ABSTRACT Introduction Children with human immunodeficiency virus (HIV) infection are living longer with the infection and are at risk of different complications. We assessed for the prevalence of and associated factors for psychiatric morbidity among HIV-infected children in a tertiary facility in Ilorin, Nigeria. Methods A descriptive cross-sectional, two-staged study involving 196 HIV-positive children (6–17 years). A semi-structured questionnaire and psychological instruments were used for the study. Results Thirty-eight (19.4%) children had psychiatric disorders: attention-deficit hyperactivity disorder and enuresis. Single parenthood, HIV clinical stages and complications were associated with psychiatric morbidity. Linear combination of the risk factors was not related to the psychiatric disorder. Bivariate correlation analysis showed the tendency to develop psychiatric disorder among the children was positively correlated with complications in the child and the person the child resides with. Conclusions Complicated HIV infection and adverse life events result in elevated risk of having psychiatric morbidity. children, HIV/AIDS, psychiatric morbidity INTRODUCTION Acquired Immunodeficiency Syndrome (AIDS) is a disease of the human immune system caused by the Human Immunodeficiency virus (HIV), which reduces the effectiveness of the immune system and leaves individuals susceptible to opportunistic infections . Sub-Saharan Africa is more heavily affected by HIV and AIDS than any other region of the world . In 2013, an estimated 24.7 million people were living with HIV in this region, which is 71% of the global total [2, 3]. In 2013, 3.2 million (2.9 million–3.5 million) children <15 years were living with HIV, while 4 million (3.6 million–4.6 million) young people 15–24 years old were living with HIV, and up to 200 000 children were newly infected worldwide, with one-quarter of these new cases in Nigeria [2, 3]. Studies have reported psychological manifestations among children with chronic illnesses [4–6]. Because of quality treatment of AIDS, children with HIV live longer and may be at greater risk of complications like psychiatric illnesses. [7–10]. Studies have shown that HIV-infected children are at increased risk of psychological abnormalities. This has been noted in 12–44% of HIV-infected children [7, 1112]. These include anxiety disorder (24.3%), attention-deficit hyperactivity disorder (ADHD), [11, 13–15] oppositional defiant disorder, conduct disorder, problems in social functioning [13, 14] and depression [7, 15–21]. Studies carried out in developing countries like Kenya found 48.8% rate of psychiatric disorders  and a study in Uganda found that 51.2% of the children had significant psychological distress . There is dearth of published information on psychiatric morbidity among children and adolescents with HIV in Nigeria. We assessed for prevalence of and associated factors for psychiatric morbidity among children attending our hospital. METHODS The study was carried out at the HIV clinic of the University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria, a tertiary health facility located in Kwara State, Nigeria. The Paediatric HIV clinic, which was the main clinic for the study, sees patients between 18 months and 14 years. The other HIV clinics see some adolescents and majorly adults. The adult HIV clinics were included to include adolescents in the study. The children eligible for the study were between age 6 and 17 years, tested HIV positive and must have their caregivers present at the clinic who must have given informed consent and the children gave assent to participate in the study. Patients who were too ill to be interviewed, who had other chronic medical illnesses or a history of psychiatric disorder before the onset of HIV infection were excluded. A sample size of 196 was used based on 50% prevalence of mental health problems in HIV-infected children in African studies, gotten from the average prevalence in two African studies [22–24]. All the 196 respondents approached for the study agreed to participate in the study, giving a response rate of 100%. The study was in two stages. In the first stage, participants/their caregivers were given the information about the study. Parents/caregivers who gave informed consent and children who gave assent were interviewed. The Sociodemographic questionnaire and the Parent version of Child Behaviour Questionnaire (CBQ; Rutter Scale A2)  were administered to all consecutive patients who were qualified by a trained research assistant. The Sociodemographic questionnaire assessed demographics like the child’s age, sex and education. Rutter scale A2 (CBQ) consists of 31 items scored on a 3-point scale concerning the child’s behaviour in and around the home during the past 12 months. It is a screening instrument used for assessing psychiatric morbidity. Although, a self-administered questionnaire, CBQ was read to each participant because of the relatively low level of literacy of the people. The medical data sheet was used to extract medical parameters like cluster of Differentiation 4 T-lymphocytes subgroup (CD4) count from the participants’ case notes. In the second stage, children scoring ≥7 on CBQ  and approximately 30% of those scoring <7 were selected for the subsequent session of the interview using the diagnostic supplements of the Schedule for Affective Disorders and Schizophrenia for School-Aged Children Present and Lifetime Version, which is a semi-structured interview for assessing specific psychiatric disorders in children and adolescents based on Diagnostic & Statistical Manual of Mental Disorders Fourth Edition diagnostic criterion . A cut-off of 7 was used based on the recommendation of a validation study carried out in a Nigerian paediatric primary care service in Ibadan, which recommended that a total score of 7 on the scale gave the best trade-off between a high sensitivity and a low false-positive rate . The setting of that study and ours are similar socio-culturally. The interviewer at the second stage was blind to the scores obtained in Stage 1. Approval for the study was obtained from the Ethics and Research Committee of the University of Ilorin Teaching Hospital, Ilorin. Informed and written consent were obtained from the caregivers. Data from this study were presented in tables. SPSS 16 was used for the analysis. Chi-square test was used to determine the significant association between variables. Statistical significance was set at p < 0.05. RESULTS Among the 196 children who participated in the study, 71.9% were between 6 and 10 years old, while 28.1% were between 11 and 17 years. The mean age of the children was 9.2 years (Table 1). Almost half of the children with HIV had their parents alive (Table 2). Table 3 showed that about one in every four patients were in Stage 3 or 4 while complications were present in about 17% of the participants. Table 1 Characteristics of HIV-infected children Variables Frequency (N = 196) Percentage (%) Age (years) 6–10 141 71.9 11–17 55 28.1 Gender Male 93 47.4 Female 103 52.6 Religion Christian 97 49.5 Islam 99 50.5 School attendance Yes 192 98.0 No 4 2.0 Level of education None 4 2 Primary 169 86.2 Secondary 23 11.7 Tribe Yoruba 145 74.0 Igbo 14 7.1 Hausa/others 37 18.9 Child awareness of HIV status Yes 36 18.4 No 160 81.6 Variables Frequency (N = 196) Percentage (%) Age (years) 6–10 141 71.9 11–17 55 28.1 Gender Male 93 47.4 Female 103 52.6 Religion Christian 97 49.5 Islam 99 50.5 School attendance Yes 192 98.0 No 4 2.0 Level of education None 4 2 Primary 169 86.2 Secondary 23 11.7 Tribe Yoruba 145 74.0 Igbo 14 7.1 Hausa/others 37 18.9 Child awareness of HIV status Yes 36 18.4 No 160 81.6 N = The total number of respondents. Table 2 Family characteristics of HIV-infected children Variables Frequency (N = 196) Percentages (%) Type of family Monogamy 170 86.7 Polygamy 26 13.3 Child’s residence Both parents 93 47.4 Single parent 64 32.7 Other relatives 39 19.9 Parents’ well-being Both alive 127 64.8 Single alive 65 33.2 Both dead 4 2.0 Other HIV persons in the family Yes 163 83.2 No 33 16.8 Variables Frequency (N = 196) Percentages (%) Type of family Monogamy 170 86.7 Polygamy 26 13.3 Child’s residence Both parents 93 47.4 Single parent 64 32.7 Other relatives 39 19.9 Parents’ well-being Both alive 127 64.8 Single alive 65 33.2 Both dead 4 2.0 Other HIV persons in the family Yes 163 83.2 No 33 16.8 N = The total number of respondents. Table 3 Clinical parameters of HIV-infected children Variables Frequency (N = 196) Percentage (%) On antiretroviral therapy Yes 161 82.1 No 35 17.9 CD4 count (cell/mm3) <350 41 21.1 >350 153 78.9 Clinical stages 1 and 2 146 74.5 3 and 4 50 25.5 Complication(s) present Yes 31 16.8 No 154 83.2 Variables Frequency (N = 196) Percentage (%) On antiretroviral therapy Yes 161 82.1 No 35 17.9 CD4 count (cell/mm3) <350 41 21.1 >350 153 78.9 Clinical stages 1 and 2 146 74.5 3 and 4 50 25.5 Complication(s) present Yes 31 16.8 No 154 83.2 N = The total number of respondents. Thirty-eight (19.4%) of the children met the criteria for a psychiatric disorder (4.6% for ADHD, while 14.8% had enuresis, mainly nocturnal enuresis). Other psychiatric disorders like depression, anxiety and psychosis were screened. However, the children did not screen positive for these disorders. A comparison of cases with psychiatric disorders with non-cases using chi-square analysis showed that cases were more likely to reside with a single parent (p ≤ 0.001), were more likely to have a single parent alive (p = 0.03), were more likely to be in World Health Organization, HIV clinical Stages 3 and 4 (p ≤ 0.001) and were more likely to have complications from HIV (p = 0.04) (Table 4). Table 4 Comparison of children with psychiatric morbidity and those without psychiatric morbidity Variables Psychiatric morbidity n1 = 38 (%) No psychiatric morbidity n2 = 158 (%) Chi square p value Living with Both parents 9 (23.7) 84 (53.2) Single parent 21 (55.2) 43 (27.2) 13.022 0.001 Other relatives 8 (21.1) 31 (19.6) Parents well-being Both alive 18 (47.4) 107 (67.7) Single alive 18 (47.4) 49 (31.0) 6.785 0.034 Both dead 2 (5.2) 2 (1.3) Awareness of HIV status 1.933 0.164 Yes 4 (10.5) 32 (20.3) No 34 (89.5) 126 (79.7) Age at diagnosis of HIV 2.147 0.143 6 weeks-2 years 4 (10.5) 33 (20.9) >2 years 34 (89.5) 125 (79.1) CD4 count 0.000 0.989 <350 8 (21.1) 33 (20.9) >350 30 (78.9) 125 (79.1) Clinical stage of HIV 1 and 2 22 (57.9) 124 (78.5) 3 and 4 16 (42.1) 34 (21.5) 6.832 0.009 Complication(s) present Yes 10 (26.3) 21 (13.3) 3.903 0.044 No 28 (73.7) 137 (58.7) Variables Psychiatric morbidity n1 = 38 (%) No psychiatric morbidity n2 = 158 (%) Chi square p value Living with Both parents 9 (23.7) 84 (53.2) Single parent 21 (55.2) 43 (27.2) 13.022 0.001 Other relatives 8 (21.1) 31 (19.6) Parents well-being Both alive 18 (47.4) 107 (67.7) Single alive 18 (47.4) 49 (31.0) 6.785 0.034 Both dead 2 (5.2) 2 (1.3) Awareness of HIV status 1.933 0.164 Yes 4 (10.5) 32 (20.3) No 34 (89.5) 126 (79.7) Age at diagnosis of HIV 2.147 0.143 6 weeks-2 years 4 (10.5) 33 (20.9) >2 years 34 (89.5) 125 (79.1) CD4 count 0.000 0.989 <350 8 (21.1) 33 (20.9) >350 30 (78.9) 125 (79.1) Clinical stage of HIV 1 and 2 22 (57.9) 124 (78.5) 3 and 4 16 (42.1) 34 (21.5) 6.832 0.009 Complication(s) present Yes 10 (26.3) 21 (13.3) 3.903 0.044 No 28 (73.7) 137 (58.7) n1 = The number of respondents with psychiatric morbidity. n2 = The number of respondents without psychiatric morbidity. MULTIPLE REGRESSION ANALYSIS Following the univariate analysis on chi square (X2), only four factors were significantly associated with psychiatric morbidity. These four factors were entered into the multivariate logistic regression analysis to predict how well the health of the child’s parent, stage of the HIV disease, type of person the child is living with and presence of complication predicted the presence of psychiatric disorder in the children. The four factors became insignificant (p values ranging between 1.00, 0.34, 0.95 and 0.94 for the type of person the child resides with, health of the child’s parent, stage of HIV disease and presence of complication, respectively). The Hosmer–Lemeshow (H-L) Goodness of Fit test was also not significant, X2 (6, N = 196) = 0.893, p = 0.99. As the H-L Goodness of Fit statistics is non-significant, we fail to reject the hypothesis, implying that the model’s estimates of the relationship between psychiatric morbidity and the four factors fit the data at an acceptable level. DISCUSSION The study showed that children with HIV/AIDS are at risk of psychiatric disorder. Similarly, New et al.  showed that 20% of the HIV-positive children had psychiatric disorder. While New et al.  showed that the percentage of psychiatric morbidity in HIV-positive children was similar to that of the general population of children; our study found that the rate of psychiatric disorder among respondents was slightly higher than that found among general population of children (11.4%) in the same area . This finding is not unusual because studies have shown that HIV-infected children and adolescents suffer a high rate of psychiatric disorders . The prevalence of psychiatric morbidity in the current study is low compared with other clinic-based studies in the Western world and some African countries [12, 29]. Pao et al.  found that 85% of the children with HIV/AIDS had a psychiatric diagnosis, while Mellins et al.  found that 61% had psychiatric disorder. The difference in methodology and absence of other confounding factors may have accounted for a lower prevalence of psychiatric disorders in the present study, which was present in the study by Pao et al.  and Mellins et al. . Musisi et al.  in Uganda and Kamau et al.  in Kenya each conducted a cross-sectional study on children and adolescents with HIV/AIDS and found that 51.2% and 48.8% had psychiatric disorders, respectively. The lower prevalence in the present study may be as a result of the presence of positive protective factors like children more in clinical Stages 1 and 2 and a lower percentage of orphans in the study. Others studies (especially those with control) have reported that children with HIV did not significantly differ from non-infected children . This study showed that about one-sixth of the respondents had medical complications, which is not surprising because more than half of the respondents had a high CD4 count, around three-quarter were in clinical Stage 1 or 2 and greater than four-fifth of the respondents were on anti-retroviral drug (ARV). ARV drugs have resulted in improved health by improving the effectiveness of the immune system, thereby improving the quality and length of life of HIV-positive children and adolescents . Despite the low number of children with medical complications resulting from HIV, the study found that the children with complications were more likely to be diagnosed with psychiatric disorders. This may be because there is usually a psychological aspect to physical disorders. Therefore, clinicians caring for children with HIV/AIDS should take measures to prevent complications and manage complications when it arises. The study also found that cases with psychiatric morbidity were more likely to be in clinical Stages 3 and 4. This draws attention to the need for clinicians to monitor the use of ARV and encourage drug compliance in their clients, as the use of ARV has been shown to reduce the progression of disease by enhancing the immunity . The HIV-infected children with psychiatric morbidity in this study were more likely to reside with a single biological parent. The finding from the present study revealed that the single parenthood was as a result of parental loss owing to HIV infection in more than half of the cases. Other causes of single parenthood from the study include family disharmony and having a child outside wedlock. These reasons for the single parenthood are also adverse experiences, which may have compounded the problems of being a single parent. Furthermore, the single parent may also be psychologically distressed owing to the social challenges of coping with limited financial resources, thereby influencing the parent–child relationship. These factors may then act individually or interact with other factors, thereby predisposing to a poor mental health outcome in the child. Bachanus et al.  found that caregiver psychological distress was a predictor of children’s psychological distress. Improvement in the treatment of HIV/AIDS makes children live longer and as they live longer, are confronted with complications associated with the illness and its treatment including psychiatric disorders. However, healthcare providers may focus on the physical health of the children. This study stresses the fact that these children and adolescents are also at risk of mental health problems. It is imperative for clinicians who care for children and adolescents with HIV to attend also to their mental health needs so that a holistic approach to management can be used. Because of the dearth of studies on the mental health of children and adolescents with HIV (especially in north-central Nigeria), this study is one of the first to our knowledge, to determine the mental health of children and adolescents with HIV/AIDS in north-central Nigeria. This study was limited by the fact that it was a descriptive cross-sectional study. A controlled study would need to be considered in future research to determine the specificity of mental health problems to HIV infection. The study did not ascertain whether the enuresis was primary or secondary. This can be a consideration in future study. Collateral reports from teachers or peers may add to the knowledge of the children behaviour outside the home environment. CONCLUSIONS The study yielded findings about the psychiatric morbidity in a sample of children and adolescents with HIV. Children with any chronic disorder may experience increased risk of psychiatric problems. However, as HIV infection is a chronic condition, their mental health should not be ignored. Therefore, there is growing need to increase the knowledge in this area so that effective and appropriate intervention are planned, thereby improving the overall health and quality of life of children and adolescents with HIV/AIDS. ACKNOWLEDGEMENT We acknowledge Drs Afolabi J. K. and Ajiboye P. O. for their contributions to the writing of this manuscript. FUNDING REFERENCES 1 AIDS. 2011. https://en.wikipedia.org/wiki/AIDS (20 April 2011, date last accessed). 2 UNAIDS. 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Journal of Tropical Pediatrics – Oxford University Press
Published: Feb 1, 2018
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