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What Is Cognitive Training And What Effect Does It Have On Neuropsychological Outcomes In HIV Affected Children In Low To Middle Income Countries

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For my second work placement I worked as an Assistant Researcher at a teaching hospital. My Department focused on Population Health and Infectious Diseases; a new area for me, as it was not covered in my degree modules. However, unlike my first placement, I did not feel daunted by new academic territory. Due to skills, such as written communication and organisation, which I developed during my first placement, I felt prepared to take on new challenges.

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These challenges came in the form of literature and systematic reviews, and experimental and user manual design, involving multiple hours sat in front of a computer. Initially, I found this difficult due to my short attention span. However, this experience challenged me to improve my focus and concentration skills, both of which are extremely valuable to me for the final year of my degree where I will have to concentrate and maintain focus during my lectures and personal study time to be sufficiently prepared for my assessments. This deskbound style of work heavily contrasted with my previous placement which involved face to face contact with service users, and regular travel in and out of the office for workshops and home visits. I therefore gained an important insight into the nature of some research roles, which caused me to consider if primarily office-based work would suit someone with a very active lifestyle, like myself.

On the other hand, extensive hours on a computer greatly enhanced my IT and written communication skills, essential for my dissertation module where I will be using computer-based analysis software such as SPSS and writing a detailed research report. In addition, I worked in close vicinity to many PhD students, meaning that I could easily reach out for support if needed. This was reassuring especially when handling big data sets, for example, during systematic reviews where I had to use large online data sources to accurately filter information from multiple studies. However, I was mostly left to work autonomously. I was given a lot of control over projects that I worked on which initially came as a surprise. However, I was also pleased that my supervisor believed me to be capable of handling big responsibilities autonomously. This encouraged me to work harder and constantly challenged me to be reliable and use my initiative.

Skills, Insight & Links to Academic PsychologyI worked on two major projects. The first was a study aimed at improving the cognitive development of HIV affected children in low to middle income countries (LMIC). I learned that HIV can substantially affect the cognitive development of affected children (McHenry et al. , 2018). This evoked an emotional response within me, it was hard to imagine that babies can be born into the world already infected with HIV which could affect their neurodevelopmental outcomes. But being part of this project showed me how working in research gives you the opportunity to affect the lives of hundreds, thousands and potentially millions of people. For instance, a successful outcome of the study could be that it provides the empirical basis for evidence-based treatment, such as Cognitive Behavioural Therapy which was a big part of my previous clinical placement. Contrastingly, during my first placement, service user treatment was usually one-to-one or in small groups. I didn’t always get the feeling that I was making as much as a difference as I would like to, despite the positive feeling of being able to help one person to have an improved quality of life.

During my first project I conducted background research from which I gained insight into how Computerised Cognitive Rehabilitation Therapy (CCRT) has previously been used to treat cognitive impairment of children in South Africa (SA). For instance, Boivin et al. found that CCRT improves neurocognition in HIV positive children in areas with low resources (2016). This gave me insight into how Computer Science and Cognitive Psychology strongly interrelate and encouraged me to think creatively when it comes to problem solving for psychological issues. I compiled my research into a literature review and presented it to my team. Based on insights from my research, I was set the challenge of mapping the intervention techniques from CCRT onto toys; the idea was to simplify cognitive treatment to make it accessible to rural parts of LMIC. I researched cognitive tasks for different cognitive domains previously used in research. I then researched interactive toys that targeted the same cognitive domains and organised the information into a table. This greatly enhanced my organization and problem-solving skills. In addition, this led to me being given the opportunity to present the project to a big charity, who work with HIV+ mothers and their children in SA, who wanted to fund the project. This enhanced my presentation, public speaking and communication skills. I also learned how to complete an ethics form which will aid me with my dissertation project ethics application. Furthermore, I learned the importance of creative thinking in research, as it widens the scope of possible interventions and interdisciplinary collaboration opportunities.

Following initial research, I worked with my supervisor to plan a randomized control trial which developed my quantitative and experimental design skills and allowed me to put into practice what I had learned in my research methods and statistics modules at university. Since the study was to take place in SA, I was asked to design a comprehensive user manual that could be used by the charity’s facilitators in SA to accurately carry out participant recruitment and data collection for the study. Designing the manual was my favourite of this project as I was able to incorporate my creative skills with newly acquired research skills. However, many components of the study were undecided at the very beginning due to waiting for information from the charity, for example how many mother-child triads there would be, whether the HIV status of all the mothers and children would be known and if someone from the charity that we know will be out there supervising the study.

Despite this I was still expected to go full steam ahead with the manual and encouraged to add my own ideas. Whilst I enjoyed creating a user manual, I constantly had to completely change entire sections several times due to the constantly changing position of the charity concerning the project, I found this extremely stressful. On the other hand, I was commended for certain components like the questionnaire design which was encouraging. In the end, there was not enough funding to carry out the project which, at the time, I saw as a major disappointment, and felt that all my hard work had been wasted. On reflection, I realised that the entire experience was just another insight into the field of research where things don’t always turn out as planned, and funding is not always secured. I believe this to be an important and transferable life lesson, for instance after submitting my dissertation research proposal or ethics application I may have to make adjustments big or small; I have therefore learned to be adaptable.

I also learned that sometimes simplicity is the best way forward. I put this into practice when I was asked to still finish the user manual but as a simple guide to cognitive development instead. For this I drew upon my neuroanatomy knowledge acquired from my Brain & Cognition modules in addition to new neuroscientific and cognitive information I learned from conducting literature reviews. Therefore, we were still able to provide the charity with a useful resource that they could use for educational purposes.

During the last month of my placement I started a new project: a systematic review of interventions for pregnant adolescent victims of intimate partner violence in LMIC. Initially the idea of starting a whole new project from scratch, with only a short time left at my placement, was intimidating. However, due to research that I conducted in my own time I discovered a great deal of information about the growing adolescent population and shocking adolescent mortality rates and causes. I found this alarming and it sparked something within me, I wanted to be able to do something about it, so I raised my idea during a team meeting. Consequently, my team decided to use adolescent’s as the population sample for the systematic review, which I found extremely encouraging. Although my time on the placement came to an end before the completion of this project I learned valuable research skills such as how to access, filter, extract and analyse specific information from big online data sources.

Conclusion

Both projects increased my awareness of world problems, namely in LMIC, and have further inspired me to pursue a career in Psychology with a philanthropic focus. CCRT research inspired me to conduct further research into computerised interventions and Cognitive Psychology. I am now set on pursuing higher education in Human Computer Interaction. In addition, one of my new career goals is now for the research & development of assistive technology for people with Developmental Disorders. I plan on using elements of this goal to guide my upcoming dissertation project. Going forward I will better prepare myself for all outcomes when it comes to research projects. I will also employ an adaptable approach to my dissertation and future projects and always bear in mind that I will likely need to revise my initial ideas and plans several times before I have the final product.

Introduction

HIV is a potentially fatal virus that attacks the body’s immune system. It can be either sexually transmitted or blood-borne and has detrimental effects on health and general-well-being of affected individuals, including children (Ravindran, Rani & Priya, 2014). With over 70% of all infections, Sub-Saharan Africa has the largest HIV prevalence in the world (Kharsany and Karim, 2016). Living in areas of high HIV prevalence (such as low to middle income countries (LMIC) young children are often affected by HIV, whether exposed, infected or living within affected communities (Richter, Foster & Sherr, 2006). HIV has biological and social implications (Baral et al. , 2013). Fortunately, the development of antiretroviral therapy (ART) has altered the course of HIV (from a fatal to a chronic illness) and children who many not have previously survived past childhood are now living. This has highlighted new challenges relating to the impacts of HIV inclusive of the implications for development (Ravindran, Rani & Priya, 2014).

For instance, many studies show that HIV (both exposure to and infection) can negatively impact child development, and especially increases the risk of cognitive deficits (Laughton et al, 2013). Research shows that over time there has been a declining incidence of severe neurological complications, such as HIV encephalopathy due to interventions such as early viral suppression (Crowell et al. , 2015). However, HIV still increases the likelihood that children will have neurocognitive deficits such as cognitive delay; this is due to the detrimental effect of HIV on the Central Nervous System (Watkins and Treisman, 2015). Young children in developing countries are uniquely at risk due to the higher rate of exposure, leading to small instabilities within cognitive development which may have long term effects within the brain both in terms of capacity and functionality Grantham-McGregor et al (2007). Understanding these cognitive deficits is important, as subtle impairments could lead to more pronounced complications that will influence future intellectual performance, job opportunities, and community participation of HIV-infected children (Cohen et al. , 2014). This essay will explore how and in which ways child cognitive performance is affected by HIV and how Cognitive Rehabilitation has been used to assess neurological deficits and improve subsequent outcomes for HIV affected children in LMIC.

Cognitive Domains Affected by HIVA study by Ravindran, Rani & Priya (2014) showed that despite having average intelligence, HIV infected children show substantial deficits in the cognitive domains of attention, language, verbal learning and memory, visuomotor functions, fine motor performance, and executive functions. This has important implications for child cognitive performance because early childhood is a critical period of development (Institute of Medicine, 2000). Neuroscientific and developmental research have shown us that while brain development continues throughout life, the first years of life are essential as they lay the foundations for what comes later (Tierny and Nelson, 2009); with almost 90% of a child’s critical brain development happening by the age of five (Brown and Jernigan, 2012). Although results from Ravindran, Rani & Priya (2014) were calculated from child participants up to the age of 12 years, more recent studies have shown that detection of neurodevelopmental impairment from as early as infancy is possible (Phillips et al. , 2016). This is helpful as it allows for early intervention. This could improve neurological outcomes as the children develop into adolescence and eventually adulthood where for example advancement in cognitive ability could be beneficial to meet the demands of social environments such as school and the workplace. Cognitive Rehabilitation Training Interventions There is strong evidence to suggest that play-informed, caregiver-implemented and home-based training can lead to positive developmental outcomes (Meissner et al. , 2017). This area of research emphasizes the importance of training cognitive skills from early within childhood to maximise the potential benefits of future intellectual performance, including job opportunities and community participation (Cohen et al. , 2014).

Cognitive rehabilitation (CR), also known as cognitive skills training, is a specifically designed intervention program for improving cognitive deficits, it involves initial testing of brain function/ ability and goal setting, in addition to the application of appropriate brain training exercises for improving cognitive performance (Alladi, Meena & Kaul, 2002). Samuel (2008) noted that CR is based on Luria (1963) theory for restoration of function after brain injury which emphasises the possibility for re-establishing cognitive function by learning new connections via cognitive re-training tasks. CR comes in different forms such as computerised cognitive rehabilitation training (CCRT). CR can be either restorative or compensatory rehabilitation; CCRT is a type of restorative CR which enables the individual to improve deficient brain functions through specific computerised and manual tasks (Sohlberg, 1989); it has been used in research to successfully assess and treat cognitive performance of HIV affected children in LMIC.

In addition, Walker at al. , (2011) suggest that early interventions such as early child development programmes and policies can ameliorate child development outcomes in low resource settings. However, a systematic review by Sherr et al. (2014) found that few effective interventions target children with cognitive defects due to HIV and are mostly tailored to specific conditions that don’t necessarily target HIV affected children; moreover, many of these studies are conducted in wealthy countries. This is problematic as it means that results cannot be generalised to LMIC where intervention is needed most. Fortunately, there has a been shift in recent years to more research focusing on assessment and intervention for cognitive delay of HIV affected children in LMIC. For example, the use of CCRT was found to improve scores on The Test of Variables of Attention (TOVA), CogState computer battery, and the Non-Verbal Index from the Kaufman Assessment Battery for Children, 2nd edition (KABC-II); following cognitive training, children showed significant improvements in particular on specific TOVA and CogState measures which highlight processing speed, attention, visual-motor coordination, maze learning, and problem solving (Giordani et al. , 2015). This is consistent with previous findings by Boivin et al. (2010) who found that CCRT is an effective intervention for improving brain function in HIV positive children, in particularly in the categories of maze learning and attention. Further support comes from subsequent research by Boivin et al. (2016) who found that CCRT was an effective intervention for improving neurocognition in HIV affected children from low resource areas.

Despite growing support for CR as an effective intervention, there is a great need for the scaling up of interventions, suitable programmes based in communities may be the best way for children in LMIC to access this support (Sherr et al. , 2017). Some researchers have expressed the intention to expand the availability of CCRT to parts of South Africa where access to facilities and treatment is limited. However, although new resources at lower costs are becoming available for deprived areas such as low-resource settings, lack of adaptability concerning computerised programmes, and the use of expensive Western-based technologies makes large scale-up studies difficult (Giordani, 2015). In addition, high costs such as development of computer software, could make wide scale distribution of intervention programs too costly in rural parts of developing countries, limiting their use to certain settings such as schools or health clinics. This often negatively affects the ability of poorer locations to find reasonable solutions for these limiting factors (Rajani et al. 2003). Currently, there is a strong focus in academic literature and policy on the cognitive development of children within LMIC. In part, this is due to an increase of available data regarding poor developmental outcomes for children in LMIC (Lu, Black & Richter, 2016).

Conclusion

The growing number of studies on the effects of CR on neurological outcomes on children affected by HIV suggest that, cognitive development can be encouraged by training programmes that target specific cognitive skills over time. It is essential that further research is conducted for HIV-infected children, a more comprehensive understanding of developmental and neurological issues will aid in informing more effective interventions (Sherr et al. , 2014). The earlier the detection of cognitive impairment, the better, as this could initiate early intervention and potentially prevent further cognitive decline in children with HIV (Cohen et al. , 2014).

15 Jun 2020

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