Factors associated with depression among HIV/AIDS children in China

Human immunodeficiency virus (HIV) infection has become a significant social emergency worldwide. HIV is threatening children as never before. According to the UNAIDS, 1.8 million children (< 15 years) were HIV positive at the end of 2017 [1]. Although the epidemic trend of global HIV infection was declining, children represent a growing share of people living with HIV worldwide and China is no exception [2]. Children infected by HIV not only suffer from the heavy burden of physical disease associated with chronic illness but are also at risk of developing mental health disorders. Depression is the most common neuropsychiatric complication in HIV-infected children and may occur during all phases of the infection [3]. Depression in HIV-infected children leads to a negative impact on a wide range of aspects of their life quality and has a profoundly deleterious influence on society [4‐6]. Previous studies have shown that HIV-infected children suffering from depression are more likely to develop maladaptive outcomes and behaviors, including dropping out of school, drug abuse, alcohol use, and engaging in high-risk sexual behaviors that increases the risk of HIV transmission [7, 8]. Depression also has a wide range of negative effects on the progression of illness in HIV-infected children. It decreases their immune status and adherence to antiretroviral therapy, which may result in the potential development of drug resistance and decreased clinical effectiveness [9, 10], increasing the disease cost burden and mortality associated with illness [11‐13]. Therefore, it is imperative to explore the factors influencing the development of depression in HIV-infected children.

Childhood is full of challenges that children have to deal with, including pressures coming from academic study, the relationships with peers, changes in the body and from the development of cognition function. Children who are early in psychological developmental stages, including cognition, are more sensitive to stressful events and more susceptible to the impact of social desirability [14, 15]. HIV-infected children may suffer from more stressors caused by a higher exposure to traumatic life events which result in depression, in addition to those events experienced by healthy children. Many of these stressors are chronic and impact on multiple levels of children’s lives. Despite the prevalence of HIV being low in China, levels of stigma remain widespread and profound [16, 17]. HIV-infected children are confronted with stereotypes, discrediting, prejudice, and discrimination caused by HIV infection-related stigma that may lead to them being isolated, helpless, and bullied [18, 19]. HIV-infected children face negative impacts in many ways within society. In terms of coping with stigma and integrating into society, HIV-infected children may also be affected by social desirability. Social desirability can be viewed as a tendency to present oneself favorably or to obtain approval by responding in a culturally and socially acceptable manner [20]. Studies have shown that social desirability correlates with depression in normal children but findings are heterogeneous [21, 22]. No known studies to date have explored the effects of social desirability on responses to depression in HIV-infected children. In addition to the pressure of stigma, HIV-infected children may suffer as a result of illness experienced by their parents, poor relationships with their parents, and even the loss of their parents. More importantly, the treatment and progression of HIV infection impact upon on HIV-infected children. The persistent use medication over a long time and uncertain trajectory of their illness likely make children susceptible to depression. When facing one or more of these above stressors in conjunction with the heavy burden of stressors associated with HIV-infection, social support is an important factor in ameliorating depression among HIV/AIDS patients. Perception of social support is a subjective aspect of social support, referring to the emotional experience and satisfaction of being respected, supported, and understood. Indeed, the perception of social support can have a directly beneficial impact on mental health [23, 24] and buffer against suicide risk created by stressful life events [25]. Cognitive emotion regulation is also an important factor. Studies have illustrated that emotion regulation plays a significant role in the mental health of children [26, 27]. Children learn to regulate their emotions by means of cognitions or thoughts about themselves and/or others. Cognitive emotion regulation refers to the cognitive means of handling the intake of emotionally arousing stimulations [28]. Studies have shown that using different cognitive emotion regulation strategies has different outcomes [29, 30]. The strongest relationships have been found between the cognitive emotion regulation strategies of rumination, catastrophizing, and self-blame and the reporting of symptoms of depression [31‐34]. These findings might imply that by using these strategies, children may be more vulnerable to developing symptoms of depression in response to negative life events than others [34].

Depression impacts on the progression of illness and quality of life in HIV-infected children resulting in outcomes that increase the social burden of disease, as well as the diffusion and mortality of HIV/AIDS. Despite the increased interest in this field and the publication of studies highlighting the high levels of depression in children, there continues to be a dearth of data concentrating on the personal subjective psychosocial perspective. Research is needed to examine the associated influencing factors of depression in HIV-infected children, especially in the Chinese socio-cultural context. Previous studies exploring depression in HIV-infected children are mostly from the perspectives of society and family. We explored the roles of children’s social desirability, cognitive emotion regulation, and perceived social support to identify the factors influencing of depression in HIV-infected children in China. It was hoped that this would provide a basis for developing measures to reduce the levels of depression and effectively improve life conditions for HIV-infected children.

The findings of this study support psychosocial factors have an important influence on the depression in HIV-infected children. Among the three influential factors, the strongest indicator of depression was perceived social support. We found that the higher levels of perceived social support are associated with lower levels of depression, consistent with the global literature on the “buffer” function of perceived social support. Studies have found that lower perceived adequacy of social support has been linked to poor mental health [44, 45]. Similarly, Bal et al. [46] revealed that a higher perceived availability of social support was found to be directly associated with fewer symptoms related to trauma among a group of adolescents who had suffered a stressful event. Importantly, in a study among individuals living with HIV/AIDS, Blaney et al. [47] reported that the perceived availability of social support was a strong predictor of reduced depression. This in line with other studies showing that people with HIV who reported greater satisfaction with their social support had lower rates of depression [48] and greater perceived social support was associated with better mental health [49]. The possible explanation for this is that the perception that one is accepted and valued in one’s interpersonal environment bolsters esteem, confidence, and efficacy, which guards against depression. Social resources are generally protective against adverse psychological responses to stressful situations [50]. The perceived availability of social support may prevent or reduce the occurrence of depressive symptoms by preventing a potential stressor from being perceived as stressful. HIV-infected children may experience a greater number of stressful situations caused by higher exposure to traumatic events. HIV-infected children with a higher level of social support may be more likely to believe that others would provide the necessary resources to solve the problem when they encounter stress. This may help them redefine the potential harm posed by their stressful situations and prevent or alter maladaptive behavioral responses to stressful events. It is possible that HIV-infected children with low levels of perceived social support may experience heightened perceptions of threats of stressful events resulting in high levels of depressive symptoms. Enhancing perceived social support may, therefore, prevent or decrease depressive symptoms in HIV-infected children.

We also observed a positive correlation between catastrophizing and depression, suggesting that by using the strategy of catastrophizing, HIV-infected children may be more vulnerable to developing and exacerbating depression in response to negative life events than others. Studies have shown that cognitive emotion regulation styles such as self-blaming, catastrophizing, and rumination show strong relationships with internalizing problems [31‐33]. Internalizing problems include difficulties that are directed inwards, such as disordered mood, anxiety, and depression [51]. A number of authors have suggested that depressive mood and symptoms could be a consequence of the frequent use of maladaptive emotion regulation [29, 52, 53]. In other words, although dysfunctional attitudes are accessible during stressful life periods, the strategies that individuals use to regulate these cognitions (self-blaming, focus on positives, planning, positive reappraisal, catastrophizing) seem to influence the occurrence of associated depression. In a study of HIV-infected men, Crues et al. [54] observed that an improvement in cognitive coping strategies and reduction in dysfunctional attitudes were closely associated with decreases in depression. Attachment theory states that early traumatic experience, especially with a caregiver, creates an environment which invalidates emotions [55, 56]. In addition, traumatic experiences with a caregiver leads to an insecure attachment style in children. An invalidating environment and insecure attachment can cause individuals to use maladaptive strategies [57, 58]. HIV-infected children often lose their parents or experience inadequate caring relationships with them. According to the theoretical perspective of social learning, emotionally neglected individuals have deficient opportunities to learn adaptive emotion regulation strategies through caregiver modeling [59]. Therefore, they are inclined to evaluate the consequences of negative events using maladaptive strategies. From the perspective of cognitive behavioral theory, the maladaptive appraisal of negative life events may be at the core of depression and anxiety. Maladaptive processing of stressful events can overwhelm patients with negative emotions, thus contributing to clinically significant depression and anxiety [60]. Similar to findings by Noel et al. [27], HIV-infected children facing pressure caused by HIV/AIDS preferring to use the cognitive emotion regulation of catastrophizing to handle stressful situations are susceptible to depression. Based on this study, suggestions for intervention in HIV-infected children may include challenging the maladaptive strategy of catastrophizing.

We also found that social desirability was a major influential factor in depression experienced by Chinese HIV-infected children. Inconsistent, however, with other studies, in our study children having high levels of social desirability reported higher levels of depression. In studies of chronic disease in children, Deirdre et al. suggest that children scoring high on a measure of social desirability reported lower depression and anxiety compared to children scoring low on a social desirability index [15]. One possible explanation, consistent with mainstream education and authority of society, children scoring high on a measure of social desirability respond in a culturally and socially acceptable manner that would obtain approval rather than blame and criticism from their parents, teachers, or peers. Phipps and Steele put forward another possible explanation. They propose that defensiveness and selective reporting may explain the low scores for depression and anxiety when children with a long-term illness are hiding their true feelings and engaging in a pretense of normality [61]. However, in our study, HIV-infected children having high levels of social desirability reported higher levels of depression. We interpret this finding to reflect the possibility that due to lower maturity of cognitive levels, children are typically susceptible to social desirability influences. Studies have suggested that children who are strongly influenced by social desirability may deny negative thoughts and feelings in an effort to normalize their social world [62, 63]. Most importantly, as HIV-infected children, they not only have to face the burden of studying, relationships with peers, and bodily changes, but also pressure coming from the stigma, treatment, and progression of HIV infection. Consequently, for being normal and thus avoid strong controls, overt disapproval, threats of rejection from society and surroundings, they felt it was necessary to suppress negative thoughts and feelings from their own awareness. Due to the potential loss of parents, or poor relationships through caring for their parents, HIV infected children lacking from warmth may respond in a culturally and socially favorable manner rather than one true to themselves in order to be accepted, recognized, and appreciated from teachers and kinsfolk. In the long progress of denying and suppression, HIV-infected children may not correctly release and express their negative emotion. According to the theory of the strategy of emotion regulation, when individuals adopted some form of suppressive emotional regulation to deal with increased subjective negative emotional experience, this eventually leads to depressive disorder [64, 65]. All of the above findings suggest to us that in the daily life of HIV infected children, we can take measures of perceived social support, cognitive emotion regulation and social desirability to address the difficulty of depression. We suggest using this knowledge to decrease the damage caused by depression in HIV-infected children.

Some limitations of this study must be acknowledged. The first limitation is the potential for sampling bias, as the participants in the present study were all recruited from the Henan province where a large number of rural residents were affected with HIV through unhygienic blood collection practices. These children infected by vertical transmission are not representative of all HIV-infected children throughout China. Second, the data are based entirely on self-evaluations, which may have introduced sources of bias and error. The third limitation involves the weak support for causal inference due to the cross-sectional design of this study. Therefore, future studies should include a longitudinal follow-up to determine the relationships between depression and other factors in HIV infected children.

To conclude, the present study examines factors associated with depression among HIV infected children in China from the psychosocial perspective. Findings suggest that perceived social support has a significant and positive effect on depression in children affected by HIV but that children’s social desirability and one dimension of cognitive emotion regulation (that is, catastrophizing) have a negative impact. Health interventions are warranted to reduce the depression so as to reduce the damage caused by depression in children affected by HIV.