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

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

The Guyana Experience

Visit #1“We don’t

talk to children” Visit # 2

“Wow, you can learn a

lot from talking to children”

Visit #3“Meet our new staff, we have to start from

the beginning….

”

Overview

Mental health Pediatric HIV and mental health Assessment and screening Implementation issues Discussion: Issues and Solutions

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

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

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

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

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

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 Anxiety disorders Behavioral disorders Developmental disorders

Issues that Contribute to Mental Health Problems for HIV+ Children

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

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

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

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

Assessment and Screening

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

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

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

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

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

Implementation Issues

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

The Guyana Experience

Visit #1“We don’t

talk to children” Visit # 2

“Wow, you can learn a

lot from talking to children”

Visit #3“Meet our new staff, we have to start from

the beginning….

”

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