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

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