This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Web of Science (22)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mellins, C. A.
Right arrow Articles by Matzen, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mellins, C. A.
Right arrow Articles by Matzen, E.
Related Collections
Right arrow Infectious Disease & Immunity
Right arrowRelated AAP Red Book topics:
Human Immunodeficiency Virus...
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Facebook   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?
PEDIATRICS Vol. 111 No. 2 February 2003, pp. 384-393

High Rates of Behavioral Problems in Perinatally HIV-Infected Children Are Not Linked to HIV Disease

Claude A. Mellins, PhD*, Renee Smith, MS{ddagger}, Peter O’Driscoll, MS§, Lawrence S. Magder, PhD§, Pim Brouwers, PhD||, Cynthia Chase, PhD, Ileana Blasini, MD#, Joan Hittleman, PhD**, Antolin Llorente, PhD||, Elaine Matzen, RN{ddagger}{ddagger} for the NIH NIAID/NICHD/NIDA-Sponsored Women and Infant Transmission Study Group

* Columbia College of Physicians and Surgeons, New York, New York
{ddagger} University of Illinois at Chicago, Chicago, Illinois
§ Institute of Human Virology, Baltimore, Maryland
|| Baylor College of Medicine, Houston, Texas
Boston Medical Center, Boston, Massachusetts
# University of Puerto Rico, San Juan, Puerto Rico
** State University of New York Health Science Center at Brooklyn, Brooklyn, New York
{ddagger}{ddagger} National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Objective. Descriptive studies and clinical reports have suggested that human immunodeficiency virus (HIV)-positive children are at risk for behavioral problems. Inadequate control groups and sample sizes have limited the ability of investigators to consider multiple influences that place HIV-positive children at risk for poor behavioral outcomes. We examined the unique and combined influences of HIV, prenatal drug exposure, and environmental factors on behavior in children who were perinatally exposed to HIV.

Methods. Participants included 307 children who were born to HIV-positive mothers (96 HIV infected and 211 seroreverters) and enrolled in a natural history, longitudinal study of women to infant HIV transmission. Caregivers completed parent behavioral rating scales, beginning when the children were 3 years old. Data were also collected on prenatal drug exposure; child age, gender, and ethnicity; caregiver relationship to child; and birth complications.

Results. Multivariate analyses comparing the HIV-infected children with perinatally exposed but uninfected children from similar backgrounds failed to find an association between either HIV status or prenatal drug exposure and poor behavioral outcomes. The strongest correlates of increased behavioral symptoms were demographic characteristics.

Conclusions. This study suggests that although a high prevalence of behavioral problems does exist among HIV-infected children, neither HIV infection nor prenatal drug exposure is the underlying cause. Rather, other biological and environmental factors are likely contributors toward poor behavioral outcomes.

Key Words: pediatric HIV infection • behavioral outcome • Conners’ Parent Rating Scale

Abbreviations: HIV, human immunodeficiency virus • ADHD, attention-deficit/hyperactivity disorder • WITS, Women and Infants Transmission Study • CPRS, Conners’ • Parent Rating Scale • CI, confidence interval


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The psychological effects of human immunodeficiency virus (HIV) infection on children range from mild to devastating. Neurologic and neuropsychological deficits resulting from HIV infection have been well characterized.1–7 Unfortunately, there have been few corresponding studies on the emotional and behavioral sequelae of HIV disease. Although clinical reports suggest that HIV-infected children are at risk for anxiety, depression, and behavioral problems,8–11 the few research studies that exist have presented mixed results and often failed to use appropriate comparison groups. Emotional or behavioral abnormalities, including social problems, anxiety, depression, and general behavior problems, have been noted in 12% to 44% of HIV-infected children.4,12–14 However, 1 study found that the majority of 24 HIV-infected children had depression, anxiety, and behavioral problem scores in the normal range.15

One of the most widespread clinical observations is that HIV-infected children present with high rates of symptoms of attention-deficit disorder and attention-deficit/hyperactivity disorder (ADHD).16–18 However, the few studies on attention deficits in HIV-infected children using appropriate control groups have found high rates of ADHD in both groups with no association between attention-deficit disorder/ADHD and HIV disease.19–22 These results suggest that factors other than HIV disease per se may be influencing behavioral outcomes.

The epidemiology of pediatric HIV disease places children with perinatally acquired HIV infection at risk for behavioral problems for reasons other than HIV disease. Corresponding with the epidemiology of HIV in women, 52% of perinatally infected children who have AIDS and are younger than 13 years were born to women whose risk factor for HIV was their own or their partner’s intravenous drug use.23 The majority of HIV-infected children live in large, urban environments and are typically confronted by daily life stress, poverty, trauma, and family disruption.9,23,24 A high prevalence of noninjection substance abuse, psychiatric disorders, and chronic stress has been found in the birth mothers of HIV-infected children.9,25–27

These comorbid risk factors make it difficult to establish causal relationships between HIV and behavioral outcomes.28–30 Some of the cofactors have been associated with mental health problems in other populations and may be more potent mediators of behavioral problems in HIV-infected children than HIV infection itself.6,9,31 Few studies have adequately controlled for these factors in examining behavioral sequelae of HIV. Understanding the cause of behavioral problems in HIV-infected children is critical for improving their mental health and quality of life. Also, given the evidence that mental health problems are associated with poor medication adherence in HIV-infected adults,32,33 improving the mental health of HIV-infected children may have an impact on their physical health.

Longitudinal studies with large sample sizes and appropriate control groups are needed to examine the unique and combined influences of HIV disease and possible confounders, including prenatal drug exposure, family influences, and birth complications. The Women and Infants Transmission Study (WITS), a multicenter, longitudinal study of maternal–infant HIV-1 infection, includes a prospective collection of data on behavioral problems as well as possible predictors in 2 groups of perinatally HIV-exposed children: those who became HIV-infected and those who seroreverted. Using WITS data, the goal of this article is to examine the influences of HIV infection, drug exposure, and family characteristics on behavioral outcomes in children.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Subjects
The study reported here is a substudy of the longitudinal, natural history multisite WITS. WITS enrolled pregnant women who were between the ages of 15 and 44 and had documented HIV infection as well as their infants in medical settings in the following cities with high HIV seroprevalence: Boston, New York, Chicago, San Juan (Puerto Rico), and Houston. A total of 2022 infants who were born to HIV-infected mothers were enrolled in WITS between 1990 and June 2000, but because of overrepresentation, 618 uninfected infants were randomized out before they reached 3 years of age.

Inclusion criteria for the current study were that the child had to be the first-born singleton and at least 3 years old. Thus, 662 children would have been eligible; 492 children were ineligible because they were <3 years of age by June 2000, and 250 children were ineligible because they were twins, triplets, or the younger sibling of an eligible child (to have independent subjects, data were included from only 1 child per family). Of the potentially eligible children, 298 dropped out of WITS before reaching the age of 3 (moving out of the area and refusing to continue with the study visits were the primary reasons). The caregivers of 307 of the remaining 364 children who were both eligible and still in the WITS completed at least 1 Conners’ Parent Rating Scale-48 (CPRS),34 a questionnaire on behavioral functioning. For 57 eligible children, the caregivers did not receive or complete the CPRS because of administrative, social, or medical reasons. In summary, we were able to obtain CPRS scores for 307 (84%; 96 HIV infected and 211 uninfected) of 364 eligible children. We examined whether there were any differences in demographic characteristics between the 355 children without CPRS scores (298 who dropped out of WITS before age 3 and the 57 who stayed in the study but did not receive the CPRS) and the 307 children with CPRS. Children without CPRS scores were less likely to be HIV infected than the children with scores (17% vs 31%; P < .0001). They were also less likely to be black (39% vs 48%; P = .0160). The 2 groups of children were similar with respect to gender, maternal education, household income, and gestational age.

Procedures
All children who were enrolled in WITS receive routine physical, neurologic, and neurodevelopmental examinations throughout the course of the study. Relevant to this article, a behavioral functioning questionnaire was administered to the primary caregivers of WITS participants every 6 months, beginning when the children attained the age of 3 years, by psychometricians or pediatric psychologists who completed centralized training in proper administration and scoring of this tool (see below).

Also, blood was drawn when the children were <2 days of age; <7 days of age; 1, 2, 4, 6, 9, 12, 15, and 18 months of age; and then at 6-month intervals. Data on demographics (eg, primary language, maternal education and hard drug use, child grade level), medical status, and changes in family composition were also collected from primary caregivers at each study visit. Before administration of the WITS procedures, informed consent was obtained for the mother and child according to local institutional review board and federal guidelines and regulations.

Instrument
The CPRS34 is a well-standardized and widely used 48-item rating scale for the identification of behavioral and emotional problems in children ages 3 to 17 years. Five cluster problem behaviors are assessed: conduct, learning, psychosomatic, impulsivity-hyperactivity, and anxiety problems. Primary caregivers are asked to describe how much a particular behavior was characteristic of their child in the past month, using a 4-point Likert scale (ranging from "not at all" to "very much"). Responses from the primary caregiver to the items yield raw and T-scores for each cluster behavior, as well as a hyperactivity index, based on age and gender normative data.34 Higher T-scores on the CPRS reflect greater degrees of symptoms. For this set of analyses, outcome variables included standardized scores for 1) conduct problems, 2) the hyperactivity index, 3) impulsivity, 4) anxiety problems, and 5) learning problems. Scores for the psychosomatic problems were excluded given that the target group had a chronic health condition. The CPRS has been used extensively in clinical work and research on attention deficits and hyperactivity in children.35

With the exception of 7 interviews, the CPRS was administered in Spanish or English, depending on the caregiver’s primary language; 90 caregivers had at least 1 CPRS administered in Spanish (69 were from the Puerto Rico site, where all CPRSs were administered in Spanish). Seven caregivers received at least 1 CPRS in Creole from qualified interpreters. All other CPRSs were administered in English.

Definitions
Child HIV infection was defined as previously described.36 Infants have peripheral venous blood obtained for HIV-1 culture and, since June of 1998, for HIV DNA polymerase chain reaction within the first 48 hours after birth and again at 6 to 10 days; at 1, 2, 4, 6, 9, 12, and 18 months; and every 6 months thereafter. Infants were defined as HIV positive when 2 or more virologic tests at 2 different times were positive at any age and as HIV negative when there were at least 2 negative cultures at or after 1 month of age (1 of which was obtained at or after 6 months of age) and no positive cultures. Gestational age was determined using an algorithm of prenatal ultrasonography, record of uterine fundal height, and menstrual history. Prenatal hard drug exposure was defined by maternal prenatal illicit use of "hard drugs" (defined as 1 or more of the following: cocaine, heroin/opiates, injection drug use, and/or methadone) assessed by self-report and urine toxicology.37 Primary caregiver was defined as the caregiver with the most responsibility for caring for the child. Abnormal CPRS score was defined as a standardized CPRS score >70, which is 2 standard deviations above the mean, and <5% of the children should have such a score.

Data Analysis
Comparisons between WITS children with and without CPRS scores and between HIV-infected and uninfected children with CPRS scores were performed using {chi}2 tests of association. To identify those factors that were independently associated with CPRS scores, we used mixed effects regression models, which included a random effect for each child and allowed for the correlation between repeated observations from the same child to be a function of the time interval between the repeated observations. These repeated-measures models were fit using SAS PROC MIXED.38 The resulting adjusted parameter estimates reflect the independent effect of each variable, after adjusting for all other variables in the model. In addition to the 2 variables of primary interest (HIV status and prenatal drug exposure), we included in our longitudinal models sociodemographic variables (age, gender, and race/ethnicity) and factors that we considered to be either related to the CPRS scores or potential confounders of the relationships between the variables of primary interest and the CPRS scores (eg, maternal education, primary caregiver, changes in living situation). We also evaluated whether significant interactions existed between the main effects of prenatal drug exposure, child’s age, and child’s HIV status. Additional univariate analyses were conducted to assess the relationships between CPRS scores and household income, gestational age, and birth weight, and CD-4% (CD-4% values that were obtained on the same day as each CPRS administration were used).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Demographic characteristics of the sample are presented in Tables 1 and 2. The participants are nearly evenly split among boys and girls; 48% are black, and 33% are Hispanic. At birth, 28% of the children were preterm (37 weeks or less of gestation) and 19% weighed <2500 g. At the time of their first CPRS assessment, two thirds of the children were cared for by their birth mothers, 20% were in the care of another relative, and 9% were in foster or adoptive care. During the course of follow-up, 55% of the HIV-infected and 38% of the uninfected subjects experienced at least 1 change in their living situation (eg, moving from the home of the birth mother to the home of the grandmother). The majority of children were born into a household with an annual income of <$20 000, and nearly half had mothers who had not finished high school at the time of the child’s birth. Forty-four percent of all children had in utero exposure to "hard drugs," and 46% were exposed to alcohol. In this cohort of children born between 1990 and 1997, 56% were born to mothers who did not use antiretroviral medications during pregnancy; 40% were born to mothers on azidothymidine monotherapy, and <3% were born to mothers on combination therapy. The HIV-infected children were more likely than their uninfected peers to have been born prematurely, to have had a low birth weight, to have had in utero exposure to heroin, and to be in the care of somebody other than their birth mother at the time of the first CPRS assessment. During the course of the study, 26 (27%) of our HIV-infected participants were observed to have acquired immunodeficiency syndrome.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Demographics and Other Characteristics of the WITS Children With CPRS Scores*

 

View this table:
[in this window]
[in a new window]
  		TABLE 2. Characteristics of the HIV-Infected Mothers of WITS Children With CPRS Scores*

 
An average of 4.1 sets of CPRS scores were collected for each child. More than 15% of the children had 8 or more CPRSs. Fifty-two percent of the children received an abnormal score (>70) on at least 1 of the 5 CPRS scales; 29% had abnormal scores on 2 or more scales. After the number of CPRS assessments were adjusted for, the proportion of HIV-infected and -uninfected children who ever had an abnormal score and the proportions with 2 or more abnormal scores on a given scale were similar for all 5 scales. Figure 1 depicts the distribution of the conduct, hyperactivity index, and impulsivity scores observed between 3 and 8 years of age. Tables 3 to 5 present results for the multivariate analyses of conduct problems, the hyperactivity index, and impulsivity problems. Data for anxiety and learning problems are described in the text only.



View larger version (48K):
[in this window]
[in a new window]
  		Fig 1. The box’s length represents the interquartile (25%–75%) range. The line across the box indicates the median.

 

View this table:
[in this window]
[in a new window]
  		Table 3. Factors Associated With the CPRS Conduct Score

 

View this table:
[in this window]
[in a new window]
  		TABLE 5. Factors Associated With the CPRS Impulsivity Score

 
Multivariate analyses revealed that 4 factors had an independent effect on the conduct scores: prenatal drug exposure, ethnicity, primary caregiver, and number of changes in living situation (Table 3). Children who were not prenatally drug exposed had conduct scores that averaged >3 points higher than children who were prenatally drug exposed (P = .032). Hispanic children from the Puerto Rican site scored >4 points higher than black children (P = .010); 6.20 points higher than white children (P = .012); and 5.22 points higher than the small combined group of Asian-American, Native American, and multiracial children (P = .151). Children in the care of their birth mother had scores that averaged 5 points higher than those of children who were cared for by their grandmothers (P = .001), and each change in a child’s living situation (eg, moving from his or her parent’s home to that of a relative) was associated with nearly a 1-point increase in the conduct score (P = .011). HIV status was not significantly associated with the conduct score in the multivariate analysis.

Gender, ethnicity, and maternal education were independently associated with the hyperactivity index scores (Table 4). On average, boys scored nearly 6 points higher than girls (P < .000). Children whose mothers did not finish high school had hyperactivity index scores that averaged >6 points higher than those of children whose mothers had some college education (P = .010) and 4.99 points higher than those of the children of college graduates, although this latter difference was just shy of statistical significance (P = .082). Hispanic children from the Puerto Rican site scored >4.5 points higher, on average, than black children (P = .008) and 6.53 points higher than the combined group of Asian, Native American, and multiracial children (P = .008). They also scored >4 points higher than white, non-Hispanic children, but this difference was not statistically significant (P = .072). Primary caregiver status was also marginally associated with the hyperactivity index. Children who lived with their birth mother had scores that averaged >2.5 points higher than children who lived with their grandmother (P = .073). HIV status and prenatal drug exposure were not significantly associated with the hyperactivity index score after controlling for other factors.


View this table:
[in this window]
[in a new window]
  		TABLE 4. Factors Associated With the CPRS Hyperactivity Score

 
Gender and maternal education were independently associated with impulsivity (Table 5). Boys scored an average of 4.53 points higher on this scale than did the girls (P = .000), and children whose mothers did not finish high school had impulsivity scores that averaged >5 points higher compared with children whose mothers had some college education (P = .025). There was a marginally significant association between ethnicity and impulsivity (Table 5). Black children scored an average of 5.31 points higher on this scale than the group of children of Asian, Native American, or mixed ancestry (P = .071). HIV status and prenatal drug exposure were not significantly associated with impulsivity in the multivariate analysis.

Gender, age, maternal education, ethnicity, and primary caregiver were each independently associated with the anxiety scores (data not shown). Girls scored nearly 2 points higher, on average, than boys (P = .032). Each 1-year increase in age was associated with nearly a half-point increase in the anxiety score (P = .013). Children whose mother did not finish high school scored >3 points higher than those whose mother had some college education (P = .042). Compared with black children, Hispanic children from the mainland United States sites scored >3.5 points higher (P = .004) and Hispanic children from the Puerto Rican site scored >4 points higher (P = .000). White, non-Hispanic children also scored higher on this scale than black children (2.06 points higher, on average), but the difference was of marginal significance (P = .097). Children who lived with their birth mother also scored >3 points higher than the children who lived with their grandmother (P = .001). Children who lived with their birth father scored >2 points higher than those who were cared for by their mother, but this finding was of borderline significance (P = .100). HIV status was also just shy of achieving a statistically significant association with the anxiety score. HIV-infected children had a mean anxiety score that was 1.51 points lower (ie, were rated as having less anxiety) than that of their uninfected peers (95% confidence interval [CI]: 3.12 points lower to 0.19 points higher; P = .082). Drug exposure was not significantly associated with the anxiety scores (estimated effect: –0.62; 95% CI: –2.41–1.16; P = .490).

Gender, maternal education, and ethnicity were independently associated with the learning scores (data not shown). Boys scored an average of 7.22 points higher (ie, more learning problems) than girls (P < .000). Children whose mother did not finish high school had scores that averaged >7 points higher than those of children whose mother had some college education (P = .006). Hispanic children from the Puerto Rican site scored nearly 4 points higher than the black children (P = .034). There was not a significant association between HIV infection and learning scores (estimated effect of HIV infection: –0.55; 95% CI: –3.39–2.29; P = .710). Also, drug exposure was not significantly associated with the learning score (estimated effect: 0.13; 95% confidence interval: –2.86–3.13; P = .930).

We also performed univariate analyses to assess the association between the CPRS and income, gestational age, birth weight, and CD-4%. There were no significant findings with respect to these variables, so they were not added to our multivariate models. In addition, we found significant interactions between maternal hard drug use during pregnancy and child’s age for 2 of the 5 CPRS scores: hyperactivity and impulsivity (data not shown). Compared with their peers whose mother did not use drugs during pregnancy, those children with in utero "hard drug" exposure had hyperactivity and impulsivity scores that decreased by approximately 1 point for each 1-year increase in age. However, the differences between children who were prenatally drug exposed and not exposed were not statistically significant at any given age. The absence of these interaction terms had a negligible affect on the parameter estimates for the other variables in the models. In the interests of ease of presentation, we did not present these data.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
There are few longitudinal studies on emotional and behavioral outcomes in perinatally HIV-infected children that use appropriate comparison groups. Thus, it has been difficult to determine the cause of observed emotional and behavioral problems in HIV-infected children, particularly attention deficits and hyperactivity.22,39 WITS is 1 of the few longitudinal studies of HIV-infected children with a comparison group and a large enough sample size to examine potential covariates of behavior problems such as prenatal drug exposure, family disruption, demographic characteristics, health status, and birth complications.

Our findings correspond with previous studies showing high rates of emotional and behavioral problems in HIV-infected children. However, multivariate analyses comparing the HIV-infected children with a group of uninfected children that were perinatally exposed to HIV and from similar backgrounds (eg, ethnic minority, low socioeconomic status, inner-city communities) failed to find an association between HIV disease and behavioral problems. In fact, the only borderline finding was that HIV-infected children were rated by their caregivers as having less anxiety than the uninfected children. This study is 1 of the few that we know of with a relatively large sample size and a comparison group to suggest that HIV-disease is not directly associated with increased attentional and behavioral problems. Considering the 95% CIs to evaluate the reliability of our findings,40 our data are not consistent with an effect of HIV on hyperactivity, impulsivity, learning problems, or conduct that exceeds 2 points on the CPRS. Two points on the CPRS would be considered a non-clinically significant group difference by most investigators. This finding corresponds with 3 previous studies using small sample sizes19,41,42 and suggests that other causes shared by HIV-infected children and uninfected children from similar backgrounds may be the cause of observed behavioral problems.

One potential covariate is prenatal drug exposure, although mixed results have appeared in the literature.29,43,44 In our study, as in several others, we failed to find a consistent association between in utero exposure to drugs and behavioral outcomes. There were no statistically significant differences between children with and without prenatal drug exposure on the anxiety, hyperactivity, impulsivity, and learning scale scores. Children who were prenatally exposed to drugs, as compared with children who were unexposed, did score significantly lower on the conduct scale (better), which is surprising, and its interpretation is unclear. The observed association was independent of primary caregiver and annual income. It could reflect a form of selection bias whereby drug-exposed children who were living in an environment that fostered poor conduct were more likely to drop out of WITS before the age of 3. Thus, our sample of prenatally drug-exposed children may be overrepresented by children whose families received interventions that improved the home environment and thus child conduct. Alternatively, drug-exposed children may exhibit more conduct problems early in life that dissipate with time. As the lingering effects of in utero drug exposure fade, the discrepancy between initial and improved conduct could cause caregivers to rate child conduct as better than they might have otherwise. Finally, we cannot rule out chance as a reason for our finding. Also, we could not examine the extent of prenatal drug exposure (eg, dose, timing), a variable that should be considered in future studies.

The strongest correlates of increased behavioral symptoms in this study consistently were demographic characteristics. Gender and maternal education both were associated with 4 CPRS scores (everything but conduct problems). These results correspond with the substantial literature indicating that boys present with more hyperactivity, impulsivity, and learning disorders than girls and that girls present with more anxiety disorders.45,46 Similarly, a large number of studies have linked limited maternal education (less than high school education) to increased rates of child behavioral problems,47–49 which may in part be attributable to decreased job opportunities for mothers with less education and, thus, more family poverty.48

Primary caregiver status was associated with conduct and anxiety and just short of statistical significance in its association with hyperactivity. In all cases, youths who lived with their grandmother had fewer behavioral problems on the CPRS than youths who lived with their birth mother. It is possible that the homes of grandmothers may be more stable than the homes of birth mothers. In addition to the responsibilities of caring for their child, HIV-infected birth mothers may be more overwhelmed by resulting psychosocial stressors and their own medical care needs, have extensive histories of drug abuse, and have fewer resources for support.50 As a result, children in these homes may have more behavioral problems or birth mothers may have less tolerance for disruptive behavior. Alternatively, there may be generational differences resulting in grandmothers’ reporting fewer behavioral symptoms.

Ethnic differences were found on all 5 scales, although impulsivity was of marginal statistical significance. The 3 dominant racial/ethnic groups in this study were black, Hispanic from Puerto Rico, and Hispanic from the mainland of the United States. The most consistent finding was that Hispanic children from the Puerto Rico site had more behavioral problems according to caregiver report than the other groups, particularly black children. We examined multiple co-factors to try to understand this finding, but none was significant. There are several possible interpretations. When translating and adapting a measure for use in different cultures, reliability and validity may be different, resulting in different rates of outcomes.51 That Hispanic children who were from the mainland United States and whose primary caregivers completed the CPRS in Spanish did not score differently from other ethnic groups suggests that our results cannot simply be attributed to Spanish language differences. However, there may be sociocultural issues that differentiate the reports of caregivers in Puerto Rico from caregivers on the mainland but that were not considered in the adaptation of the CPRS. This latter group included children from Mexico, Puerto Rico, and the Dominican Republic. In reviewing the literature on the normative sample of the CPRS, there were very few children of color, particularly of Hispanic decent, and normative data on Hispanic children is not readily available at this time. Although it is possible that Hispanic children in Puerto Rico have a higher prevalence of behavioral symptoms than the other groups, normative data on the use of the CPRS with different Hispanic populations and other ethnic and cultural groups is needed to interpret our findings further.

The results of this study have important implications for treatment. Not only do HIV-infected children need to have access to mental health treatment, but also their uninfected siblings and HIV-exposed but uninfected peers may be at equal risk for poor behavioral outcomes. Although HIV-infected children in the United States typically have access to extensive medical and social services, mental health services are often not included in this care. A number of recent studies have now documented the extensive mental health needs of both infected and uninfected children from HIV-affected families.41,52 Emerging are models of mental health care that focus on family-based treatment that addresses the needs of infected and "affected" family members by stabilizing the family system, reducing stress, improving support for the child and family system, and providing psychiatric evaluations and treatment for multiple family members from multiple generations.53,54 Our study supports the need for stabilization of families so that children do not need to undergo multiple home placements, as well as increased support services for HIV-infected mothers and their children.


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
To summarize, a number of reports have suggested that HIV-infected children are at high risk for behavioral problems, particularly ADHD. However, the results of our study, conducted among a sample of largely poor, inner-city, black and Hispanic children, demonstrate that when other factors are held constant, there are no significant differences in behavioral outcomes, as assessed by the CPRS scores, between HIV-infected children and uninfected children who were born to HIV-positive mothers. To the extent that there is a high prevalence of behavioral problems among HIV-infected children, our results suggest that neither HIV infection itself nor prenatal exposure to drugs is the underlying cause. A variety of stressors are experienced by the majority of HIV-infected and HIV-affected children in the United States, including family disruption; exposure to poverty, trauma, and ongoing parental drug use; and familial mental illness in the home that may be contributors toward poor behavioral outcomes. Future studies are needed to further our understanding of how other environmental and biological factors influence behavior in this population. As HIV-infected children continue to live longer into school age and the population of HIV-exposed but uninfected children continues to grow, identifying the factors that place these groups at risk for behavioral problems is critical for providing proper treatment and ensuring improved quality of life for them and their families.


   ACKNOWLEDGMENTS
 
Scientific Leadership Core: Kenneth Rich, PI (1 U01 AI 50274-01). Additional support has been provided by local clinical research centers as follows: Baylor College of Medicine (Houston, TX), NIH GCRC RR00188; and Columbia University (New York, NY), NIH GCRC RR00645.

Principal investigators, study coordinators, program officers, and funding: Clemente Diaz, Edna Pacheco-Acosta (University of Puerto Rico, San Juan, PR; U01 AI 34858); Ruth Tuomala, Ellen Cooper, Donna Mesthene (Boston/Worcester Site, Boston, MA; 9U01 DA 15054); Jane Pitt, Alice Higgins (Columbia Presbyterian Hospital, New York, NY; U01 DA 15053); Sheldon Landesman, Edward Handelsman, Gail Moroso (State University of New York, Brooklyn, NY; HD-3–6117); Kenneth Rich, Delmyra Turpin (University of Illinois at Chicago, Chicago, IL; U01 AI 34841); William Shearer, Susan Pacheco, Norma Cooper (Baylor College of Medicine, Houston, TX; U01 HD 41983); Samuel Adeniyi-Jones, Rodney Hoff (National Institute of Allergy and Infectious Diseases, Bethesda, MD); Robert Nugent, (National Institute of Child Health and Human Development, Bethesda, MD); Vincent Smeriglio, Katherine Davenny (National Institute on Drug Abuse, Bethesda, MD); and Bruce Thompson (Clinical Trials & Surveys Corp, Baltimore, MD, N01 AI 85339).


   FOOTNOTES
 
Received for publication Apr 29, 2002; Accepted Sep 4, 2002.

Reprint requests to (C.A.M.) HIV Center for Clinical and Behavioral Studies, Box 15, 1051 Riverside Dr, New York, NY 10032. E-mail: cam14{at}columbia.edu


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Belman AL, Muenz LR, Marcus JC, et al. Neurologic status of human immunodeficiency virus 1-infected infants and their controls: a prospective study from birth to 2 years. Pediatrics.1996; 98 :1109 –1118[Abstract/Free Full Text]
  2. Chase C, Ware J, Hittleman J, et al. Early cognitive and motor development among infants born to women infected with human immunodeficiency virus. Pediatrics.2000; 106(2) . Available at: www.pediatrics.org/cgi/content/full/106/2/e25
  3. Drotar D, Olness K, Wiznitzer M, et al. Neurodevelopmental outcomes of Ugandan infants with HIV infection: an application of growth curve analysis. Health Psychol.1999; 18 :114 –121[CrossRef][Web of Science][Medline]
  4. Englund JA, Baker CJ, Raskino C, et al. Clinical and laboratory characteristics of symptomatic, human immunodeficiency virus-infected infants and children. Pediatr Infect Dis J.1996; 15 :1025 –1036[CrossRef][Web of Science][Medline]
  5. Cooper E, Hanson C, Diaz C, et al. Encephalopathy and progression of human immunodeficiency virus in a cohort of children with perinatally acquired human immunodeficiency virus infection. Women and Infants Transmission Group. J Pediatr.1998; 132 :808 –812[CrossRef][Web of Science][Medline]
  6. Mellins CA, Levenson RL, Zawadzki R, Kairam R, Weston, M. Effects of pediatric HIV infection and prenatal drug exposure on mental and psychomotor development. J Pediatr Psychol.1994; 19 :617 –628[Abstract/Free Full Text]
  7. Wolters P, Brouwers P, Moss H, Pizzo P. Differential receptive and expressive language functioning of children with symptomatic HIV disease and relation to CT scan brain abnormalities. Pediatrics.1995; 95 :112 –119[Abstract/Free Full Text]
  8. Esposito S, Musetti L, Musetti MC, et al. Behavioral and psychological disorders in uninfected children aged 6 to 11 years born to human immunodeficiency virus-seropositive mothers. J Dev Behav Pediatr.1999; 20 :411 –417[Web of Science][Medline]
  9. Havens JF, Mellins CA, Pilowsky D. Mental health issues in HIV-affected women and children. Int Rev Psychiatry.1996; 8 :217 –225
  10. Speigal L, Mayers A. Psychosocial aspects of AIDS in children and adolescents. Pediatr Clin North Am.1991; 38 :153 –167[Web of Science][Medline]
  11. Wiener L, Septius A. Psychosocial consideration and support for the child and family. In: Pizzo PA, Wilfert CM, eds. Pediatric AIDS: The Challenge of HIV Infection in Infants, Children and Adolescents. Baltimore, MD: Williams & Wilkins; 1991: 577–594
  12. Bose S, Moss H, Brouwers P, Pizzo P, Lorion R. Psychological adjustment of human immunodeficiency virus-infected school-age children. J Dev Behav Pediatr.1994; 15 :S26 –S33[CrossRef][Web of Science][Medline]
  13. Pao M, Lyon M, D’Angelo L, Schuman W, Tipnis T, Mrazek D. Psychiatric diagnoses in adolescents seropositive for the human immunodeficiency virus. Arch Pediatr Adolesc Med.2000; 154 :240 –244[Abstract/Free Full Text]
  14. Tardieu M, Mayaux MJ, Seibel N, et al. Cognitive assessment of school-age children infected with maternally transmitted human immunodeficiency virus type 1. J Pediatr.1995; 126 :375 –379[CrossRef][Web of Science][Medline]
  15. Moss HA, Bose S, Wolters P, Brouwers PA. preliminary study of factors associated with psychological adjustment and disease course in school-age children infected with human immunodeficiency virus. J Dev Behav Pediatr.1998; 19 :18 –25[Web of Science][Medline]
  16. Corsi A, Albizzati A, Cervini R, et al. Hyperactive disturbance in the behavior of children with congenital HIV infection. In: Abstracts of the Seventh International AIDS Conference. Vol 2. Florence, Italy; 1991 (abstr WD 4380)
  17. Hittelman J, Willoughby A, Mendez H, et al. Neurodevelopmental outcome of perinatally acquired HIV infection in the first 15 years of life. In: Final Program and Abstracts of the Sixth International AIDS Conference. Vol 3. San Francisco, CA; 1990 (abstr SB200, 130)
  18. Hopkins KM, Grosz J, Cohen H, et al. The developmental and family services unit: a model AIDS project serving developmentally disabled children and their families. AIDS Care.1989; 1 :281 –285[Medline]
  19. Havens J, Whitaker A, Feldman J, Ehrhardt A. Psychiatric morbidity in school-age children with congenital HIV-infection: a pilot study. J Dev Behav Pediatr.1994; 15 :S18 –S25[CrossRef][Web of Science][Medline]
  20. Loveland KA, Stehbens J, Contant C, et al. Hemophilia growth and development study: baseline neurodevelopmental findings. J Pediatr Psychol.1994; 19 :223 –239[Abstract/Free Full Text]
  21. Whitt JK, Hooper SR, Tennison MB, et al. Neuropsychologic functioning of human immunodeficiency virus-infected children with hemophilia. J Pediatr.1993; 122 :52 –59[Web of Science][Medline]
  22. Brouwers P, Moss H, Wolters P, et al. Neurobehavioral typology of school-age children with symptomatic HIV disease. J Clin Exp Neuropsychol.1992; 12 :113 (abstr)
  23. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. December 2000 Year-End Edition. Vol 12, No 2. Atlanta, GA: Centers for Disease Control and Prevention
  24. Boyd-Franklin N, Steiner GL, Boland MG, eds. Children, Families, and HIV/AIDS. New York, NY: The Guilford Press; 1995
  25. Hardy M, Armstrong F, Routh D, et al. Coping and communication among parents and children with human immunodeficiency virus and cancer. J Dev Behav Pediatr.1994; 15 :S49 –S53[CrossRef][Web of Science][Medline]
  26. Mellins CA, Ehrhardt AA, Grant WF. Psychiatric symptomatology and psychological functioning in HIV-infected mothers. AIDS Behav.1997; 1 :233 –244
  27. Rotheram-Borus MJ, Robin L, Reid HM, Draimin B. Parent-adolescent conflict and stress when parents are living with AIDS. Fam Process.1998; 37 :83 –94[CrossRef][Web of Science][Medline]
  28. Bendersky M, Lewis M. Environmental risk, biological risk, and developmental outcome. Dev Psychol.1994; 30 :484 –494[CrossRef][Web of Science]
  29. Chasnoff IJ, Griffith DR, Freier C, Murray J. Cocaine/polydrug use in pregnancy: two-year follow-up. Pediatrics.1992; 89 :284 –289[Abstract/Free Full Text]
  30. Murrain M, Barker T. Investigating the relationship between economic status and HIV risk. J Health Care Poor Underserved.1997; 8 :416 –423[Web of Science][Medline]
  31. Campbell T. A review of the psychological effects of vertically acquired HIV infection in infants and children. Br J Health Psychol.1997; 2 :1 –13
  32. Mellins CA, McCaskill E, Havens J, et al. Factors mediating medical adherence in HIV-infected mothers. Paper presented at the annual conference of the NIMH on "The Role of Families in Preventing and Adapting to HIV-infection and AIDS." July 1999; Philadelphia, PA
  33. Rabkin C, Chesney MA. Adhering to complex regimens for HIV. GMHC Treat Iss.1998; 12 :8 –11
  34. Conners CK. Conners’ Rating Scales Manuals: Conners’ Teacher Rating Scales and Conners’ Parent Rating Scales. Los Angeles, CA: Western Psychological Services; 1989
  35. Conners CK. Conners Rating Scales. In: Maruish ME, ed. The Use of Psychological Testing for Treatment Planning and Outcome Assessment. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994: 550–578
  36. McIntosh K, Pitt J, Brambilla D, et al. Blood culture in the first 6 months of life for the diagnosis of vertically transmitted human immunodeficiency virus infection. J Infect Dis.1994; 170 :996 –1000[Web of Science][Medline]
  37. Rodriguez EM, Mofenson LM, Chang BH, et al. Association of maternal drug use during pregnancy with maternal HIV culture positivity and perinatal HIV transmission. AIDS.1996; 10 :273 –282[Web of Science][Medline]
  38. SAS PROC MIXED. Cary, NC: SAS Institute; 1999
  39. Havens JF, Mellins CA, Hunter J. Psychiatric aspects of HIV/AIDS in childhood and adolescence. In: Rutter M, Taylor E, eds. Child and Adolescent Psychiatry: Modern Approaches. 4th ed. Oxford, UK: Blackwell; 2002: 828–841
  40. Smith AH, Bates MN. Confidence limit analyses should replace power calculations in the interpretation of Epidemiologic studies. Epidemiology.1992; 3 :449 –452[Web of Science][Medline]
  41. Bachanas PJ, Kullgren K, Suzman Schwartz K, et al. Predictors of psychological adjustment in school-age children infected with HIV. J Pediatr Psychol.2001; 26 :343 –352[Abstract/Free Full Text]
  42. Achenbach T, Edelbrock C. Manual for the Child Behavior Checklist 4–18 and 1991 Profile. Burlington, VT: University of Vermont, Department of Psychiatry; 1991
  43. O’Connor MJ, Sigman M, Kasari C. Attachment behavior of infants exposed prenatally to alcohol: mediating effects of infant affect and mother-infant interaction. Dev Psychopathol.1992; 4 :243 –256[CrossRef][Web of Science]
  44. Singer L, Farkas K, Kliegman R. Childhood medical and behavioral consequences of maternal cocaine use. J Pediatr Psychol.1992; 17 :389 –406[Abstract/Free Full Text]
  45. Goyette CH, Conners CK, Ulrich RE. Normative data on revised Conners Parent and Teacher Rating Scales. J Abnorm Child Psychol.1978; 6 :221 –236[CrossRef][Web of Science][Medline]
  46. Conners CK, Sitarenios G, Parker JDA, Epstein JN. The revised Conners’ Parent Rating Scale (CPRS-R): factor structure, reliability and criterion validity. J Abnorm Child Psychol.1998; 4 :257 –268
  47. Querido JG, Warner TD, Eyberg SM. Parenting styles and child behavior in African American families of preschool children. J Clin Child Adolesc Psychol.2002; 31 :272 –277
  48. Horwitz SM, Kerker BD Preschool and school age children under welfare reform. Child Psychiatry Hum Dev.2001; 32 :107 –124[CrossRef][Web of Science][Medline]
  49. Gortmaker SC, Walker DK, Weitzman M. Chronic conditions, socioeconomic risks, and behavioral problems in children and adolescents. Pediatrics.199085 :267 –276[Abstract/Free Full Text]
  50. Mellins CA, Ehrhardt AA. Families affected by pediatric AIDS: sources of stress and coping. J Dev Behav Pediatr.1994; 15(suppl) :S54 –S60[CrossRef][Web of Science][Medline]
  51. Canino G, Bravo M. The adaptation and testing of diagnostic and outcome measures for cross-cultural research. Int Rev Psychiatry.1994; 6 :281 –286
  52. Forsyth BW, Damour L, Nagler S, Adnopoz J. The psychological effects of parental human immunodeficiency virus infection on uninfected children. Arch Pediatr Adolesc Med.1996; 150 :1015 –1020[Abstract/Free Full Text]
  53. Havens JF, Mellins CA, Ryan S. The mental health treatment of children and families affected by HIV-AIDS. In Wicks L, ed. AIDS and Psychotherapy. Washington, DC: Taylor and Francis; 1997: 101–114
  54. Kotchick BA, Forehand R. The family health project: a longitudinal investigation of children whose mothers are HIV-infected. Paper presented at the annual conference of the NIMH on "The Role of Families in Preventing and Adapting to HIV-Infection and AIDS." July 1999; Philadelphia, PA
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Facebook Facebook   Add to Reddit Reddit   Add to Technorati Technorati   Add to Twitter Twitter    What's this?


This article has been cited by other articles:


Home page
 PediatricsHome page
M. Chernoff, S. Nachman, P. Williams, P. Brouwers, J. Heston, J. Hodge, V. Di Poalo, N. S. Deygoo, K. D. Gadow, and IMPAACT P1055 Study Team
Mental Health Treatment Patterns in Perinatally HIV-Infected Youth and Controls
Pediatrics, August 1, 2009; 124(2): 627 - 636.
[Abstract] [Full Text] [PDF]

Home page
 J Pediatr PsycholHome page
M. J. New, S. S. Lee, and B. M. Elliott
Psychological Adjustment in Children and Families Living with HIV
J. Pediatr. Psychol., March 1, 2007; 32(2): 123 - 131.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
M. L. Nozyce, S. S. Lee, A. Wiznia, S. Nachman, L. M. Mofenson, M. E. Smith, R. Yogev, K. McIntosh, K. Stanley, and S. Pelton
A Behavioral and Cognitive Profile of Clinically Stable HIV-Infected Children
Pediatrics, March 1, 2006; 117(3): 763 - 770.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
R. Smith, K. Malee, R. Leighty, P. Brouwers, C. Mellins, J. Hittelman, C. Chase, I. Blasini, and for the Women and Infants Transmission Study Group
Effects of Perinatal HIV Infection and Associated Risk Factors on Cognitive Development Among Young Children
Pediatrics, March 1, 2006; 117(3): 851 - 862.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
D. S. Storm, M. G. Boland, S. L. Gortmaker, Y. He, J. Skurnick, L. Howland, J. M. Oleske, and for the Pediatric AIDS Clinical Trials Group Proto
Protease Inhibitor Combination Therapy, Severity of Illness, and Quality of Life Among Children With Perinatally Acquired HIV-1 Infection
Pediatrics, February 1, 2005; 115(2): e173 - e182.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
D. M. Gaughan, M. D. Hughes, J. M. Oleske, K. Malee, C. A. Gore, S. Nachman, and for the Pediatric AIDS Clinical Trials Group 219C
Psychiatric Hospitalizations Among Children and Youths With Human Immunodeficiency Virus Infection
Pediatrics, June 1, 2004; 113(6): e544 - e551.
[Abstract] [Full Text]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Web of Science (22)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mellins, C. A.
Right arrow Articles by Matzen, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mellins, C. A.
Right arrow Articles by Matzen, E.
Related Collections
Right arrow Infectious Disease & Immunity
Right arrowRelated AAP Red Book topics:
Human Immunodeficiency Virus...
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Facebook   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?