Introduction: Across the globe, children born with perinatal HIV infection (PHIV) are reaching ad... more Introduction: Across the globe, children born with perinatal HIV infection (PHIV) are reaching adolescence and young adulthood in large numbers. The majority of research has focused on biomedical outcomes yet there is increasing awareness that long-term survivors with PHIV are at high risk for mental health problems, given genetic, biomedical, familial and environmental risk. This article presents a review of the literature on the mental health functioning of perinatally HIV-infected (PHIV') adolescents, corresponding risk and protective factors, treatment modalities and critical needs for future interventions and research. Methods: An extensive review of online databases was conducted. Articles including: (1) PHIV' youth; (2) age 10 and older; (3) mental health outcomes; and (4) mental health treatment were reviewed. Of 93 articles identified, 38 met inclusion criteria, the vast majority from the United States and Europe. Results: These studies suggest that PHIV' youth experience emotional and behavioural problems, including psychiatric disorders, at higher than expected rates, often exceeding those of the general population and other high-risk groups. Yet, the specific role of HIV per se remains unclear, as uninfected youth with HIV exposure or those living in HIV-affected households displayed similar prevalence rates in some studies, higher rates in others and lower rates in still others. Although studies are limited with mixed findings, this review indicates that child-health status, cognitive function, parental health and mental health, stressful life events and neighbourhood disorder have been associated with worse mental health outcomes, while parentÁchild involvement and communication, and peer, parent and teacher social support have been associated with better function. Few evidence-based interventions exist; CHAMP', a mental health programme for PHIV' youth, shows promise across cultures. Conclusions: This review highlights research limitations that preclude both conclusions and full understanding of aetiology. Conversely, these limitations present opportunities for future research. Many PHIV' youth experience adequate mental health despite vulnerabilities. However, the focus of research to date highlights the identification of risks rather than positive attributes, which could inform preventive interventions. Development and evaluation of mental health interventions and preventions are urgently needed to optimize mental health, particularly for PHIV' youth growing up in low-and-middle income countries.
To examine the longitudinal association between sexual behavior and substance use in perinatally... more To examine the longitudinal association between sexual behavior and substance use in perinatally HIV-infected (PHIV+) and perinatally HIV-exposed-but-uninfected (PHIV-) youth. METHODS: Growth curve modeling was used with data from N = 340 PHIV-exposed youth (60.6% PHIV+; 9-22 years) to estimate the onset of penetrative and unprotected sex across time, adding alcohol and marijuana use trajectories as time-varying covariates and examining HIV-status differences. RESULTS: The odds of penetrative or unprotected sex more than doubled across time. Alcohol and marijuana use significantly increased the odds of engaging in sex and unprotected sex, with no HIV-status differences. The association between unprotected sex and alcohol use was less salient for PHIV+ than PHIV- youth. CONCLUSIONS: Similar to youth from other populations, PHIV+ and PHIV- youth are increasingly engaging in sex and substance use as they age. Targeted interventions to prevent sexual risk behavior and further HIV...
More than 2 million children are infected with HIV globally. Pediatric antiretroviral therapy (AR... more More than 2 million children are infected with HIV globally. Pediatric antiretroviral therapy (ART) adherence is complex, and current levels are often suboptimal. As established treatment programs in developed settings struggle with chronic therapy and nascent treatment programs in resource-limited settings expand, the importance and challenges of good adherence to ART are becoming ever more clear. Adherence behavior is influenced by many factors, which may be categorized as characteristics of the child, the caregiver(s) and family, the regimen, and society and culture. Many of these influences complicate measurement of pediatric adherence, and there is no gold standard. This article provides a conceptual framework and evidence-based look at the factors influencing ART adherence in children and aims to identify areas for intervention for this vulnerable population in need.
Purpose: During early and middle adolescence, a subset of perinatally HIV infected youth (PHIVþ y... more Purpose: During early and middle adolescence, a subset of perinatally HIV infected youth (PHIVþ youth) engage in sexual behavior that poses transmission risks to their partners. The risk posed to their partners may be greater when these youth are nonadherent to antiretroviral therapy (ART), as nonadherence may lead to greater risks of transmission overall, and greater risks of transmission of ART-resistant virus. Problem Behavior Theory suggests that such risky adolescent behaviors may co-occur, because determinants of multiple risky behaviors may be similar. This analysis explored the extent to which PHIVþ youth who engage in sexual behavior (defined as oral, vaginal, or anal sex) are also engaging in antiretroviral nonadherence. Methods: Data were derived from the baseline visit of a longitudinal study of youth (ages 9-16 years) who were perinatally exposed to HIV. Youth in these analyses: (a) were living with HIV; (b) were prescribed ART; (c) provided child and parent/caregiver reports of ART adherence; (d) completed a sexual behavior assessment; and (e) had concurrent virologic data documented in their medical record. After conducting descriptive statistics, the relationship between adherence and viral load was tested with logistic regression to establish convergent validity of the adherence assessment. Subsequent bivariate and multivariate logistic regression analyses were conducted to assess the likelihood that nonadherent (vs. adherent) youth had engaged in any sex (oral, vaginal, or anal). Results: Complete data on sexual risk behavior and antiretroviral therapy were available for 144 PHIVþ youth (52% male; 58% Black; 28% Latino; M age ¼ 12.37 years, SD ¼ 2.18). Only 15 of these youth reported ever engaging in any sex, but 13 of them (87%) were nonadherent, based on caregiver or self-report of at least one missed dose of antiretroviral therapy in the prior month. PHIVþ youth who were older and nonadherent were more likely to have engaged in any sex; youth's race was not associated with engagement in any sex. Even when controlling for the effects of age, nonadherent PHIVþ youth were nearly five times more likely than adherent youth to engage in any sex (see .
In the era of more efficacious prevention of mother-to-child transmission (PMTCT) regimens, docum... more In the era of more efficacious prevention of mother-to-child transmission (PMTCT) regimens, documenting the profile of drug resistance in HIV-infected infants and young children is critical to our efforts to improve care and treatment for children. HIV drug resistance mutations in plasma virus were ascertained using population sequencing among 230 newly diagnosed HIV-infected children under 2 years of age recruited in Johannesburg, South Africa, during 2011. By this time, more effective PMTCT regimens, including combination antiretroviral therapy for pregnant women, were being implemented. Two-thirds (67.4%) of HIV-infected children had been exposed to some form of maternal (89%) and/or infant (97%) PMTCT. Among PMTCT-exposed, 56.8% had nonnucleoside reverse transcriptase inhibitor (NNRTI), 14.8% nucleoside reverse transcriptase inhibitor (NRTI), and 1.3% protease inhibitor mutations. NNRTI mutations were strongly related to younger age. The remaining third (32.6%) had no reported or recorded PMTCT exposures, but resistance to NNRTI was detected in 24.0%, NRTI in 10.7%, and protease inhibitor in 1.3%. The new PMTCT strategies dramatically reduce the number of children who acquire infection, but among those who do become infected, NNRTI resistance prevalence is high. In this South African setting with high PMTCT coverage, almost a quarter of children with no reported or recorded PMTCT also have drug resistance mutations. PMTCT history is an inadequate means of ruling out pretreatment drug resistance. Our results support the use of protease inhibitor-based first-line regimens in HIV-infected infants and young children regardless of PMTCT history.
This review article provides a conceptual framework for human papillomavirus (HPV) vaccine accept... more This review article provides a conceptual framework for human papillomavirus (HPV) vaccine acceptance and adherence, with a focus on improving understanding of the sociocultural factors impacting vaccine adherence behaviour. We include a systematic review of the slowly expanding literature on HPV vaccine acceptability and uptake in developed nations, as well as the relatively few publications from poorer nations, where more than 80% of global cervical cancer related deaths occur and where the vaccine will probably have the largest impact. We suggest that this conceptual framework will not only improve our understanding of HPV vaccine uptake and adherence, but it may also guide future sociobehavioural research geared towards improving adherence to the HPV vaccine and other multi-step vaccines in a young population at risk for sexually transmissible infections.
Page 1. Sex Roles, Vol. 16, Nos. 11/12, 1987 The Influence of Individual and Family Characteristi... more Page 1. Sex Roles, Vol. 16, Nos. 11/12, 1987 The Influence of Individual and Family Characteristics upon Career Aspirations of Girls During Childhood and Adolescence 1 David E. Sandberg, 2 Anke A. Ehrhardt, Claude A. Mellins ...
This study examines the validity, feasibility, and utility of the Client Diagnostic Questionnaire... more This study examines the validity, feasibility, and utility of the Client Diagnostic Questionnaire (CDQ), a brief diagnostic screening tool designed for use by non-mental health professionals and designed specifically to assess the range of psychiatric disorders known to be prevalent among persons infected with HIV or at high risk of infection: depression, anxiety, PTSD, substance abuse. Non-clinically trained personnel administered the CDQ to a diverse sample of 260 HIV infected individuals at six primary care or social service agencies; a second interview was conducted by an experienced mental health clinician. There was good agreement between positive screen on the CDQ and diagnosis made by an independent mental health professional. For the diagnosis of any disorder, sensitivity = 91%, specificity = 78%, and overall accuracy = 85%. Clients who screened positive for disorder based on the CDQ interview had significantly impaired mental health functioning compared to individuals without CDQ screening diagnosis. CDQ was well received by both clients and agency staff. Findings support the feasibility and utility of the CDQ. The CDQ can be used by providers in a range of service settings to identify persons in need of formal mental health assessment and treatment, to more effectively target scarce mental health resources, and to reduce the negative impact of unrecognized disorder on the health and well-being of individuals in their care.
Professional Psychology: Research and Practice, 1989
We propose a developmental model to describe how student-therapists learn to appropriately consid... more We propose a developmental model to describe how student-therapists learn to appropriately consider cultural factors in their clinical work with culturally diverse clients. The model is derived from discussions held in a seminar concerning mental health services and culture and from students' written accounts of how they considered cultural factors in providing therapy. Vignettes based on the written accounts are presented to illustrate the key developmental processes hypothesized to underlie psychotherapists' growing cultural sensitivity. The proposed model is contrasted with past models of therapist development. A research agenda guided by a social cognitive perspective is offered to test the proposed model.
Background: Adherence to HIV antiretroviral therapy (ART) among children in developing settings i... more Background: Adherence to HIV antiretroviral therapy (ART) among children in developing settings is poorly understood.
OBJECTIVE. We examined the effect of HIV, in combination with other important health and social f... more OBJECTIVE. We examined the effect of HIV, in combination with other important health and social factors, on the development of cognitive abilities of children perinatally exposed to HIV.
Clinical reports from the United States indicate substantive mental health problems in perinatall... more Clinical reports from the United States indicate substantive mental health problems in perinatally human immunodeficiency virus (HIV)-infected youth that pose substantial barriers to optimizing their health. This pilot study explores rates and types of psychiatric and substance use disorders, as well as emotional and behavioral functioning in perinatally HIV-infected children and adolescents. Forty-seven perinatally-infected youths (9-16 years of age) and their primary caregivers recruited from a pediatric HIV clinic were interviewed using standardized assessments of youth psychiatric disorders and emotional and behavioral functioning, as well as measures of health and caregiver mental health. According to either the caregiver or child report, 55% of youths met criteria for a psychiatric disorder. The most prevalent diagnoses were anxiety disorders (40%), attention deficit hyperactivity disorders (21%), conduct disorders (13%), and oppositional defiant disorders (11%). However, the majority of caregivers and children scored in the normative range on the symptom questionnaires on emotional and behavioral functioning. None of the demographic or child health variables or measures of caregiver mental health was significantly associated with presence of a child psychiatric disorder. There was an association between caregiver mental health and child emotional and behavioral functioning. Standardized assessments of mental health identified very high rates of psychiatric disorders, primarily in the anxiety and behavioral domains, in this sample of youth with perinatal HIV infection. Mental health interventions should be integrated into medical care to help members of this highly vulnerable population optimize their health and well-being.
Identifying HIV-1-infected children who are at greatest risk for disease-related morbidities is c... more Identifying HIV-1-infected children who are at greatest risk for disease-related morbidities is critical for optimal therapeutic as well as preventive care. Several factors have been implicated in HIV-1 disease onset and severity, including maternal and infant host characteristics, viral phenotype and timing of HIV-1 infection. Early HIV-1 culture positivity, i.e. intrauterine infection, has been associated with poor immunologic, virologic and clinical outcomes in children of HIV-infected women. However, a direct effect of timing of infection on neurodevelopmental outcome in infancy has not yet been identified. Serial neurodevelopmental assessments were performed with 114 infants vertically infected with HIV-1 in a multicenter natural history, longitudinal study. Median mental and motor scores were compared at three time points. Longitudinal regression analyses were used to evaluate the neurodevelopmental functioning of children with early positive cultures and those with late positive cultures. Early infected infants scored significantly lower than late infected infants by 24 months of age and beyond on both mental (P = 0.05) and motor (P = 0.03) measures. Early HIV-1 infection was associated with a decline in estimated motor scores of 1 standard score point per month compared with 0.28 point in the late infected group (P < 0.02). Estimated mental scores of the early infected group declined 0.72 point/ month, whereas the average decline of the late infected group was 0.30 point/month (P < 0.13). Early HIV-1 infection increases a child's risk for poor neurodevelopmental functioning within the first 30 months of life.
The toxicity and complexity of antiretroviral therapy (ART) regimens are substantial challenges i... more The toxicity and complexity of antiretroviral therapy (ART) regimens are substantial challenges in the context of patients' lives. This study examines child psychosocial and caregiver/family factors influencing adherence to ART in perinatally human immunodeficiency virus (HIV)-infected children. Seventy-five children (ages 3-13 years) prescribed ART, and their primary caregivers were recruited from 2 urban pediatric HIV programs. A battery of psychologic assessments and self-report adherence data were collected from all caregivers and 48 children who were > or =7 years old. Forty percent of caregivers and 56% of children reported missed doses of medication in the past month. Families in which the caregiver or child reported missed doses (nonadherent) were compared with families who reported no missed doses (adherent). In univariate analyses, nonadherence was significantly associated with older child age (P < 0.05), worse parent-child communication (P < 0.017), higher caregiver stress (P < 0.002), lower caregiver quality of life (P < 0.003) and worse caregiver cognitive functioning (P = 0.033), and of borderline significance in its association with increased (1) child responsibility for medications (P < 0.07), (2) HIV disclosure to the child (P < 0.07) and (3) child stress (P < 0.08) In logistic regressions controlling for age, caregiver/family factors were the most strongly associated with nonadherence, including worse parent-child communication (P < 0.03), higher caregiver stress (P < 0.01), less disclosure to others (P < 0.05) and quality of life (P < 0.01). Our data suggest that efforts to improve children's adherence to complex antiretroviral regimens requires addressing developmental, psychosocial and family factors.
Objective: Improvements in treatment-related knowledge and self-efficacy may improve clinical out... more Objective: Improvements in treatment-related knowledge and self-efficacy may improve clinical outcomes in HIV-infected populations. We examined whether caregivers' knowledge and self-efficacy was associated with better clinical outcomes and anti-retroviral therapy (ART) adherence among HIV-infected children. Methods: Caregivers of 77 perinatally HIV-infected children were administered a semi-structured interview which included scales of HIV treatment-related knowledge, adherence self-efficacy and caregiver reports of child medication adherence. Results: While caregivers correctly answered 74% of the knowledge questions, specific misconceptions were noted. Caregivers rated themselves as having high adherence self-efficacy, but were least confident in their ability to adhere to ART if it caused side effects or might result in social disclosure. Higher caregiver treatment-related knowledge and self-efficacy were associated with better clinical outcomes, as measured by viral load and CD4+ count, but not with caregiver reports of ART adherence. Conclusion/discussion: While additional factors may be important determinants of adherence to ART in this population, improving the HIV treatment-related knowledge and self-efficacy of caregivers may help to improve the clinical outcomes of HIV-infected children.
... has been associated with high rates of unprotected intercourse, teen pregnancy, and sexually ... more ... has been associated with high rates of unprotected intercourse, teen pregnancy, and sexually ... sizes the internal (mental health) and external (environmen-tal) context in which ... parent-child communication, parent supervision and monitoring, and overall parent-child relationship. ...
A large proportion of perinatally HIV-infected (PHIV) children are becoming adolescents and explo... more A large proportion of perinatally HIV-infected (PHIV) children are becoming adolescents and exploring their sexuality. This study explored the prevalence of sexual behaviors (kissing, touching, engaging in oral sex, or having vaginal/anal intercourse) in a sample of predominantly ethnic minority youths (N = 339; 54.1% Black and 30.4% Latino; 51% female; ages 9-16)
Journal of the American Academy of Child & Adolescent Psychiatry, 2009
Objective: As perinatally human immunodeficiency virus (HIV)Yinfected (PHIV+) youths enter adoles... more Objective: As perinatally human immunodeficiency virus (HIV)Yinfected (PHIV+) youths enter adolescence, they are at high risk for poor behavioral and health outcomes. This study examines relations between youth mental health problems and sexual and substance use risk behavior, the impact of caregiver mental health and family functioning on youth mental health and risk behavior outcomes, and the role of youth HIV status in this process. Method: Participants were recruited from four medical centers. Individual interviews were administered to 193 PHIV+ and 127 perinatally HIV exposed but uninfected (PHIVj) 9-to 16-year-old boys and girls and their primary caregivers. Participants were primarily African American and Latino. The interview assessed child sexual and drug risk behavior, child and caregiver mental health, and family functioning. Results: Exploratory latent-variable structural equation modeling revealed no differences in rates of sexual risk behavior or substance use between PHIV+ and PHIVj youths. However, adolescent mental health was significantly associated with sexual risk behavior and substance use. Caregiver mental health was associated with youth mental health and indirectly with sexual risk behavior and drug use through its impact on youth mental health. Family functioning did not significantly predict youth outcomes. Conclusions: Over and above other key environmental factors and family functioning, youth and caregiver mental health problems are related to sex and drug use risk behaviors in PHIV+ and PHIVj youths. Given high rates of youth and caregiver mental health problems in this population, family-based mental health interventions may be a key component of HIV prevention programs for perinatally HIV-exposed youth. J. Am.
Virtually all human individual diVerences have been shown to be moderately heritable. Much of thi... more Virtually all human individual diVerences have been shown to be moderately heritable. Much of this research, however, focuses on measures of dysfunctional behavior and relatively fewer studies have focused on positive traits. The values in action (VIA) project is a comprehensive and ambitious classiWcation of 24 positive traits, also known as character strengths (Peterson, C., & Seligman, M. E. P. . Character strengths and virtues: A handbook and classiWcation. Washington, DC: American Psychological Association), the majority of which have received no behavior genetic attention. Using a sample of 336 middle-aged twins drawn from the Minnesota Twin Registry who completed the VIA inventory of strengths, we detected signiWcant genetic and non-shared environmental eVects for 21 of 24 character strengths with little evidence of shared environmental contributions. Associations with a previously administered measure of normal personality found moderate phenotypic overlap and that genetic inXuences on personality traits could account for most, but not all, of the heritable variance in character strengths.
Introduction: Across the globe, children born with perinatal HIV infection (PHIV) are reaching ad... more Introduction: Across the globe, children born with perinatal HIV infection (PHIV) are reaching adolescence and young adulthood in large numbers. The majority of research has focused on biomedical outcomes yet there is increasing awareness that long-term survivors with PHIV are at high risk for mental health problems, given genetic, biomedical, familial and environmental risk. This article presents a review of the literature on the mental health functioning of perinatally HIV-infected (PHIV') adolescents, corresponding risk and protective factors, treatment modalities and critical needs for future interventions and research. Methods: An extensive review of online databases was conducted. Articles including: (1) PHIV' youth; (2) age 10 and older; (3) mental health outcomes; and (4) mental health treatment were reviewed. Of 93 articles identified, 38 met inclusion criteria, the vast majority from the United States and Europe. Results: These studies suggest that PHIV' youth experience emotional and behavioural problems, including psychiatric disorders, at higher than expected rates, often exceeding those of the general population and other high-risk groups. Yet, the specific role of HIV per se remains unclear, as uninfected youth with HIV exposure or those living in HIV-affected households displayed similar prevalence rates in some studies, higher rates in others and lower rates in still others. Although studies are limited with mixed findings, this review indicates that child-health status, cognitive function, parental health and mental health, stressful life events and neighbourhood disorder have been associated with worse mental health outcomes, while parentÁchild involvement and communication, and peer, parent and teacher social support have been associated with better function. Few evidence-based interventions exist; CHAMP', a mental health programme for PHIV' youth, shows promise across cultures. Conclusions: This review highlights research limitations that preclude both conclusions and full understanding of aetiology. Conversely, these limitations present opportunities for future research. Many PHIV' youth experience adequate mental health despite vulnerabilities. However, the focus of research to date highlights the identification of risks rather than positive attributes, which could inform preventive interventions. Development and evaluation of mental health interventions and preventions are urgently needed to optimize mental health, particularly for PHIV' youth growing up in low-and-middle income countries.
To examine the longitudinal association between sexual behavior and substance use in perinatally... more To examine the longitudinal association between sexual behavior and substance use in perinatally HIV-infected (PHIV+) and perinatally HIV-exposed-but-uninfected (PHIV-) youth. METHODS: Growth curve modeling was used with data from N = 340 PHIV-exposed youth (60.6% PHIV+; 9-22 years) to estimate the onset of penetrative and unprotected sex across time, adding alcohol and marijuana use trajectories as time-varying covariates and examining HIV-status differences. RESULTS: The odds of penetrative or unprotected sex more than doubled across time. Alcohol and marijuana use significantly increased the odds of engaging in sex and unprotected sex, with no HIV-status differences. The association between unprotected sex and alcohol use was less salient for PHIV+ than PHIV- youth. CONCLUSIONS: Similar to youth from other populations, PHIV+ and PHIV- youth are increasingly engaging in sex and substance use as they age. Targeted interventions to prevent sexual risk behavior and further HIV...
More than 2 million children are infected with HIV globally. Pediatric antiretroviral therapy (AR... more More than 2 million children are infected with HIV globally. Pediatric antiretroviral therapy (ART) adherence is complex, and current levels are often suboptimal. As established treatment programs in developed settings struggle with chronic therapy and nascent treatment programs in resource-limited settings expand, the importance and challenges of good adherence to ART are becoming ever more clear. Adherence behavior is influenced by many factors, which may be categorized as characteristics of the child, the caregiver(s) and family, the regimen, and society and culture. Many of these influences complicate measurement of pediatric adherence, and there is no gold standard. This article provides a conceptual framework and evidence-based look at the factors influencing ART adherence in children and aims to identify areas for intervention for this vulnerable population in need.
Purpose: During early and middle adolescence, a subset of perinatally HIV infected youth (PHIVþ y... more Purpose: During early and middle adolescence, a subset of perinatally HIV infected youth (PHIVþ youth) engage in sexual behavior that poses transmission risks to their partners. The risk posed to their partners may be greater when these youth are nonadherent to antiretroviral therapy (ART), as nonadherence may lead to greater risks of transmission overall, and greater risks of transmission of ART-resistant virus. Problem Behavior Theory suggests that such risky adolescent behaviors may co-occur, because determinants of multiple risky behaviors may be similar. This analysis explored the extent to which PHIVþ youth who engage in sexual behavior (defined as oral, vaginal, or anal sex) are also engaging in antiretroviral nonadherence. Methods: Data were derived from the baseline visit of a longitudinal study of youth (ages 9-16 years) who were perinatally exposed to HIV. Youth in these analyses: (a) were living with HIV; (b) were prescribed ART; (c) provided child and parent/caregiver reports of ART adherence; (d) completed a sexual behavior assessment; and (e) had concurrent virologic data documented in their medical record. After conducting descriptive statistics, the relationship between adherence and viral load was tested with logistic regression to establish convergent validity of the adherence assessment. Subsequent bivariate and multivariate logistic regression analyses were conducted to assess the likelihood that nonadherent (vs. adherent) youth had engaged in any sex (oral, vaginal, or anal). Results: Complete data on sexual risk behavior and antiretroviral therapy were available for 144 PHIVþ youth (52% male; 58% Black; 28% Latino; M age ¼ 12.37 years, SD ¼ 2.18). Only 15 of these youth reported ever engaging in any sex, but 13 of them (87%) were nonadherent, based on caregiver or self-report of at least one missed dose of antiretroviral therapy in the prior month. PHIVþ youth who were older and nonadherent were more likely to have engaged in any sex; youth's race was not associated with engagement in any sex. Even when controlling for the effects of age, nonadherent PHIVþ youth were nearly five times more likely than adherent youth to engage in any sex (see .
In the era of more efficacious prevention of mother-to-child transmission (PMTCT) regimens, docum... more In the era of more efficacious prevention of mother-to-child transmission (PMTCT) regimens, documenting the profile of drug resistance in HIV-infected infants and young children is critical to our efforts to improve care and treatment for children. HIV drug resistance mutations in plasma virus were ascertained using population sequencing among 230 newly diagnosed HIV-infected children under 2 years of age recruited in Johannesburg, South Africa, during 2011. By this time, more effective PMTCT regimens, including combination antiretroviral therapy for pregnant women, were being implemented. Two-thirds (67.4%) of HIV-infected children had been exposed to some form of maternal (89%) and/or infant (97%) PMTCT. Among PMTCT-exposed, 56.8% had nonnucleoside reverse transcriptase inhibitor (NNRTI), 14.8% nucleoside reverse transcriptase inhibitor (NRTI), and 1.3% protease inhibitor mutations. NNRTI mutations were strongly related to younger age. The remaining third (32.6%) had no reported or recorded PMTCT exposures, but resistance to NNRTI was detected in 24.0%, NRTI in 10.7%, and protease inhibitor in 1.3%. The new PMTCT strategies dramatically reduce the number of children who acquire infection, but among those who do become infected, NNRTI resistance prevalence is high. In this South African setting with high PMTCT coverage, almost a quarter of children with no reported or recorded PMTCT also have drug resistance mutations. PMTCT history is an inadequate means of ruling out pretreatment drug resistance. Our results support the use of protease inhibitor-based first-line regimens in HIV-infected infants and young children regardless of PMTCT history.
This review article provides a conceptual framework for human papillomavirus (HPV) vaccine accept... more This review article provides a conceptual framework for human papillomavirus (HPV) vaccine acceptance and adherence, with a focus on improving understanding of the sociocultural factors impacting vaccine adherence behaviour. We include a systematic review of the slowly expanding literature on HPV vaccine acceptability and uptake in developed nations, as well as the relatively few publications from poorer nations, where more than 80% of global cervical cancer related deaths occur and where the vaccine will probably have the largest impact. We suggest that this conceptual framework will not only improve our understanding of HPV vaccine uptake and adherence, but it may also guide future sociobehavioural research geared towards improving adherence to the HPV vaccine and other multi-step vaccines in a young population at risk for sexually transmissible infections.
Page 1. Sex Roles, Vol. 16, Nos. 11/12, 1987 The Influence of Individual and Family Characteristi... more Page 1. Sex Roles, Vol. 16, Nos. 11/12, 1987 The Influence of Individual and Family Characteristics upon Career Aspirations of Girls During Childhood and Adolescence 1 David E. Sandberg, 2 Anke A. Ehrhardt, Claude A. Mellins ...
This study examines the validity, feasibility, and utility of the Client Diagnostic Questionnaire... more This study examines the validity, feasibility, and utility of the Client Diagnostic Questionnaire (CDQ), a brief diagnostic screening tool designed for use by non-mental health professionals and designed specifically to assess the range of psychiatric disorders known to be prevalent among persons infected with HIV or at high risk of infection: depression, anxiety, PTSD, substance abuse. Non-clinically trained personnel administered the CDQ to a diverse sample of 260 HIV infected individuals at six primary care or social service agencies; a second interview was conducted by an experienced mental health clinician. There was good agreement between positive screen on the CDQ and diagnosis made by an independent mental health professional. For the diagnosis of any disorder, sensitivity = 91%, specificity = 78%, and overall accuracy = 85%. Clients who screened positive for disorder based on the CDQ interview had significantly impaired mental health functioning compared to individuals without CDQ screening diagnosis. CDQ was well received by both clients and agency staff. Findings support the feasibility and utility of the CDQ. The CDQ can be used by providers in a range of service settings to identify persons in need of formal mental health assessment and treatment, to more effectively target scarce mental health resources, and to reduce the negative impact of unrecognized disorder on the health and well-being of individuals in their care.
Professional Psychology: Research and Practice, 1989
We propose a developmental model to describe how student-therapists learn to appropriately consid... more We propose a developmental model to describe how student-therapists learn to appropriately consider cultural factors in their clinical work with culturally diverse clients. The model is derived from discussions held in a seminar concerning mental health services and culture and from students' written accounts of how they considered cultural factors in providing therapy. Vignettes based on the written accounts are presented to illustrate the key developmental processes hypothesized to underlie psychotherapists' growing cultural sensitivity. The proposed model is contrasted with past models of therapist development. A research agenda guided by a social cognitive perspective is offered to test the proposed model.
Background: Adherence to HIV antiretroviral therapy (ART) among children in developing settings i... more Background: Adherence to HIV antiretroviral therapy (ART) among children in developing settings is poorly understood.
OBJECTIVE. We examined the effect of HIV, in combination with other important health and social f... more OBJECTIVE. We examined the effect of HIV, in combination with other important health and social factors, on the development of cognitive abilities of children perinatally exposed to HIV.
Clinical reports from the United States indicate substantive mental health problems in perinatall... more Clinical reports from the United States indicate substantive mental health problems in perinatally human immunodeficiency virus (HIV)-infected youth that pose substantial barriers to optimizing their health. This pilot study explores rates and types of psychiatric and substance use disorders, as well as emotional and behavioral functioning in perinatally HIV-infected children and adolescents. Forty-seven perinatally-infected youths (9-16 years of age) and their primary caregivers recruited from a pediatric HIV clinic were interviewed using standardized assessments of youth psychiatric disorders and emotional and behavioral functioning, as well as measures of health and caregiver mental health. According to either the caregiver or child report, 55% of youths met criteria for a psychiatric disorder. The most prevalent diagnoses were anxiety disorders (40%), attention deficit hyperactivity disorders (21%), conduct disorders (13%), and oppositional defiant disorders (11%). However, the majority of caregivers and children scored in the normative range on the symptom questionnaires on emotional and behavioral functioning. None of the demographic or child health variables or measures of caregiver mental health was significantly associated with presence of a child psychiatric disorder. There was an association between caregiver mental health and child emotional and behavioral functioning. Standardized assessments of mental health identified very high rates of psychiatric disorders, primarily in the anxiety and behavioral domains, in this sample of youth with perinatal HIV infection. Mental health interventions should be integrated into medical care to help members of this highly vulnerable population optimize their health and well-being.
Identifying HIV-1-infected children who are at greatest risk for disease-related morbidities is c... more Identifying HIV-1-infected children who are at greatest risk for disease-related morbidities is critical for optimal therapeutic as well as preventive care. Several factors have been implicated in HIV-1 disease onset and severity, including maternal and infant host characteristics, viral phenotype and timing of HIV-1 infection. Early HIV-1 culture positivity, i.e. intrauterine infection, has been associated with poor immunologic, virologic and clinical outcomes in children of HIV-infected women. However, a direct effect of timing of infection on neurodevelopmental outcome in infancy has not yet been identified. Serial neurodevelopmental assessments were performed with 114 infants vertically infected with HIV-1 in a multicenter natural history, longitudinal study. Median mental and motor scores were compared at three time points. Longitudinal regression analyses were used to evaluate the neurodevelopmental functioning of children with early positive cultures and those with late positive cultures. Early infected infants scored significantly lower than late infected infants by 24 months of age and beyond on both mental (P = 0.05) and motor (P = 0.03) measures. Early HIV-1 infection was associated with a decline in estimated motor scores of 1 standard score point per month compared with 0.28 point in the late infected group (P < 0.02). Estimated mental scores of the early infected group declined 0.72 point/ month, whereas the average decline of the late infected group was 0.30 point/month (P < 0.13). Early HIV-1 infection increases a child's risk for poor neurodevelopmental functioning within the first 30 months of life.
The toxicity and complexity of antiretroviral therapy (ART) regimens are substantial challenges i... more The toxicity and complexity of antiretroviral therapy (ART) regimens are substantial challenges in the context of patients' lives. This study examines child psychosocial and caregiver/family factors influencing adherence to ART in perinatally human immunodeficiency virus (HIV)-infected children. Seventy-five children (ages 3-13 years) prescribed ART, and their primary caregivers were recruited from 2 urban pediatric HIV programs. A battery of psychologic assessments and self-report adherence data were collected from all caregivers and 48 children who were > or =7 years old. Forty percent of caregivers and 56% of children reported missed doses of medication in the past month. Families in which the caregiver or child reported missed doses (nonadherent) were compared with families who reported no missed doses (adherent). In univariate analyses, nonadherence was significantly associated with older child age (P < 0.05), worse parent-child communication (P < 0.017), higher caregiver stress (P < 0.002), lower caregiver quality of life (P < 0.003) and worse caregiver cognitive functioning (P = 0.033), and of borderline significance in its association with increased (1) child responsibility for medications (P < 0.07), (2) HIV disclosure to the child (P < 0.07) and (3) child stress (P < 0.08) In logistic regressions controlling for age, caregiver/family factors were the most strongly associated with nonadherence, including worse parent-child communication (P < 0.03), higher caregiver stress (P < 0.01), less disclosure to others (P < 0.05) and quality of life (P < 0.01). Our data suggest that efforts to improve children's adherence to complex antiretroviral regimens requires addressing developmental, psychosocial and family factors.
Objective: Improvements in treatment-related knowledge and self-efficacy may improve clinical out... more Objective: Improvements in treatment-related knowledge and self-efficacy may improve clinical outcomes in HIV-infected populations. We examined whether caregivers' knowledge and self-efficacy was associated with better clinical outcomes and anti-retroviral therapy (ART) adherence among HIV-infected children. Methods: Caregivers of 77 perinatally HIV-infected children were administered a semi-structured interview which included scales of HIV treatment-related knowledge, adherence self-efficacy and caregiver reports of child medication adherence. Results: While caregivers correctly answered 74% of the knowledge questions, specific misconceptions were noted. Caregivers rated themselves as having high adherence self-efficacy, but were least confident in their ability to adhere to ART if it caused side effects or might result in social disclosure. Higher caregiver treatment-related knowledge and self-efficacy were associated with better clinical outcomes, as measured by viral load and CD4+ count, but not with caregiver reports of ART adherence. Conclusion/discussion: While additional factors may be important determinants of adherence to ART in this population, improving the HIV treatment-related knowledge and self-efficacy of caregivers may help to improve the clinical outcomes of HIV-infected children.
... has been associated with high rates of unprotected intercourse, teen pregnancy, and sexually ... more ... has been associated with high rates of unprotected intercourse, teen pregnancy, and sexually ... sizes the internal (mental health) and external (environmen-tal) context in which ... parent-child communication, parent supervision and monitoring, and overall parent-child relationship. ...
A large proportion of perinatally HIV-infected (PHIV) children are becoming adolescents and explo... more A large proportion of perinatally HIV-infected (PHIV) children are becoming adolescents and exploring their sexuality. This study explored the prevalence of sexual behaviors (kissing, touching, engaging in oral sex, or having vaginal/anal intercourse) in a sample of predominantly ethnic minority youths (N = 339; 54.1% Black and 30.4% Latino; 51% female; ages 9-16)
Journal of the American Academy of Child & Adolescent Psychiatry, 2009
Objective: As perinatally human immunodeficiency virus (HIV)Yinfected (PHIV+) youths enter adoles... more Objective: As perinatally human immunodeficiency virus (HIV)Yinfected (PHIV+) youths enter adolescence, they are at high risk for poor behavioral and health outcomes. This study examines relations between youth mental health problems and sexual and substance use risk behavior, the impact of caregiver mental health and family functioning on youth mental health and risk behavior outcomes, and the role of youth HIV status in this process. Method: Participants were recruited from four medical centers. Individual interviews were administered to 193 PHIV+ and 127 perinatally HIV exposed but uninfected (PHIVj) 9-to 16-year-old boys and girls and their primary caregivers. Participants were primarily African American and Latino. The interview assessed child sexual and drug risk behavior, child and caregiver mental health, and family functioning. Results: Exploratory latent-variable structural equation modeling revealed no differences in rates of sexual risk behavior or substance use between PHIV+ and PHIVj youths. However, adolescent mental health was significantly associated with sexual risk behavior and substance use. Caregiver mental health was associated with youth mental health and indirectly with sexual risk behavior and drug use through its impact on youth mental health. Family functioning did not significantly predict youth outcomes. Conclusions: Over and above other key environmental factors and family functioning, youth and caregiver mental health problems are related to sex and drug use risk behaviors in PHIV+ and PHIVj youths. Given high rates of youth and caregiver mental health problems in this population, family-based mental health interventions may be a key component of HIV prevention programs for perinatally HIV-exposed youth. J. Am.
Virtually all human individual diVerences have been shown to be moderately heritable. Much of thi... more Virtually all human individual diVerences have been shown to be moderately heritable. Much of this research, however, focuses on measures of dysfunctional behavior and relatively fewer studies have focused on positive traits. The values in action (VIA) project is a comprehensive and ambitious classiWcation of 24 positive traits, also known as character strengths (Peterson, C., & Seligman, M. E. P. . Character strengths and virtues: A handbook and classiWcation. Washington, DC: American Psychological Association), the majority of which have received no behavior genetic attention. Using a sample of 336 middle-aged twins drawn from the Minnesota Twin Registry who completed the VIA inventory of strengths, we detected signiWcant genetic and non-shared environmental eVects for 21 of 24 character strengths with little evidence of shared environmental contributions. Associations with a previously administered measure of normal personality found moderate phenotypic overlap and that genetic inXuences on personality traits could account for most, but not all, of the heritable variance in character strengths.
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Papers by Claude Mellins