RESPONDING TO MENTAL
      HEALTH NEEDS OF HIV-
       POSITIVE PEDIATRIC
     PATIENTS IN RESOURCE-
       POOR COMMUNITI...
There can be no health without
mental health1




            1WHO.    Mental health: facing the challenges, building solu...
The Guyana Experience



   Visit #1
“We don’t talk
 to children”
                    Visit # 2
                   “Wow, y...
Overview
   Mental health
   Pediatric HIV and mental health
   Assessment and screening
   Implementation issues
   ...
Mental Health in Developing
Countries: Burden
   Mental health disorders make up a substantial
    burden of disease worl...
Mental Health in Developing
Countries: Unmet Need
   Country-level information about mental health
    systems of care is...
Mental Health in Developing
Countries: Unmet Need
 In all of the African continent, outside of
  South Africa, fewer than...
Cultural Aspects of Mental
    Health
   When considering mental health:
     Do mental illnesses occur across most cult...
Outcomes of Poor Mental
Health
   Negative impact on physical health
   Lower educational achievement
   Substance use/...
Mental Health and Pediatric HIV
   Almost all research conducted in United States
   Very few studies using DSM psychiat...
Issues that Contribute to Mental
Health Problems for HIV+
Children
Emotional Issues
   Sadness and hopelessness
   Depression
   Anxiety and fear
   Disclosure (HIV specific)
   Stigma...
Neurodevelopmental Problems:
HIV infection and CNS in
children
   Broad variability in severity and timing
   Highest in...
HIV infection and CNS in children and
HAART (NeuroAIDS)

   Prevalence of Pediatric NeuroAIDS in pre-
    HAART era in th...
HIV
Encephalopathy/NeuroAIDS
   As children with HIV encephalopathy get older
    many present with significant learning ...
Assessment and Screening
What are Developmental
Assessments?
 What is child development?
   Orderly progression of skills
   Increasing independ...
Domains to Assess
   General cognitive function
   Language (expressive and receptive)
   Motor (gross and fine)
   At...
Tools for Assessment
   Observational
   Self-report
   Standardized psychometric tests
     Have  normative data from...
Issues Related to Assessment
Across Cultures
   Use a standardized assessment from
    another culture
     Issues:
    ...
Benefits of Developmental Testing

   Serial evaluations allow the medical team to
    monitor treatment effectiveness ov...
Implementation Issues
Implementation Issues/Barriers
   Beliefs/Attitudes
     Religious
     Community

   Stigma
   Public Health Agenda/...
The Guyana Experience



   Visit #1
“We don’t talk
 to children”
                    Visit # 2
                   “Wow, y...
Discussion: Issues and
solutions
   Policy: Public health significance
   Capacity: Training models
   Access: Consider...
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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

Vicki Tepper, University of Maryland School of Medicine

CORE Group Spring Meeting, April 29, 2010

Published in: Health & Medicine
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Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resource-Poor Communities

  1. 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. 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. 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. 4. Overview  Mental health  Pediatric HIV and mental health  Assessment and screening  Implementation issues  Discussion: Issues and Solutions
  5. 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. 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. 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. 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. 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. 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. 11. Issues that Contribute to Mental Health Problems for HIV+ Children
  12. 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. 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. 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. 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. 16. Assessment and Screening
  17. 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. 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. 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. 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. 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. 22. Implementation Issues
  23. 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. 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. 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

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