The relationship between psychosocial factors and poor neurocognitive and socio-emotional development in children perinatally infected with HIV in South Africa.
Background: Survival among perinatally HIV infected children has increased over the last few years in South Africa, mainly due to the availability and accessibility of combination antiretroviral therapy (cARTs). These children, however, remain a vulnerable group with respect to heightened behavioural and socio-emotional problems as well as neurocognitive deficits. The majority of HIV-positive children live in an environment of multiple deprivations; i.e. poverty, parental death or ill health, stress associated with daily living and poor stimulation in the home environment. Early childhood is known to be a sensitive period for brain development, especially in forming neural circuits underlying behaviours and higher cognitive functions. Injury or insult and environmental deprivation (impoverishment, nutritional deficits and lack of nurturance) have the potential to create vulnerability which can negatively impact on the life trajectory of the child. With this in mind, the aim of this study was to investigate the impact of key psychosocial factors, namely, socio-economic status, caregiver depression, quality of home environment and nutritional status, on the neurocognitive and socio-emotional functioning of perinatally acquired HIV-positive children living in semi-rural Eastern Cape, South Africa. Method: A cross-sectional, convergent mixed method design using non-probability sampling was employed. Quantitative data was collected on 152 dyads of perinatally infected HIV positive children on cARTs (mean age = 63.13 months) and their caregivers. The Wechsler Preschool and Primary Scale of Intelligence-III (WPPSI-III) was administered to assess the neurocognitive functioning of the children, while the Strengths and Difficulties Questionnaire (SDQ) (caregiver report version) was administered to assess the children’s socio-emotional function. Anthropometric data was obtained from the HIV-positive children through the WHO-anthro-programme to assess nutritional status. The Home Screening Stimulation Questionnaire (HSQ) was administered to assess the quality of home environment the children were living in. The Beck Depression Inventory, 2nd edition (BDI-II) was used to assess caregiver depression among the 152 (mean age = 45 years) caregivers. Qualitative data was obtained through a series of semi-structured in-depth interviews with a sub-set of 44 caregivers of the HIV-positive children who were conveniently recruited from the quantitative sample. A series of one-way ANOVAs, independent t-tests, chi-square and correlation analyses was performed on the quantitative data. The qualitative data was analysed using interpretive phenomenological analysis. Results: The converging quantitative and qualitative results in this doctoral study provides evidence that various psychosocial factors differentially impact neurocognitive and socioemotional development of perinatally HIV-infected children. Older HIV-positive boys who lived in suboptimal, poor quality homes and who demonstrated stunting, wasting and /or were underweight (indicators of nutritional status) were worse off neurocognitively when compared to younger boys and girls infected with HIV from similar environmental deprivation context. Socio-emotional adjustment was also generally poor, with caregiver depression strongly associated with poor socio-emotional functioning among HIV-positive children. This relationship existed whether or not the child was raised by a biological or nonbiological caregiver and was greater in younger children. The children’s overall psychosocial difficulties mean score was 16.9 (SD = 5.05), with indications of the significant presence of psychological and behavioural symptoms. Hyperactivity problems was reported in 40.1 % (M = 5.27, SD = 1.72) of the children, emotional problems in 29.6 % (M = 4.31, SD = 2.34), conduct problems in 41.4 % (M = 3.13, SD = 2.18) and peer related problems in 51.3 % (M = 3.49, SD = 1.46). The qualitative data indicated, inter alia, that stigma negatively impacts on caregivers’ mental health and deters them from seeking social support. This in turn, exacerbates caregivers’ poor mental health and capacity to adequately meet the needs of their HIVvii positive children, ultimately leading to negative child outcomes. This finding highlights the importance of Bronfenbrenner’s micro- and meso-system variables, such as the importance of quality parent/child interaction, adequate language stimulation through dialogue, and availability of tools within the home and school environment that could act as a buffer against the negative effects of HIV on the infected child’s developing brain. The children’s neurocognitive, psychological and behavioural development is influenced by their ecological context. Conclusion: This is the first study in South Africa investigating the impact of psychosocial factors associated with poor neurocognitive and socio-emotional functioning in perinatally HIV-infected children. The findings highlight that it is not enough to just focus attention on the medical management of paediatric HIV. Despite having access to cART’s, HIV-positive children are vulnerable to developing neurocognitive deficits and socio-emotional and behavioural problems. These problems can impact negatively on their ability to learn and thrive academically, establish pro-social relationships with peers, and importantly, adhere to their treatment regimes. The need for integrative interventions including the identification and treatment of caregiver depression as well as nutritional supplementation, early parenting skills training and psychosocial stimulation to improve overall health and future quality of life of this population is recommended.