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Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resource-Poor Communities

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Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resource-Poor Communities …

Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resource-Poor Communities

Vicki Tepper, University of Maryland School of Medicine

CORE Group Spring Meeting, April 29, 2010

Published in: Health & Medicine

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  • 1. RESPONDING TO MENTAL HEALTH NEEDS OF HIV- POSITIVE PEDIATRIC PATIENTS IN RESOURCE- POOR COMMUNITIES Vicki Tepper, Ph.D. Associate Professor of Pediatrics University of Maryland School of Medicine
  • 2. There can be no health without mental health1 1WHO. Mental health: facing the challenges, building solutions. Report from the WHO European Ministerial Conference. Copenhagen, Denmark: WHO Regional Office for Europe, 2005
  • 3. The Guyana Experience Visit #1 “We don’t talk to children” Visit # 2 “Wow, you can learn a lot Visit #3 from talking to “Meet our new children” staff, we have to start from the beginning….”
  • 4. Overview  Mental health  Pediatric HIV and mental health  Assessment and screening  Implementation issues  Discussion: Issues and Solutions
  • 5. Mental Health in Developing Countries: Burden  Mental health disorders make up a substantial burden of disease worldwide  Mental, behavioral, and developmental disorders with childhood onset are a major public health concern
  • 6. Mental Health in Developing Countries: Unmet Need  Country-level information about mental health systems of care is limited, with many gaps  Specific services for children and adolescents are even less detailed if they exist at all  Between ½ and 2/3rds of the need for mental health services goes unmet in most countries, with significantly higher proportions of unmet need in low and middle income countries  A significant factor contributing to the lack of services is the lack of professionals trained to work with children
  • 7. Mental Health in Developing Countries: Unmet Need  In all of the African continent, outside of South Africa, fewer than 10 psychiatrists can be identified who are trained to work with children  Outside of South Africa, there are no child and adolescent psychiatry training programs  On the African continent, only Algeria, South Africa and Tunisia have more than 1 psychiatrist per 100,000 population. Only Namibia and South Africa have more than 1 psychologist per 100,000 population
  • 8. Cultural Aspects of Mental Health  When considering mental health:  Do mental illnesses occur across most cultures – do they present in the same way?  Differentiate mental illness from environmental response  Historical barriers to care  Suspicion  Desire for best care  Religious/spiritual  Beliefs about life and death  Meaning of pain and suffering  Stigma– social difficulties resulting from stigma and discrimination
  • 9. Outcomes of Poor Mental Health  Negative impact on physical health  Lower educational achievement  Substance use/abuse  Violence  Poor reproductive and sexual health  Increased risk behavior  Suicide
  • 10. Mental Health and Pediatric HIV  Almost all research conducted in United States  Very few studies using DSM psychiatric diagnoses  Clinical reports indicate significant mental health problems with rates between 12-70%  Depression  Anxietydisorders  Behavioral disorders  Developmental disorders
  • 11. Issues that Contribute to Mental Health Problems for HIV+ Children
  • 12. Emotional Issues  Sadness and hopelessness  Depression  Anxiety and fear  Disclosure (HIV specific)  Stigma  Loss  Grief over parental loss may be compounded by multiple foster care placements and high degree of stigmatization associated with HIV  Adjustment to living with a life-threatening condition
  • 13. Neurodevelopmental Problems: HIV infection and CNS in children  Broad variability in severity and timing  Highest incidence rate of HIV-related CNS manifestations in first two years of life (in the absence of treatment):  10 % incidence rate in the first year of life,  4 % incidence rate in the second year of life  < 1% incidence rate the in the third year of life and thereafter
  • 14. HIV infection and CNS in children and HAART (NeuroAIDS)  Prevalence of Pediatric NeuroAIDS in pre- HAART era in the USA:  13-35% of all children with HIV infection and  35-50 % of all children diagnosed with AIDS  Treatment with antiretroviral agents can reverse CNS manifestations  Access to HAART has led to a dramatic decrease in the incidence of active NeuroAIDS
  • 15. HIV Encephalopathy/NeuroAIDS  As children with HIV encephalopathy get older many present with significant learning problems that affect their ability to function in school, develop friendships, and function independently  These problems put them at risk for having difficulty with abstract reasoning, and anticipating the consequence of behavior, including non–adherence to medication and risky sexual behavior
  • 16. Assessment and Screening
  • 17. What are Developmental Assessments?  What is child development?  Orderly progression of skills  Increasing independence and autonomy  What do assessments do?  Measure domains of development  Determines area(s) of strength and weakness  Assists in planning rehabilitative, educational, psychological and medical interventions for the child
  • 18. Domains to Assess  General cognitive function  Language (expressive and receptive)  Motor (gross and fine)  Attention  Memory  Academic skills  Social skills and development  Emotional functioning  Temperament
  • 19. Tools for Assessment  Observational  Self-report  Standardized psychometric tests  Have normative data from a large, representative sample of test-takers for comparison  Test selection varies with the age of the child
  • 20. Issues Related to Assessment Across Cultures  Use a standardized assessment from another culture  Issues:  Questionable cultural relevance  May miss important components of constructs  Psychometric properties of tests– validity  Training of staff to conduct assessments and finding time for assessment to take place  Waiting room  Triage  Resources for intervention
  • 21. Benefits of Developmental Testing  Serial evaluations allow the medical team to monitor treatment effectiveness over time - testing can reveal early changes in neurological/ neurodevelopmental status  More frequent global testing recommended in younger children, while less frequent but more comprehensive testing is recommended for older children
  • 22. Implementation Issues
  • 23. Implementation Issues/Barriers  Beliefs/Attitudes  Religious  Community  Stigma  Public Health Agenda/Policy  Capacity  Shortage of mental health professionals trained to work with children  Limited space to provide services  Reduced economic resources to support provision of care
  • 24. The Guyana Experience Visit #1 “We don’t talk to children” Visit # 2 “Wow, you can learn a lot Visit #3 from talking to “Meet our new children” staff, we have to start from the beginning….”
  • 25. Discussion: Issues and solutions  Policy: Public health significance  Capacity: Training models  Access: Consider providing mental health services in other settings where children may be found - e.g., schools, community centers