This study set out to examine the effect of a care-giver behavioural intervention for children admitted with severe malaria to prevent mental health problems 6 months after discharge. There were no differences in mental health outcomes between the two groups after 6 months. Mental health problems in the children during admission were associated with caregiver depression, caregiver education and the child’s sex.
Admission for children in hospitals can be a stressful experience and is associated with anxiety and depression in caregivers and children in both the acute period of the disease and in the long-term period [8, 9]. Ugandan children with severe malaria have mental health problems in both the short and long-term that include hyperactivity, aggression and mood changes [3, 4]. Studies show that mental health problems in children admitted in hospital are associated with illness severity, duration of admission and premorbid mental health problems [26, 27]. In the present study, only caregiver depression, caregiver education and child’s sex were associated with the child’s mental health problems during admission. However disease severity in terms of having diarrhoea during admission was associated with caregiver anxiety and depression scores. Caregivers of admitted children feel out of control, leading to anxiety which can be transferred on the child who sees the caregiver in that state [10]. The present study found a correlation between caregivers’ anxiety and depression scores and the child’s mental health scores which is in line with the emotional contagion theory [10].
The present study’s intervention is based on the above premise that there is an association between caregiver and the child’s mental health during admission. Thus targeting behavioural problems in the caregiver by providing information about the admission (to create a feeling of control) and creating avenues for playful interaction between the caregiver and child (to reduce anxiety associated with admission) is a possible avenue to prevent mental health problems in children after admission for severe malaria. In this study however, the intervention was not associated with improved mental health outcomes in the children six months after discharge. The same intervention has been used in children admitted in intensive care and was associated with less mental health problems in the children and their caregivers [10, 12]. Some effects were observed at six months, while others were observed at twelve months. The six month follow-up in our study may have been too short to observe any effect. Alternatively, an intervention developed for children in a US intensive care unit setting may not translate into an effective intervention for the very different and more resource-limited hospital setting for severe illness in a Uganda hospital, even with adaptation for the Ugandan context.
The evaluation of behaviour was also different, with the present study using the SDQ (primary) and the CBCL (secondary), while the US intensive care unit study used the Behavior Assessment System for Children (BASC) [12]. The SDQ assesses primarily emotional, conduct, hyperactivity, peer and prosocial problems, while the BASC version they used evaluates externalizing problems, internalizing problems, behavioral symptoms, and adaptive skills [12]. Differences in areas being evaluated may have contributed to the differences in study findings, and future studies may need to assess adaptive skills that are tested in BASC but not the SDQ. In addition, in the study of COPE in US ICUs, the BASC scores for the control group were variable over time and increased (more behavioural problems) substantially from 6 months to 12 months. This could reflect variability in response to a questionnaire over time, or might reflect increased behavioural problems 12 months after illness. If the latter was the primary driver for differences, then testing at 12 months in this cohort may have revealed problems not found at 6-month follow-up. Finally, malaria is uncommon in the US, and it is unlikely that any child had malaria (11% in Melnyk et al were admitted for infections like sepsis and meningitis). Diseases can affect behaviour in different ways, so it is possible that the COPE intervention is less effective for children with severe malaria. Countering this is that children in the US COPE ICU study were admitted with many different underlying diagnoses, yet appeared to have a benefit at 12 months after their illness from the COPE intervention. The COPE intervention has been used in other populations, including premature neonates [28] and children with neurological problems [29], with some success in improved mental health for the caregiver, child or both, so it will be important to determine if in longer-term follow-up better outcomes are seen with the intervention in children with severe malaria.
The study’s inability to completely conceal the interventions participants received on the ward may have resulted in bias as caregivers rated behavioural problems of their children and their own. Children in the intervention received different play activities from the control group. This bias in reporting may have affected the intervention resulting in no differences in outcomes between the groups.
The present study was limited by its short follow-up duration of six months which could have resulted in no effect seen at that time point. Additionally, there was a higher rate of loss to follow-up in the intervention arm leading to a smaller sample size that limited the power of the study. It was not possible to separate participants from the different treatment arms on the ward which may have led to caregivers noticing different interventions being given to their child. The strengths of the study include its randomised design and blinding of the assessors that limits bias in assessing the outcomes.
This study’s behavioural intervention had no effect on children’s mental health problems six months after discharge. There is need to identify other behavioural interventions that could improve mental health outcomes for children admitted in this setting. A prior study in Uganda identified neurologic deficits and seizures during admission as being associated with these behavioural problems [3]. Thus, in addition to behavioural interventions, adjunctive therapies to improve outcome after severe malaria may potentially lead to improved mental health outcomes, and could supplement behavioural interventions as this one [30].