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Effect of Caregiver Training on the Neurodevelopment of HIV-Exposed Uninfected Children and Caregiver Mental Health: A Ugandan Cluster-Randomized Controlled Trial

Boivin, Michael J. PhD, MPH*,†,‡; Nakasujja, Noeline MMed, PhD§; Familiar-Lopez, Itziar MD, PhD; Murray, Sarah M. PhD, MPH; Sikorskii, Alla PhD*,**; Awadu, Jorem MS††; Shohet, Cilly PhD‡‡; Givon, Deborah MS‡‡; Ruiseñor-Escudero, Horacio MD, PhD§§; Schut, Elizabeth E. MD‖‖; Opoka, Robert O. MMed, MPH¶¶; Bass, Judith K. PhD, MPH

Journal of Developmental & Behavioral Pediatrics: November/December 2017 - Volume 38 - Issue 9 - p 753–764
doi: 10.1097/DBP.0000000000000510
Original Articles

Objective: Early childhood development programs typically combine healthy nutrition and cognitive stimulation in an integrated model. We separately delivered these 2 components in a cluster-randomized controlled trial to evaluate their comparative effectiveness in promoting healthy child development and caregiver mental health. This is the first study to do so for HIV-affected children and their infected mothers.

Methods: Two hundred twenty-one HIV-exposed but uninfected child (2–3 years old) and caregiver dyads in 18 geographic clusters in Eastern Uganda were randomized by cluster to receive biweekly individualized sessions of either (1) Mediational Intervention for Sensitizing Caregivers (MISC) training emphasizing cognitive stimulation or (2) Uganda Community Based Association for Child Welfare (UCOBAC) program that delivered health and nutrition training. Children were evaluated at baseline, 6 months, 1 year (training conclusion), and 1-year posttraining with the Mullen Scales of Early Learning (MSEL), the Color-Object Association Test for memory, the Early Childhood Vigilance Test of attention, and the Behavior Rating Inventory of Executive Function (BRIEF-parent). The Caldwell Home Observation for the Measurement of the Environment (HOME) was completed by observers to gauge caregiving quality after training. Caregiver depression/anxiety (Hopkins Symptom Checklist-25) and functionality (list of activities of daily living) were also evaluated. Data collectors were blinded to trial arm assignment.

Results: Mediational Intervention for Sensitizing Caregivers resulted in significantly better quality of caregiving compared with UCOBAC midintervention with an adjusted mean difference (MadjDiff) of 2.34 (95% confidence interval [CI]: 1.54–3.15, p < .01), postintervention (MadjDiff = 2.43, 95% CI: 1.61–3.25, p < .01), and at 1-year follow-up (MadjDiff = 2.07, 95% CI: 1.23–2.90, p < .01). MISC caregivers reported more problems on the BRIEF for their child at 1-year posttraining only (p < .01). Caregiving quality (HOME) was significantly correlated with MSEL composite performance 1-year posttraining for both the MISC and the UCOBAC trial arms. Likewise, physical growth was significantly related to child development outcomes even though it did not differ between trial arms.

Conclusion: Even though MISC demonstrated an advantage of improving caregiving quality, it did not produce better child cognitive outcomes compared with health and nutrition training.

Trial Registration: Identifier: NCT01640561.

This article has supplementary material on the web site:

Departments of *Psychiatry and

Neurology & Ophthalmology, Michigan State University, East Lansing, MI;

Department of Psychiatry, University of Michigan, Ann Arbor, MI;

§Department of Psychiatry, Makerere University, Kampala, Uganda;

Department of Statistics & Probability, Michigan State University, East Lansing, MI;

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;

**Department of Statistics and Probability, Michigan State University, East Lansing, MI;

††College of Education, Michigan State University, East Lansing, MI;

‡‡Child Development Program, School of Education, Bar Ilan University, Ramat-Gan, Israel;

§§Department of Psychiatry, Michigan State University, East Lansing, MI;

‖‖Department of Pediatrics, College of Human Medicine, Michigan State University, East Lansing, MI;

¶¶Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda.

Address for reprints: Michael J. Boivin, PhD, MPH, Department of Psychiatry, Research Division, 909 Fee Rd, Room 321 West Fee Hall, East Lansing, MI 48824; e-mail:

Supported by NIH grant RO1 HD070723 (PIs: M.J.B., J.K.B.). S. M. Murray was supported by NIMH Global Mental Health training grant (MH103210). The study sponsor had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Disclosure: The authors declare no conflict of interest.

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Author contributions are moved to the acknowledgments section.

Received April , 2017

Accepted August , 2017

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