Mebrahtu, Helen; (2020) The impact of maternal mental health on child cognitive development in the presence of HIV-a study in Zimbabwe. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Early childhood is a critical period for development. Exposure to factors such as HIV and poor maternal mental health may negatively impact child cognitive development. The evidence points to lack of evaluated interventions in sub-Saharan Africa and Zimbabwe specifically, aimed at enhancing child developmental outcomes in the last nine years. The aim of this thesis was to investigate the impact of maternal mental health on cognitive development of 0-36 month old children in Zimbabwe in the presence of maternal HIV infection. The research was nested within a large cluster randomised controlled trial (Child Health Intervention for Development Outcomes-CHIDO trial) aimed at enhancing child outcomes. The study focussed on 574 child-caregiver dyads recruited through the HIV exposed clinic registers in two rural districts of Zimbabwe. The cognitive performance of participating HIV positive and HIV-exposed uninfected (HEU) children was investigated using the 5 Mullen child development inventory sub-scales (visual reception, expressive language, receptive language, fine motor, and gross motor), and the mental health of their mothers in the trial (n=562) assessed using the Edinburgh Postnatal Depression Scale, Parental Stress Index-Short Form, and 8-item Shona Symptom Questionnaire. The use of standardised child development tools and the potential for exploring shorter forms was also undertaken as part of this research. Child cognitive development outcomes pre and post CHIDO intervention roll out were investigated. There was no evidence of a difference in Mullen composite scores after intervention implementation between the trial arms (mean of 88.1 in the intervention arm and 87.6 in standard of care arm; adjusted mean difference (aMD): 0.06; 95% CI: -2.68 to -2.80; p=0.97); thus the caregiver-child data from all arms of the trial were pooled and used for subsequent analyses. Child cognitive development were examined at baseline and there was no evidence of difference in the overall cognitive functioning of the children by HIV status (HIV+ve children 101.3 vs. HEU: 100.0; aMD: -1.18; 95% CI: -9.14 to 6.79; p=0.77). The prevalence and association of common mental disorders (CMD), depression symptoms and stress, as well as maternal suicidal ideation with child cognitive scores at baseline and 12 months follow-up were examined individually. Chronic maternal CMD (i.e. over 12 months period) was negatively associated with child receptive vocabulary (aMD: -2.8, 95% CI: -5.1 to -0.6; p=0.05) when compared to those with no CMD. Similarly emerging maternal suicidal ideation was negatively associated with overall poorer child cognition (aMD: -6.1; 95% CI: -10.3 to -1.8; p=0.03), and developmental sub-domains, visual reception (aMD: -4.4; 95% CI: -7.6 to -1.2; p=0.04), and receptive language ability (aMD: -4.2; 95% CI:-7.2 to -1.2; p=0.02). Of importance, children of mothers reporting any emerging mental disorder (either depression symptoms, CMD or suicidal ideation) had lower cognitive scores across all the developmental domains at the end of the trial compared to those without any mental disorders. The research in this thesis demonstrates the importance of maternal mental health in child language and visual reception development within an HIV affected population. Timely identification of these HEU children, as well as prompt multicomponent interventions which include treatment of maternal mental health, are required to ensure that these children are able to reach their maximum developmental potential.

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