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4.3.1 – Mental Functions

Many children living with HIV have problems with learning and concentration, especially if they did not start ART at an early age. These problems can occur as the virus gets into the brain tissue of infants and causes inflammation and destruction of neural tissue. This damage to the central nervous system can be irreversible. Children in resource-poor settings who are infected with HIV are at great risk for developing HIV encephalopathy.

The presentation of children with neurologic involvement varies significantly and is influenced by social as well as clinical differences.

Some of the clinical signs which have been seen in children with neurocognitive problems include:

  • Microcephaly
  • Cognitive delays
  • Cerebral atrophy
  • Calcification of the basal ganglia
  • Delay or loss of developmental milestones
  • Abnormal reflexes
  • Electroencephalogram (EEG) abnormalities.

Additional factors which may contribute to a child’s learning or behavioural problems include:

  • Secondary infections
  • Poor prenatal care
  • Repeated hospitalizations
  • Social isolation
  • Neglect and lack of stimulation at home
  • Malnutrition e.g. marasmus and kwashiorkor, micronutrient deficiencies
  • Lack of structure and security at home
  • Side effects of medication
  • Maternal substance abuse (including alcohol abuse)

In children who are not infected perinatally (e.g., those who are infected through blood transfusions or sexually active teenagers), the cognitive problems tend to be similar to those experienced by adults.

Potential causes of these impairments and rehabilitation interventions are shown in the table below.

Table 4.3.1: Clinical Aspects of Mental Functions

Impairments Possible Etiologies Rehabilitation Interventions3
Developmental delay

HIV encephalopathy

Other infections e.g., cytomegalovirus, meningitis

Slow acquisition of developmental milestones in babies and toddlers

  • Consider developmental testing using standardized psychological measures
  • Use infant stimulation programs using bright, interesting toys or household objects to stimulate the infant to participate in play
  • Provide play materials that stimulate a variety of senses (e.g., toys that feel different; toys that roll, bounce, and make noises; water and sand play)
  • Provide a variety of play opportunities both within the home and in settings where the child is exposed to other people, environments, and situations (e.g., playgroup or creche)
  • Consider enrollment in crèche or pre-school to provide opportunities for peer modelling, as well as rest for parents
Increased or decreased muscle tone

Basal ganglia calcification

HIV encephalopathy

  • Encourage active movement of affected muscles using functional activities through full range of movement

Poor or absent expressive language (speech)

HIV encephalopathy

Hearing loss from chronic ear infections

Lack of stimulation

 

  • Administer standardized language measures
  • Provide many speech examples by talking to the baby/child about everything around you
  • Pause in conversations with the baby/child to allow her/him to respond with some kind of verbal utterance
  • Provide names for everything and encourage the baby/child to copy the sounds you make
  • Do not anticipate the baby/child's every wish. Allow the baby/child to use what language she/he does have (e.g., if the baby/child gestures and grunts, do not immediately hand the baby/child what she/he wants; first try to encourage her/him to use a word or sound)
  • Expand on the baby/child's use of words (e.g., when the baby/child says "juice," the caregiver can say "Do you want some juice?")
  • As the baby/child learns words, ask open-ended questions instead of those requiring only a yes or no response
  • Look at picture books or magazines with the baby/child and talk about the pictures
  • Sing songs and play games with the baby/child
  • Assess for hearing loss, a common cause of language delay in children
  • Initiate assessment by a speech-language pathologist
Poor memory

HIV encephalopathy

Fatigue

Poor memory in children

  • Conduct neuropsychological assessment
  • Repeat instructions and verbal reminders
  • Present materials in various forms (e.g., visual, verbal)
  • Support verbal information with written information
  • Use cues to help remember (e.g., use of a watch alarm to remind child when to take pills).  However it is important to determine whether or not the child is ready for this step and depends upon his or her cognitive abilities and other variables
  • Use lists when more than one thing is required of the child
  • Use a daily diary book containing all important information for the day (for older children)
  • Give the child simple, one-step instructions and ask the child to repeat the directions to be certain that he or she has understood the instructions accurately
Poor learning and/or attention

Pre-existing learning problems

HIV encephalopathy

Fatigue

Pain

Fatigue

Attention deficit disorder

  • Administer standardized tests
  • Seek remedial classes or extra help in areas of difficulty
  • Set aside specific time (e.g., 30 minutes every night after dinner) to work on homework and projects in a quiet environment (if there is no homework, the child can use the time for a quiet activity such as reading)
  • Set short-term goals and use reward system when the child reaches goals (e.g., stickers, stars)
  • Revise learned material frequently
  • Have preferential seating to avoid distractions (e.g., away from windows, doors, and noisy classmates and at the front of the class near the teacher)
  • Allow for sufficient rest times during the day to ensure maximum alertness and ability to participate in the school day
Poor visuomotor skills

HIV

Lack of stimulation

  • Allow the child to draw and color
  • Practice cutting out shapes with scissors
  • Do puzzles with the child
  • Look at books and talk about the colors and shapes in the pictures
Depression or behavioural problems e.g. aggression and fighting

HIV

Side effects of medication

Social problems at home and /or school

  • Provide a safe place for children to talk
  • Refer for psychological assessment and counselling

 

3Choice of rehabilitation interventions will depend on patient assessment and available resources.