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poster
There is a growing awareness that depressive symptoms in mothers has an impact on their parenting, and ultimately on the development of their children. Infants born to mothers with HIV are at particular risk of having a depressed caregiver. Many mothers with HIV are highly stressed by poverty and upset by their diagnosis of HIV. As a result of maternal social problems, some seropositive infants are cared for by kin or foster parents. Little is known about depressive symptoms and parenting in these caregivers. The purpose of this paper was to determine whether chronicity of depressive symptoms in caregivers had an impact on parenting of infants seropositive for HIV. Maternal caregivers included 68 biologic mothers with HIV, 18 kin, and 17 foster mothers. The mean age of mothers was 31; most (85%) were African American, and had a high school or higher level of education (58%). Infants and their caregivers were enrolled when the infants were around 3 months of age and followed to 18 months, with a subset followed to 24 months. The CES-D was used to assess depressive symptoms. Parenting was assessed using observational methods971-hour naturalistic observations of mother-child interaction, the HOME inventory, and the observations of caregiver behaviors during the infant's medical exam (ADS), and maternal self-report of amount of caregiving and perception of self as a mother. Maternal caregivers were clustered into three depressive groups based on the CES-D cut-off score of 16: no depressive symptoms, episodic depressive symptoms at some time points, and chronicity of depressive symptoms with most scores over 16. At each time point, biologic mothers with HIV were more likely to be in either the episodic or the chronic depressed group. Repeated measures analysis of variance were conducted using a general linear mixed model analysis to test whether the caregivers in the three depression differed in their overall level or patterns of change in parenting variables over time. The three depression groups differed significantly on the amount of positive attention during naturalistic observations [F(2,61)3D3.40, p<.05] and on the HOME total score [F(2,97)3D3.43, p<.05]. Women in the not depressed groups had higher HOME total scores and spend more time positively with their child than women in the episodic depressed group. There also was a difference among the three depressive groups in terms of their protectiveness toward their child during a clinic examination (ADS scores) [F(2,132)3D3.75, p<.05]. Caregivers in the not depressed group showed disproportionately higher ADS scores initially and at the final assessment than the caregivers in the two depressed group. The three depression groups differed in the amount of caregiving [(F(2,229)3D11.95), p<.0001] and there was a significant time by depression group interaction [F(2,229)3D3.05,p<.05]. Chronically depressed mothers showed slightly greater increases in amount of caregiving over time than the other two depressive groups, and foster and biological mothers had higher caregiving scores than kin. There were no depressive group differences in perception of self as a mother. Findings are both similar to and different from other literature on depression and parenting. Of particular concern is the prevalence of depressive symptoms in mothers with HIV. Attention should be placed on helping mothers with HIV with personal distress and psychosocial concerns associated with their illness in order to improve the parenting of their children.
poster
Advances in the treatment of perinatally acquired HIV have increased children's life expectancies and decreased the incidence of severe neurological sequelae. Our clinical impressions, supported by the literature, suggest a high incidence of language, learning, and behavior problems in these longer-term survivors. We conducted a retrospective study of our surviving HIV infected children to determine most recent neurodevelopmental status. Potentially pertinent variables considered in our analyses included severity of disease, age of initiation of antiretroviral therapy, maternal substance abuse, and guardianship.The study cohort included 29 children (20male/9 female, age range 3-10 years), primarily inner-city minority, born 1988 through 1996 and followed by both our HIV Comprehensive Care Program and the Divisions of Neurology and Developmental Pediatrics. Severity of disease was classified by degree of immune suppression (1994 Revised Classification System for HIV Infection in Children Less Than 13 Years) with 16 (55%) children mildly, 6 (21%) moderately, and 7 (24%) severely immunosuprpressed. Four (14%) children received antiretroviral therapy prior to 5 months of age. Twenty children (69%) were born to known substance abusers. Thirteen (45%) children were cared for by a single biologic parent, 9 (31%) by extended family members, 3 (10%) by both parents, and 4 (14%) were adopted or in residential placement.Members of our multidisciplinary team determined neurodevelopmental status (cognitive, motor, and sensory) via neurological exams and psychometric tests including Bayley, McCarthy, and Wechsler scales. Of the 29 children (mean age 7.0 years at last visit): 4 (14%) were normal (NL) (IQ>85, without neurosensory dysfunction); 18 (62%) were mildly impaired (MI) (IQ 71-85, learning problems, motor incoordination, and/or ADHD); and 7 (24%) were moderately to severely impaired (MSI) (IQ(70, and/or serious neurosensory disability). Sixteen of the 18 (89%) children in the MI group had language-based learning deficits and 8 (44%) had ADHD. All 7 children in the MSI group had significant cognitive impairment (i.e., mental retardation).Neurodevelopmental status varied inversely with severity of disease (p < .0089). The initiation of antiretroviral therapy prior to 5 months of age did not correlate with better outcome. Maternal substance abuse and guardianship were also not directly associated with neurodevelopmental status. However, our sample size may have been insufficient to fully examine these variables.Our findings, corroborating recent research, revealed that 86% (25/29) of the children in this HIV infected cohort had impairment in language, learning, and behavioral areas and 28% (7/25) of these had significant neurodevelopmental disabilities. The majority, however, had less severe deficits, most commonly a pattern of language delays or disorders in the younger children and language-based learning disabilities in those of school age.Since early identification of developmental problems is critical to optimize learning, special educational intervention should be initiated during the children's preschool years, with particular focus on language development. Continuing surveillance is essential to address both medical and educational needs and to monitor any changes in status as the younger children progress through their elementary school years.
poster
The Pediatric Aids Clinical Trials Group (PACTG) are responsible fordeveloping and executing drug trials for HIV infected children. An importantcomponent in these protocols are regular neurodevelopmental assessments.These assessments consist of evaluations which monitor the cognitive, motorand behavioral development of children on drug trials. The present studyinvestigated the prevalence of behavioral problems in one specific PACTGprotocol, Protocol 338, A Phase II Rolling Arm Master Protocol of NovelAntiretroviral Therapy in Stable Experienced HIV-Infected Children.PACTG Protocol 338 was a randomized, open-label, multi-center, Phase IIclinical trial designed to evaluate the effectiveness of specific drugs onseveral medical and neurodevelopmental outcomes. This analysis focusedexclusively on baseline information obtained from the behavioral andcognitive assessment of these children at the time of enrollment into thisProtocol. At entry, each subject was administered a standardized, ageappropriate cognitive assessment (Bayley, WPPSI-R or WISC-III) and theConners Parent Rating Scale. The study included 274 subjects who wereperinatally HIV infected and aged 24 months to 17 years (mean age 7.2years). 49% of the subjects were African-American, 34% were Hispanic, 15%were White and 2% were other. Forty-seven percent were males.Analysis of baseline data for the Conners found that 20% of the childrenwere identified as having ADHD. In addition, 16% were classified as having aconduct problem, 25% as having a learning problem, 28% as psychosomatic, 19%as impulsive-hyperactive and 8% were classified as having anxiety problems.The mean indices and scores of the neurodevelopmental evaluations were allless than the norm, however, the standard deviation was close to the normalstandard deviation values. Analysis of cognitive assessments found thatscores were significantly lower for children classified as ADHD or withlearning problems. These results demonstrate that children with ADHD or alearning problem have lower IQ scores and a lower IQ score implies a higherchance of experiencing ADHD or a learning problem.Results of this study indicate that HIV infected children in PACTG Protocol338 have more behavioral and learning difficulties than is expected in anon-HIV infected population. This outcome suggests that children with HIVinfection are at higher risk for behavioral and learning problems, however,since this study did not have a matched control group, the results should beviewed with caution. Additional analysis of the data will include measuresof immune function and viral load.