Document Type



Doctor of Philosophy


School Psychology

First Adviser

DuPaul, George J.

Other advisers/committee members

Barrett, Susan; Rudski, Jeff; Silova, Iveta


Study Objectives: Perinatal HIV infection has been linked to problems in both behavioral functioning (BF) and cognitive functioning (CF). The differential impact of psychosocial and disease-related factors on CF and BF has been described, but synthesis of findings has been difficult due to methodological differences. Utilizing structural equation modeling (SEM) analysis, our study investigated the individual and combined contributions of psychosocial factors on CF and BF in youth with perinatal HIV infection (PHIV) and those HIV-exposed but uninfected (PHEU), and examined the role of disease related-factors among PHIV youth. It was also determined whether CF was a mediator of the relationship of disease severity and psychosocial factors with BF. Methods: Child and caregiver psychosocial interviews and age-standardized assessments of CF and BF were administered to participants enrolled in the Adolescent Master Protocol of the Pediatric HIV/AIDS Cohort Study (PHACS) network, a prospective longitudinal study examining the long-term effects of HIV and its treatment. Preliminary exploratory factor analyses were used to identify latent variables reflecting clusters of predictors, in order to establish four parsimonious SEMs: child-assessed BF, and caregiver-assessed BF in PHIV and PHEU youth. Results: Participants included PHIV (N=231) and PHEU (N= 151) youth; 47% male, 62% black, 27% Hispanic; mean age at entry was 10.9 years. Among PHIV youth, most were well controlled (median CD4%, 34%; HIV plasma RNA values <400 copies/ml., 75%); 24% had a prior AIDS diagnosis (8% with encephalopathy). Youth demonstrated CF within the low average range (Wechsler mean Full Scale IQ= 86.8, sd= 15.1) and BF t-scores within average range (Behavioral Assessment Scale for Children, 2nd ed. (BASC-2) mean caregiver reported t-score= 50.2, sd= 10.8; child reported t-score= 45.9, sd=8.5). SEM results indicated that higher levels of Caregiver Stress and Family Emotional Stress predicted higher (worse) BF scores in PHIV and PHEU youth. Caregiver Educational Opportunity (reflecting IQ, education, and income) and two disease severity variables, Late Presenter and Better Past HIV Health were significant predictors of youth CF. Higher child CF was associated with significantly lower (better) caregiver-reported BF in both PHIV and PHEU. Caregiver Educational Opportunity predicted caregiver-reported BF in PHEU youth. Results of mediation analyses suggested that among PHEU youth, the effect of Caregiver Educational Opportunity on caregiver-assessed BF was mediated by CF. Among PHIV youth, both Better Past Disease Severity and Caregiver Educational Opportunity mediated the effects of CF on caregiver-assessed BF. No significant direct relationships between disease severity variables and child-assessed BF were found.Conclusions: Using a novel statistical approach, the deleterious impact of caregiver and family stress on BF among youth affected by HIV was identified, suggesting that the impact of compounding stressors may negatively influence the BF of PHIV youth more than the disease itself. Expected associations of HIV disease severity factors and previous disease status with CF among PHIV youth reinforce the importance of early antiretroviral treatment of HIV to reduce the risk of cognitive impairment. These results communicate the need for evidence-informed child, caregiver and/or family support to diminish behavioral risk among youth living with and affected by HIV.