positively associated with family conflict (β = 0.21). Adolescent-reported family participation was associated with self-reported problem behaviors (β = -0.35). Our study reported discrete perceptions of adolescent problem behaviors from parents' and adolescents' points of view. Future intervention efforts should emphasize family contextual factors to improve behavioral outcomes in adolescents affected by HIV.

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.

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.

Meaning in life, resilience, and psychological well-being among children affected by parental HIV

Meaning in life has been posited to improve psychological well-being. People facing adversities can reduce psychological distress through pursuing a sense of purpose in life. However, the effectiveness of meaning in life in promoting psychological well-being has been found varied, and what factors may affect the function of meaning in life remain unclear. In this paper, the authors suggest that resilience, the positive adaptation during or following significant adversity, can strengthen the protective effects of meaning in life on psychological well-being. To test this hypothesis, we analyzed data from a sample of 518 vulnerable children of parents living with HIV about their meaning in life, resilience, depression, and loneliness. Results showed that resilience moderated the relationship between meaning in life and depression, and between meaning in life and loneliness. Meaning in life was associated with lower levels of depression and loneliness among children high in resilience, in comparison to children low in resilience. Future interventions targeting meaning in life and well-being should consider children's resilience, which can allow for better individualization of the treatment.

The impact of daily and trait loneliness on diurnal cortisol and sleep among children affected by parental HIV/AIDS

Dysregulation of the Hypothalamic-Pituitary-Adrenal (HPA) axis and disruptions of restorative processes (e.g., sleep) have been proposed as two key mechanisms through which loneliness leads to medical morbidity in adults and late adolescents. Whether loneliness acts through these biological and behavioral intermediaries in children as well remains unexplored. In a sample of 645 children aged 8-15 affected by parental HIV/AIDS in rural China, trait and state (i.e., daily) loneliness were measured in a 3-day diary study, wherein participants also provided cortisol samples and sleep measures. Whereas high levels of trait loneliness were found to predict lower morning cortisol levels, longer time in bed, lower sleep quality, and a higher number of night awakenings, daily loneliness was associated with a flatter diurnal cortisol slope and shorter time in bed. Although the association between trait loneliness and daily loneliness with HPA activity remained significant after controlling for psychological constructs that overlap with loneliness (e.g., depression and daily negative affect), some of the associations between loneliness and sleep measures became non-significant after including these additional covariates. These findings provide the first empirical evidence to our knowledge of associations between trait and state loneliness and health-related outcomes among school-aged children and young adolescents.

The effects of trait and state affect on diurnal cortisol slope among children affected by parental HIV/AIDS in rural China

Affect is believed to be one of the most prominent proximal psychological pathway through which more distal psychosocial factors influence physiology and ultimately health. The current study examines the relative contributions of trait affect and state affect to the hypothalamic-pituitary-adrenal axis activity, with particular focus on cortisol slope, in children affected by parental HIV/AIDS. A sample of 645 children (8-15 years old) affected by parental HIV/AIDS in rural China completed a multiple-day naturalistic salivary cortisol protocol. Trait and state affect, demographics, and psychosocial covariates were assessed via self-report. Hierarchical linear modeling was used for estimating the effects of trait affect and state affect on cortisol slope. Confidence intervals for indirect effects were estimated using the Monte Carlo method. Our results indicated that both trait and state negative affect (NA) predicted flatter (less "healthy") diurnal cortisol slopes. Subsequent analyses revealed that children's state NA mediated the effect of their trait NA on diurnal cortisol slope. The same relationships did not emerge for trait and state positive affect. These findings provide a rationale for future interventions that target NA as a modifiable antecedent of compromised health-related endocrine processes among children affected by parental HIV/AIDS.

Civic engagement among orphans and non-orphans in five low- and middle-income countries

BACKGROUND

Communities and nations seeking to foster social responsibility in their youth are interested in understanding factors that predict and promote youth involvement in public activities. Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in resource-poor settings. Understanding whether and how OSC are engaged in civic activities is important for community and world leaders who need to provide care for OSC and ensure their involvement in sustainable development.

METHODS

The Positive Outcomes for Orphans study (POFO) is a multi-country, longitudinal cohort study of OSC randomly sampled from institution-based care and from family-based care, and of non-OSC sampled from the same study regions. Participants represent six sites in five low-and middle-income countries. We examined civic engagement activities and government trust among subjects > =16 years old at 90-month follow-up (approximately 7.5 years after baseline). We calculated prevalences and estimated the association between key demographic variables and prevalence of regular volunteer work using multivariable Poisson regression, with sampling weights to accounting for the complex sampling design.

RESULTS

Among the 1,281 POFO participants > =16 who were assessed at 90-month follow-up, 45 % participated in regular community service or volunteer work; two-thirds of those volunteers did so on a strictly voluntary basis. While government trust was fairly high, at approximately 70 % for each level of government, participation in voting was only 15 % among those who were > =18 years old. We did not observe significant associations between demographic characteristics and regular volunteer work, with the exception of large variation by study site.

CONCLUSION

As the world's leaders grapple with the many competing demands of global health, economic security, and governmental stability, the participation of today's youth in community and governance is essential for sustainability. This study provides a first step in understanding the degree to which OSC from different care settings across multiple low- and middle-income countries are engaged in their communities.

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.

Childhood Adversity, Self-Esteem, and Diurnal Cortisol Profiles Across the Life Span

Childhood adversity is associated with poor health outcomes in adulthood; the hypothalamic-pituitary-adrenal (HPA) axis has been proposed as a crucial biological intermediary of these long-term effects. Here, we tested whether childhood adversity was associated with diurnal cortisol parameters and whether this link was partially explained by self-esteem. In both adults and youths, childhood adversity was associated with lower levels of cortisol at awakening, and this association was partially driven by low self-esteem. Further, we found a significant indirect pathway through which greater adversity during childhood was linked to a flatter cortisol slope via self-esteem. Finally, youths who had a caregiver with high self-esteem experienced a steeper decline in cortisol throughout the day compared with youths whose caregiver reported low self-esteem. We conclude that self-esteem is a plausible psychological mechanism through which childhood adversity may get embedded in the activity of the HPA axis across the life span.

Perceived social support, hopefulness, and emotional regulations as mediators of the relationship between enacted stigma and post-traumatic growth among children affected by parental HIV/AIDS in rural China

Some previous studies have revealed a negative impact of enacted stigma on post-traumatic growth (PTG) of children affected by HIV/AIDS, but little is known about protective psychological factors that can mitigate the effect of enacted stigma on children's PTG. This study aims to examine the mediating effects of perceived social support, hopefulness, and emotional regulation on the relationship between enacted stigma and PTG among HIV-affected children. Cross-sectional data were collected from 790 children affected by parental HIV (382 girls, 408 boys) aged 6-17 years in 2012 in rural central China. Multiple regression was conducted to test the mediation model. The study found that the experience of enacted stigma had a negative effect on PTG among children affected by HIV/AIDS. Emotional regulation together with hopefulness and perceived social support mediated the impact of enacted stigma on PTG. Perceived social support, hopefulness, and emotional regulation offer multiple levels of protection that can mitigate the impact of enacted stigma on PTG. Results suggest that future psychological intervention programs should seek strategies to reduce the stigmatizing experience of these children and promote children's level of PTG, and health professionals should also emphasize the development of these protective psychological factors.

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.

Parenting Mediates the Impact of Caregivers' Distress on Children's Well-Being in Families Affected by HIV/AIDS

Parental illness imposes great challenges to children's life and mental health. Having a parent infected by HIV may further challenge children's psychological well-being. Existing studies have demonstrated a negative impact of caregiver's distress on children's well-being. Limited studies examined the potential pathways of the link. This study aims to examine whether parenting stress, parenting competence and parental responsiveness can explain the relationship between caregivers' distress and children's well-being. A community sample of children of parents living with HIV and their current caregivers (n = 754 dyads) was recruited in rural central China. Children completed the measures on their psychological well-being and perceived parental responsiveness of their caregivers. Caregivers reported on their psychological well-being, parenting stress, and parenting competence. Structural equation modeling analysis showed that caregivers' distress indirectly affect children's well-being through parenting stress, parenting competence and parental responsiveness. Parenting stress explained the impact of caregiver's distress on parental responsiveness and showed pervasive effects on parenting competence. Our findings lend credence to family-based intervention for children affected by HIV and affirm the importance of incorporating the cognitive, emotional and behavioral components of parenting practices in such intervention.

Prevalence and Incidence of Traumatic Experiences Among Orphans in Institutional and Family-Based Settings in 5 Low- and Middle-Income Countries: A Longitudinal Study

BACKGROUND

Policy makers struggling to protect the 153 million orphaned and separated children (OSC) worldwide need evidence-based research on the burden of potentially traumatic events (PTEs) and the relative risk of PTEs across different types of care settings.

METHODS

The Positive Outcomes for Orphans study used a 2-stage, cluster-randomized sampling design to identify 1,357 institution-dwelling and 1,480 family-dwelling orphaned and separated children in 5 low- and middle-income countries (LMICs) in sub-Saharan Africa and Asia. We used the Life Events Checklist developed by the National Center for Posttraumatic Stress Disorder to examine self-reported PTEs among 2,235 OSC ages 10-13 at baseline. We estimated prevalence and incidence during 36-months of follow-up and compared the risk of PTEs across care settings. Data collection began between May 2006 and February 2008, depending on the site.

RESULTS

Lifetime prevalence by age 13 of any PTE, excluding loss of a parent, was 91.0% (95% confidence interval (CI) = 85.6, 94.5) in institution-dwelling OSC and 92.4% (95% CI = 90.3, 94.0) in family-dwelling OSC; annual incidence of any PTE was lower in institution-dwelling (23.6% [95% CI = 19.4, 28.7]) than family-dwelling OSC (30.0% [95% CI = 28.1, 32.2]). More than half of children in institutions (50.3% [95% CI = 42.5, 58.0]) and in family-based care (54.0% [95% CI = 50.2, 57.7]) had experienced physical or sexual abuse by age 13. Annual incidence of physical or sexual abuse was lower in institution-dwelling (12.9% [95% CI = 9.6, 17.3]) than family-dwelling OSC (19.4% [95% CI = 17.7, 21.3]), indicating statistically lower risk in institution-dwelling OSC (risk difference = 6.5% [95% CI = 1.4, 11.7]).

CONCLUSION

Prevalence and incidence of PTEs were high among OSC, but contrary to common assumptions, OSC living in institutions did not report more PTEs or more abuse than OSC living with families. Current efforts to reduce the number of institution-dwelling OSC may not reduce incidence of PTEs in this vulnerable population. Protection of children from PTEs should be a primary consideration, regardless of the care setting.

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.

Perceived Stigmatization, Resilience, and Diurnal Cortisol Rhythm Among Children of Parents Living With HIV

Stigmatization often puts at risk the health and well-being of children from marginalized groups. One potential protective factor for such children is resilience--one's capability to adapt flexibly, persistently, and resourcefully to stressful situations. In this study, we investigated the associations among stigmatization, resilience, and hypothalamic-pituitary-adrenal (HPA) axis function in a sample of 645 youths affected by parents infected with HIV. Perceived stigmatization was associated with lower cortisol levels at awakening and flatter cortisol slopes, whereas resilience was independently associated with higher levels of salivary cortisol at awakening and steeper cortisol slopes. We found evidence for an indirect effect of resilience on diurnal cortisol through lower perceived stigmatization. These associations remained significant after we controlled for demographic and health factors and stressful life events. Our findings demonstrate that perceived stigmatization and resilience are associated with HPA-axis functioning in childhood. Broadly, the data suggest that resilience-promoting and stigma-reducing efforts should be considered to improve the health of children from disadvantaged groups.

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.

Gender (in) differences in prevalence and incidence of traumatic experiences among orphaned and separated children living in five low- and middle-income countries

BACKGROUND

Approximately 153 million children worldwide are orphaned and vulnerable to potentially traumatic events (PTEs). Gender differences in PTEs in low- and middle-income countries (LMIC) are not well-understood, although support services and prevention programs often primarily involve girls.

METHODS

The Positive Outcomes for Orphans study used a two-stage, cluster-randomized sampling design to identify 2837 orphaned and separated children (OSC) in five LMIC in sub-Saharan Africa and Asia. We examined self-reported prevalence and incidence of several PTE types, including physical and sexual abuse, among 2235 children who were ≥10 years at baseline or follow-up, with a focus on gender comparisons.

RESULTS

Lifetime prevalence by age 13 of any PTE other than loss of a parent was similar in both boys [91.7% (95% confidence interval (CI) (85.0-95.5)] and girls [90.3% CI (84.2-94.1)] in institutional-based care, and boys [92.0% (CI 89.0-94.2)] and girls [92.9% CI (89.8-95.1)] in family-based care; annual incidence was similarly comparable between institution dwelling boys [23.6% CI (19.1, -29.3)] and girls [23.6% CI (18.6, -30.0)], as well as between family-dwelling boys [30.7% CI (28.0, -33.6)] and girls [29.3% CI (26.8,-32.0)]. Physical and sexual abuse had the highest overall annual incidence of any trauma type for institution-based OSC [12.9% CI (9.6-17.4)] and family-based OSC [19.4% CI (14.5-26.1)], although estimates in each setting were no different between genders.

CONCLUSION

Prevalence and annual incidence of PTEs were high among OSC in general, but gender-specific estimates were comparable. Although support services and prevention programs are essential for female OSC, programs for male OSC are equally important.

Community-based family-style group homes for children orphaned by AIDS in rural China: an ethnographic investigation

As the number of children orphaned by AIDS (Acquired Immunodeficiency Syndrome) has reached 17.3 million, most living in resource-poor settings, interest has grown in identifying and evaluating appropriate care arrangements for them. In this study, we describe the community-based family-style group homes ('group homes') in rural China. Guided by an ecological framework of children's wellbeing, we conducted a series of ethnographic observations, in-depth interviews and group discussions in the rural areas of Henan Province, which has been severely impacted by the AIDS endemic through commercial blood collection. Based on our observations and discussions, group homes appear to provide stable and safe living environments for children orphaned by AIDS. Adequate financial support from non-government organizations (NGOs) as well as the central and provincial governments has ensured a low child-caregiver ratio and attention to the basic needs of the children at group homes. The foster parents were selected from the local community and appear to have adequate qualifications and dedication. They receive a monthly stipend, periodical evaluation and parenting consultation from supporting NGOs. The foster parents and children in the group homes have formed strong bonds. Both children and foster parents reported positively on health and education. Characteristics of community-based group homes can be replicated in other care arrangements for AIDS orphans in resource-poor settings for the optimal health outcomes of those vulnerable children. We also call for capacity building for caregivers and communities to provide sustainable and supportive living environment for these children.

The role of perceived social support in loneliness and self-esteem among children affected by HIV/AIDS: a longitudinal multilevel analysis in rural China

OBJECTIVES

To delineate the trajectories of loneliness and self-esteem over time among children affected by parental HIV and AIDS, and to examine how their perceived social support (PSS) influenced initial scores and change rates of these two psychological outcomes.

DESIGN

We collected longitudinal data from children affected by parental HIV/AIDS in rural central China. Children 6-18 years of age at baseline were eligible to participate in the study and were assessed annually for 3 years.

METHODS

Multilevel regression models for change were used to assess the effect of baseline PSS on the trajectories of loneliness and self-esteem over time. We employed maximum likelihood estimates to fit multilevel models and specified the between-individual covariance matrix as 'unstructured' to allow correlation among the different sources of variance. Statistics including -2 Log Likelihood, Akaike Information Criterion and Bayesian Information Criterion were used in evaluating the model fit.

RESULTS

The results of multilevel analyses indicated that loneliness scores significantly declined over time. Controlling for demographic characteristics, children with higher PSS reported significantly lower baseline loneliness score and experienced a slower rate of decline in loneliness over time. Children with higher PSS were more likely to report higher self-esteem scores at baseline. However, the self-esteem scores remained stable over time controlling for baseline PSS and all the other variables.

CONCLUSIONS

The positive effect of PSS on psychological adjustment may imply a promising approach for future intervention among children affected by HIV/AIDS, in which efforts to promote psychosocial well being could focus on children and families with lower social support. We also call for a greater understanding of children's psychological adjustment process in various contexts of social support and appropriate adaptations of evidence-based interventions to meet their diverse needs.

Vicious circle of perceived stigma, enacted stigma and depressive symptoms among children affected by HIV/AIDS in China

Previous research has found a deleterious impact of stigma on the mental health of children affected by HIV/AIDS. Little is known about the longitudinal relationship of stigma and children's mental health. This study explores the longitudinal reciprocal effects of depressive symptoms and stigma, specifically enacted stigma and perceived stigma, among children affected by HIV/AIDS aged 6-12. Longitudinal data were collected from 272 children orphaned by AIDS and 249 children of HIV-positive parents in rural China. Cross-lagged panel analysis was conducted in the study. Results showed that the autoregressive effects were stable for depressive symptoms, perceived stigma and enacted stigma suggesting the substantially stable individual differences over time. The cross-lagged effects indicated a vicious circle among the three variables in an order of enacted stigma → depressive symptom → perceived stigma → enacted stigma. The possibility of employing equal constraints on cross-lagged paths suggested that the cross-lagged effects were repeatable over time. The dynamic interplay of enacted stigma, perceived stigma and depressive symptoms suggests the need of a multilevel intervention in stigma reduction programming to promote mental health of children affected by HIV/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.

Relational self-esteem, psychological well-being, and social support in children affected by HIV

Self-esteem can be derived from the relationships with significant others (relational self-esteem). However, it is unclear what the importance of relational self-esteem is for mental health and whether social support from others promotes relational self-esteem. The aim of this study was to examine the relationship between relational self-esteem and a multitude of indicators of psychological well-being among children affected by HIV. We also examined how social support from others would affect relational self-esteem. Results indicated that relational self-esteem was positively associated with psychological well-being. Support from significant others rather than others predicted increased relational self-esteem. Implications and directions for future research are discussed.

Extracurricular interest as a resilience building block for children affected by parental HIV/AIDS

Parental illness and death due to human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) impose challenges to children's psychological adjustment. Positive psychology emphasizes individual's resilience in the face of adversity, trauma, and tragedy. Limited data are available regarding the factors that can cultivate resilience of children affected by HIV/AIDS. This study aims to examine the role of extracurricular interest in strengthening resilience among children affected by HIV/AIDS. Participants included 755 children orphaned by parental HIV/AIDS, 466 vulnerable children living with HIV-positive parent(s), and 404 comparison children from HIV-free families in the same community in rural China. The measures include extracurricular interest (i.e., reading, sports, music, painting, science, and playing chess) and indicators of psychological adjustment (i.e., depression, loneliness, and self-esteem). Having extracurricular interest was positively associated with self-esteem and negatively associated with depression and loneliness. Having extracurricular interest attenuated the negative effect of parental HIV/AIDS on children's self-esteem and loneliness, after controlling for children's age, gender, and family socioeconomic status. The findings underscore the importance of nurturing extracurricular interest and make available of such activities to promote resilience for children affected by HIV/AIDS in resource-limited settings.

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.

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.

Caregiver's HIV disclosure to children 12 years and under: a review and analysis of the evidence

A systematic review and analysis of the empirical evidence through June 2010 on HIV disclosure to children 12 and under was conducted using methods validated by the Cochrane group. Fifteen articles focusing on caregiver disclosure (255 total) were analyzed using GradePro 3 software. Results suggest that there is evidence of health and future care planning benefit for HIV+ and healthy children (12 and under) of HIV+ caregivers if the caregiver discloses his/her HIV status to them. Children of the maturity of school age youth (e.g., beginning at 6 years and continuing through 12) can be told of their caregivers' HIV status, while younger children may be informed partially in an age-appropriate manner.

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.