Management of mental health disorders and central nervous system sequelae in HIV-positive children and adolescents
R NassenI; K DonaldI; K WalkerI; S ParukI; M VujovicI; W DuncanI; B LaughtonI; B MoosI; B EleyII; A LachmanII; J WilmshurstII
IPanel members. Southern African HIV Clinicians Society
IIReviewers. Southern African HIV Clinicians Society
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ABSTRACT
HIV-positive children and adolescents are at increased risk of both central nervous system (CNS) sequelae and mental disorders owing to a number of factors, including the impact of HIV infection on the brain, social determinants of health (e.g. poverty and orphanhood) and psychosocial stressors related to living with HIV. Every effort should be made to identify perinatally HIV-infected children and initiate them on antiretroviral therapy early in life. HIV clinicians should ideally screen for mental health and neurocognitive problems, as part of the routine monitoring of children attending antiretroviral clinics. This guideline is intended as a reference tool for HIV clinicians to support the early identification, screening and management of mental health disorders and/or CNS impairment in children and adolescents. This guideline covers mental disorders (section 1) and HIV-associated neurocognitive disorders (section 2) among children and adolescents.
Untreated perinatally HIV-infected (PHIV) children are at increased risk of central nervous system (CNS) sequelae compared with HIV-infected children who begin antiretroviral therapy (ART) in infancy. HIV invades the developing CNS earlier and with greater severity than observed in adults and with a more rapid progression to death. In addition, patients receiving ART may remain vulnerable to the effects of HIV on the brain because the CNS may be a reservoir for persistent viral replication. Initiation of ART, therefore, does not fully reverse CNS insults, particularly if treatment is not initiated during infancy.[1] Psychosocial stressors, such as poverty, orphanhood and parental illness (physical and mental), experienced by HIV-positive children living in disadvantaged communities place them at further risk of poor educational and mental health outcomes. Furthermore, the onset of adolescence presents new challenges related to adherence issues, the provision of adolescent-friendly clinical environments, academic problems, mental health problems, and sexual and other risk behaviours.[2]
1. Mental disorders among HIV-infected children and adolescents
PHIV children present with high rates of mental disorders that exceed population norms and rates in other chronically ill children.[3]
1.1 Overview of mental disorders in children and adolescents
]]> Prevalence:Risk factors:
Effects:
1.2 Screening for mental disorders
Refer or discuss the child with a mental health professional (mental health nurse, psychologist, child psychiatrist, psychiatrist) if the child presents with the following:
Refer or discuss with a social worker if additional information reveals the following:
1.3 Assessment and diagnosis of mental disorders
Tables 4 and 5 outline the assessment and diagnosis of ADHD and major depressive episodes, respectively.
1.4 Assessment and diagnosis of anxiety disorders
1.5 Assessment and diagnosis of psychotic disorders
Neuropsychiatric symptoms in an HIV-positive child or adolescent include psychosis, severe mood disturbance, delirium or encephalopathy. Psychotic symptoms (hallucinations, delusions, formal thought disorder) and mania are less common among HIV-positive children and adolescents compared with adults, and therefore have a high index of suspicion of a comorbid medical condition such as a CNS disorder.
Children who have not been initiated on ART due to adequate CD4+ counts and who have psychiatric symptoms that are poorly responsive to antipsychotics may have detectible/high CNS viral loads despite undetectable serum viral loads (due to differing mutations in cerebrospinal fluid (CSF) and serum). These children should be initiated on ART, which may contribute to the resolution of psychotic symptoms.
Children already on ART who have psychotic symptoms poorly responsive to antipsychotics should be assessed for a comorbid CNS disorder and/or have their ART regimen reviewed and a CNS penetrating regimen considered.[6] The Montreal Cognitive Assessment may be a useful screening instrument to detect cognitive impairment in adolescents.
1.7 Mental status examination of the child or adolescent
The mental status examination of a child comprises observation of play, quality of caregiver-child interactions, verbalisations and also interpretation of drawings. The mental state of an adolescent more closely resembles that of an adult patient.
1.7.1 Recording the mental state examination (MSE)
]]> The MSE is an essential part of the psychiatric evaluation. The objective is to describe the child or adolescent's appearance, behaviour, symptoms and cognitive functioning during the examination.The child should ideally be interviewed in his/her first language.
1.8 Management of HIV-positive children and adolescents presenting with mental disorders
See Fig. 1, which summarises the assessment and management of HIV-positive children presenting to primary care services.
1.8.1 Risk assessment
1.8.2 Referral
1.8.3 Liaison
1.8.4 Attitude to family
1.8.5 Management of depression and anxiety in HIV-positive children and adolescents
Fluoxetine or citalopram may be prescribed for moderate to severe depression and anxiety disorders. Citalopram is preferable because of potential drug-drug interactions between fluoxetine and certain antiretroviral medications. Fluoxetine can increase agitation and impulsivity, so monitor closely.
1.8.6 Management of ADHD in HIV-positive children and adolescents
1.8.7 Management of children presenting with psychotic symptoms and/or mania
1.8.8 Medication management
1.8.9 Other diagnoses or symptomatology to consider as part of the assessment and management of HIV-positive children and adolescents
1.8.9.1 Suicide
Suicide risk assessment
High suicide risk is indicated by any one or more of the factors below:
The following may further contribute to risk:
Management of suicidal ideation
1.8.9.2 Management of trauma-related disorders in children and adolescents with HIV
Post-traumatic stress disorder
1.8.9.3 Adjustment disorders
Common stressful life events for HIV-positive children
Grief and bereavement
1.8.9.4 The disruptive and aggressive child and adolescent
Conduct disorder
Definition: a repetitive and persistent pattern of behaviour that violates the basic rights of others or where major age-appropriate societal norms or rules are transgressed (Table 10).[5]
Oppositional defiant disorder
Common co-occurring disorders in children with disruptive or aggressive behaviour
Aggressive and disruptive behaviour may present with co-occurring difficulties such as:
Management of behaviour problems in children and adolescents with HIV
Management of conduct disorder and oppositional defiant disorder in HIV-positive children and adolescents
1.8.10 Psychological interventions
1.8.10.1 Psychosocial support for children
1.8.10.2 Therapeutic support
Psychosocial intervention can take various forms including referral to support groups, psychotherapy or counselling (Table 12).[15]
1.8.10.3 Psychosocial support for adolescents
1.8.10.4 Benefits of group interventions for adolescents
1.8.11 Youth-centred interventions
1.8.11.1 Overcoming obstacles to providing AFYS
1.8.12 Adherence in adolescents
1.8.12.1 Improving adherence in adolescents
]]> 2. HIV-associated neurocognitive disorders
2.1 Neurocognitive sequelae
2.1.1 Prevalence and impact of HIV-associated neurocognitive disorders (HANDs) in children
Prevalence:
Must include at least one of the following for at least 2 months in the absence of a concurrent illness:
2.2 Specific neuropsychological deficits
Cognition refers to a group of mental processes that include attention, memory, producing and understanding language, learning, reasoning, problem-solving and decision-making.
2.3 Identification and management of neurocognitive disorders
2.3.1 Screening tools to detect neurocognitive impairment
Conflict of interest. All expert panel members have completed and submitted conflict of interest disclosure statements. Disclosure information represents the previous 3 years (updated 3 September 2014) and includes relationships with pharmaceutical companies and medical aids: A Lachman reports receiving honoraria from Cipla Medpro and Lilly for speaking engagements; R Nassen reports receiving an honorarium from AstraZeneca for a speaking engagement. All other panel members report no conflict of interest.
Acknowledgement. This work was supported and funded by the Southern African HIV Clinicians Society through unrestricted educational grants.
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Correspondence: ]]>
R Nassen
(rnassen@sun.ac.za)
Disclaimer. Specific recommendations provided here are intended as only a guide to clinical therapy, based on expert consensus and best current evidence. Treatment decisions for patients should be made by their responsible clinicians, with due consideration for individual circumstances. The most current version of this document should always be consulted.
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