Psychological Distress, Substance Use, and
Adjustment among Parents Living with HIV
http://www.jabfm.org/cgi/content/full/18/5/362
Risë B. Goldstein, PhD, MPH,
Mallory O. Johnson, PhD, Mary Jane Rotheram-Borus, PhD, Sheri B.
Kirshenbaum, PhD, Rogério M. Pinto, PhD, LMSW, Lauren Kittel,
PsyD, Willo Pequegnat, PhD, Joanne D. Mickalian, MA, Lance S.
Weinhardt, PhD, Jeffrey A. Kelly, PhD, Marguerita Lightfoot, PhD
the National Institute Mental Health Healthy Living Project Team
Center for Community Health,
UCLA Neuropsychiatric Institute (RBG, MJR-B, ML)
Center for AIDS Prevention Studies, University of California-San
Francisco, San Francisco, CA (MOJ, JDM)
HIV Center for Clinical and Behavioral Studies, New York State
Psychiatric Institute and Columbia University, New York, NY (SBK,
RMP, LK)
National Institute of Mental Health, Bethesda, MD (WP)
Center for AIDS Intervention Research, Medical College of
Wisconsin, Milwaukee, WI (LSW, JAK)
Correspondence:
Corresponding author: Risë B. Goldstein, PhD, MPH,
Laboratory of Epidemiology and Biometry, Division of Intramural
Clinical and Biological Research, National Institute on Alcohol
Abuse and Alcoholism, National Institutes of Health, 5635
Fishers Lane, Room 3068, MS 9304, Bethesda, MD 20892-9304
(e-mail
goldster@mail.nih.gov )
Abstract
Background: Being a parent, especially a custodial
parent, living with HIV was anticipated to increase
psychological distress and challenges to self-care.
Methods: Mental health symptoms, substance use, and
health care utilization were assessed among 3818
HIV-infected adults, including custodial parents,
noncustodial parents, and nonparents, in 4 AIDS
epicenters.
Results: Custodial parents demonstrated significantly
poorer medication adherence and attendance at medical
appointments but were similar to nonparents and
noncustodial parents in mental health symptoms and
treatment utilization for mental health and substance
use problems. Noncustodial parents demonstrated the
highest levels of recent substance use and substance abuse
treatment. Other markers of risk, such as African American
ethnicity, lack of current employment income, and
injection drug use moderated many of the apparent
psychosocial disadvantages exhibited by parents.
Conclusions: Interventions specific to the
psychosocial stressors facing families living with
HIV are needed.
Parents comprise 20%
of HIV-positive (HIV+) persons in the United States
and are increasing in numbers1
as advances in medical care enable HIV+ women and men
to live longer, healthier lives,1
and undertake pregnancies with low risk of vertical HIV
transmission to their offspring.2
Psychological distress and substance abuse are common among
HIV+ adults. Over a third of HIV+ adults in medical care
screen positive for a psychiatric disorder.3
Symptoms of depression and anxiety have been reported
in several studies of HIV+ persons.4–6
Similar to samples of adults without HIV, significantly
more HIV+ women than men are emotionally distressed.7,8
In addition, 12% of adults living with HIV were
dependent on illicit drugs during the preceding year.3
However, limited data are available about how
parental roles are associated with mental health among
HIV+ parents.
Role Theory, Mental Health,
and Adjustment in HIV+ Parents
Role theory concerns behaviors that characterize persons within
contexts and with the processes that may produce, explain,
or be affected by those behaviors.9
The role of "parent" carries extensive expectations
for behavior: providing for families’ basic survival
needs such as housing, food, and health care;
psychologically nurturing and disciplining children; and
educating children to become productive, contributing
citizens.10
However, within this general framework, there are
very different expectations for custodial versus
noncustodial parents, and mothers versus fathers,
some reflecting externally imposed norms and others
reflecting parents’ own beliefs about parenting.11–13
Role Negotiation, Role
Overload, and Role Conflict
Rather than merely signifying understanding and compliance on
the part of the person holding a role (the "focal
person"), role development is characterized by
interactive negotiation toward mutually satisfactory
role definition between the focal person and others
whose expectations define and shape the role, known
as the "role set."14–17
However, for HIV+ parents, many of whom are ethnic
minority women heading households of low
socioeconomic status, options for satisfactory role negotiation
may be constrained by poverty, lack of social support, and
multiple competing obligations.
More than many other parents,18,19
those with HIV, particularly custodial parents, may
become overwhelmed by the simultaneous demands of
multiple roles, including medical patient, breadwinner,
and caregiver for HIV+ family members.20–27
HIV+ parents may thus experience role overload as
divergent demands are superimposed on each other and
cannot be easily accomplished given available time
and resources.12
Parents with HIV, especially custodial mothers, may
also be particularly vulnerable to role conflict; for
example, their obligations to attend to their children,
earn a living, and care for other family members, may
render them unable to meet their own health needs.21,28–30
Parental Role and Mental
Health of HIV+ Parents
Both rewards and stressors related to parenthood have been well
documented. Parents may benefit from the bond with the
child and the opportunity to nurture the child’s
development,13,31
experiencing psychological growth in the process.32
However, child physical and behavioral problems,
financial strains, and caregiving demands may leave
little time for parental self-care.29,31,33–35
Among custodial, inner-city mothers with HIV, perceived
parenting stress, more household members, and
disclosure of HIV seropositivity to fewer family
members predicted medication non-adherence and missed
medical appointments.29
However, little is known about whether parenthood,
particularly custodial parenting, is associated with
differential risk for conditions like depression, anxiety,
substance use and abuse, or, conversely, increased
positive states of mind or coping self-efficacy,
among HIV+ adults, especially since highly active
antiretroviral therapy (HAART) has become widely
available.
Because mothers more often than fathers are custodial parents
and primary caretakers of children,24,36–40
most studies of mental health in HIV+ parents have
focused on mothers. However, fathers1,38
and noncustodial parents may also be actively involved
in parenting. To our knowledge, no study has yet examined
whether associations between parenthood and mental
health vary by custodial role, gender, sexual
orientation, or behavioral risk.
The present study examines mental health, substance use,
coping self-efficacy, positive states of mind, and
physical and mental health service utilization, among
a large, diverse, HAART era sample of HIV+ custodial
parents, noncustodial parents, and nonparents.
Grounded in the concepts of role theory, we hypothesized
the following:
- Custodial parents would demonstrate
the greatest distress including
depression, anxiety, perceived stress, and anger
burnout, as well as the lowest coping
self-efficacy and mental health and
substance abuse treatment utilization.
- Custodial parents would
demonstrate poorer medication adherence and
attendance at scheduled medical appointments than
noncustodial parents and nonparents.
- Larger numbers of total and coresident
minor offspring would be associated
with greater distress and less service
utilization.
- Noncustodial parents would demonstrate
distress, coping self-efficacy, and service
utilization intermediate between those of
custodial parents and those of nonparents.
- Associations of parental status with
distress and adjustment would be moderated by
behavioral risk group and ethnicity, with women
and ethnic minority group members scoring highest on
distress and lowest on coping self-efficacy and
treatment utilization.
- Associations of parental status with
distress and adjustment would also be moderated
by current employment and welfare income, with
parents reporting current employment income being less
and those reporting current welfare income being more
distressed.
Methods
Study Participants
A total of 3818 HIV+ adults in San Francisco, Los Angeles, New
York City, and Milwaukee were screened for recruitment
into a clinical trial of an individually administered
cognitive-behavioral intervention to enhance coping
skills, decrease sexual transmission risk behaviors,
and improve antiretroviral medication adherence.
Participants were classified by behavioral risk group using
a hierarchy similar to the one established by the Centers
for Disease Control and Prevention41:
women, injection drug users (IDU), men who have sex
with men (MSM), and heterosexual men. If women were
IDUs, they were classified as women; if MSM were IDU,
they were classed as IDU. MSM were men who reported sexual
contact with other males in the past 3 months, regardless
of self-identification as gay or whether they also
had female partners. IDU were men who reported
injecting illicit substances in the past 12 months.
Recruitment and screening were undertaken in medical clinics,
community agencies, and through advertisements in
newspapers and magazines. Persons learning of the
study by word of mouth were also eligible for
screening. Interested persons who provided verbal
consent were briefly screened to determine their self-reported
HIV status as well as basic demographic and contact
information. If they then wished to participate, they
were scheduled for a baseline interview.
Participants were required to be at least 18 years old and
provide written informed consent and medical
documentation of their HIV+ serostatus. Potential
participants were excluded if they showed severe
neuropsychological impairment or psychosis as
assessed on a case-by-case basis by senior project personnel
in collaboration with the clinical supervisor at the
involved institution.
Assessment Procedures
We report data from the baseline interview that determined
eligibility for the trial. All procedures and forms
were reviewed and approved by the sites’
Institutional Review Boards. Interviews were
conducted in private settings at research offices,
community-based organizations, and clinics in the 4
cities over periods of 2 to 4 hours with regular
breaks to minimize respondent fatigue. Participants
were compensated $50 for completing the baseline
interview; those needing childcare could also receive $10 to
defray childcare costs.
Procedures involved a combination of audio computer-assisted
self-interviewing (ACASI) and computer-assisted personal
interviewing using Questionnaire Development System
version 2.0 by Nova Research Company. ACASI has been
proposed as an effective method of decreasing social
desirability and thereby enhancing veracity of self-report
of sensitive behaviors and attitudes.42,43
Interviewers were centrally trained with the use of a
detailed assessment manual, practice with the
computer programs, participation in an intensive
3-day training program, and review and certification
of audiotaped mock interviews based on standardized criteria.
All interviews were audiotaped; quality assurance ratings
indicated 90%
adherence to assessment protocols.
Measures
Demographics
Demographic data included participant age, race/ethnicity,
gender, relationship status, education, employment,
income sources, and housing arrangements.
Parental Status
Total number of offspring, number residing with participants,
and how many of those residing with participants were
under the age of 18 were ascertained. Participants
were classified as custodial parents (offspring under
age 18 residing with respondents), noncustodial
parents (offspring all over age 18 or not residing
with respondents), or nonparents.
Health Status
Respondents were asked how long ago they learned of their HIV
infection. In addition, they were asked whether they had
experienced each of 25 symptoms in the preceding 30
days based on the AIDS Clinical Trials Group symptom
checklist44
and to rate how much each symptom experienced
bothered them. Further, participants were asked to
report their most recent CD4 and viral load counts.
Health Care
Utilization
Current utilization of antiretroviral therapy; antidepressant,
antianxiety, and other psychiatric medications; and mental
health and substance abuse treatment visits over the
past 3 months were assessed using items adapted from
the Health Outcomes Study.45
In addition, respondents were asked about missed
appointments with care providers.
Medication adherence was assessed with a survey developed for
use in AIDS clinical trials.46
The measure allowed respondents to indicate how many
prescribed antiretroviral pills they had missed
taking during each of the previous 3 days. Respondents
were classified as adherent if they reported no missed
doses, and non-adherent if they reported any, during
the 3 days.
Mental Health,
Psychosocial Adjustment, and Substance Use
Response variables for the present report consisted of:
depression, anxiety, anger burnout, "frequent"
substance use (defined below), perceived stress, and
positive states of mind.
Depression was assessed using the 21-item Beck Depression
Inventory (BDI),47,48
with score cutpoints for defining moderate (14 to 20)
and severe (21),
versus none or minimal (0 to 4) and mild (5 to 13)
depression as recommended by Shaver and Brennan.49
This measure assesses the severity of depression during
the past week.
Anxiety was assessed with the State Form of the State-Trait
Anxiety Inventory (STAI).50
The State Form assesses feelings of anxiety at the
time the subject completes the scale. This measure
was modeled both as a continuous variable and as >
versus < = the median score for general medical patients50
of 42.
Anger burnout was assessed with a 16-item scale adapted from
the Anger and Fatigue subscales of the Profile of Mood
States.51
An overall burnout score was created by summing the
ratings using a 5-point Likert-type response format
and a dichotomous variable was created denoting
scores >2.
Substance use frequency in the past 3 months was assessed for
alcohol, cocaine/crack, sedatives, tranquilizers,
stimulants, analgesics, inhalants, marijuana,
hallucinogens, heroin, and other,
participant-specified substances. Participants were asked
to report which drugs they injected, their frequency of
injection, and the ways they obtained injection
equipment.52
Participants were classified as having "frequent"
substance use if they reported consuming alcohol more
than daily, any other drug 4 or more times weekly, or
any IDU in the past 3 months.
Perceived stress was assessed with the 10-item form of the
Perceived Stress Scale53
by summing ratings on a 5-point scale. The questions
in the scale ascertain the frequency with which subjects have
experienced stress-related thoughts and feelings during
the past month.
The Positive States of Mind Scale assesses satisfying states
a person may have experienced in the past week.54
This self-report 6-item measure assesses: focused
attention, productivity, responsible care-taking,
restful repose, sensuous nonsexual pleasure, and
sharing. A general composition of positive states of mind was
obtained by summing across each domain on a 4-point
Likert-type scale.
Coping self-efficacy was assessed with an abbreviated 15-item
version of the 26-item scale developed for a coping skills
training study55
in collaboration with Dr. Albert Bandura of Stanford
University. Participants rate on a scale from 0 to 10 the extent
to which they believe they can perform behaviors important
to adaptive coping.
Statistical Analyses
Bivariate associations of categorical response variables with
parental status were analyzed using contingency table
approaches and 2
statistics; those between continuous response variables
and parental status were analyzed using normal-theory
analyses of variance and post hoc Scheffé
comparisons. Among custodial parents, associations
between number of coresident minor children and
response variables were examined using nonparametric Spearman
rank-order correlation coefficients for continuous and
Wilcoxon rank-sum tests for categorical responses.
Multivariable regression models were fit to control for
potentially confounding effects of respondent
demographic and clinical characteristics on
associations between parental status and response variables.
Normal-theory regression was used for continuous
responses, and binary logistic regression was used
for dichotomous responses.56
Parental status was modeled using 2 indicator variables,
one denoting custodial and one denoting noncustodial
parents, with nonparents as the referent group. Other
covariates were included based on associations in
bivariate analyses with parental status at P <
.10 or subject matter considerations: (a) age; (b)
behavioral risk group; (c) study site; (d) education; (e)
primary relationship (none, noncohabiting,
cohabiting); (f) employment income; (g) welfare
income; (h) use of antiretroviral medications; and
(i) distress because of HIV symptoms.
Odds ratios were considered statistically significant when
the surrounding 95% CI excluded 1.00; normal-theory
regression coefficients were considered statistically
significant when the surrounding 95% CI excluded
0.00. Two-way interactions of parental status with
behavioral risk group, ethnicity, employment income, welfare
income, distress because of HIV symptoms, and age were
tested for statistical significance, with an -to-stay
of 0.05. All analyses were performed with SAS
Statistical Software, version 8.2.57
Results
Sample Demographics
Demographic characteristics are shown by parental status in
Table 1. Custodial parents comprised 10.5%, noncustodial
parents 34.6%, and nonparents 54.9% of the sample.
Women were over-represented among custodial parents
(72.6%), whereas nonparents were predominantly MSM
(69.7%). Custodial parents were significantly younger than
nonparents and noncustodial parents; nonparents were
significantly younger than noncustodial parents (data
available on request). Respondents differed
significantly by parental status on ascertainment
site, with nonparents disproportionately ascertained in Los
Angeles (36.9%) and San Francisco (29.4%), and
noncustodial parents in New York (47.7%; P <
.0001). Differences by parental status on most other
demographic characteristics parallel geographic
differences in the epidemiology and demography of HIV.58
Table 1. Sociodemographic Characteristics
of Adults Living with HIV by Parental Status (N = 3810)*
|
Characteristic |
Total Sample (%) |
Custodial Parents of Minor Children (n = 401)
(%) |
Noncustodial/Parents of Grown Children (n =
1319) (%) |
Nonparents (n = 2090) (%) |
PValue |
|
|
|
Age in years, mean ± SD |
41.5 ± 7.6 |
38.9 ± 6.2 |
43.4 ± 7.4 |
40.7 ± 7.7 |
<.0001 |
|
Behavioral risk group |
|
|
|
|
<.0001 |
|
MSM |
45.6 |
6.7 |
19.3 |
69.7 |
|
|
IDU |
8.1 |
1.8 |
6.4 |
10.3 |
|
|
Women |
27.1 |
72.6 |
41.3 |
9.4 |
|
|
Heterosexual men |
19.2 |
19.0 |
33.0 |
10.6 |
|
|
Ethnicity |
|
|
|
|
<.0001 |
|
African American |
48.3 |
59.6 |
62.8 |
36.9 |
|
|
Hispanic |
19.1 |
25.9 |
17.2 |
19.0 |
|
|
White |
25.7 |
10.2 |
13.9 |
36.1 |
|
|
Other |
7.0 |
4.2 |
6.2 |
8.0 |
|
|
Currently in a cohabiting
primary relationship |
23.5 |
40.4 |
24.9 |
19.3 |
<.0001 |
|
Educational attainment <
high school graduation |
26.2 |
40.5 |
34.5 |
18.2 |
<.0001 |
|
Currently residing in own
house or apartment |
62.8 |
77.0 |
57.8 |
63.2 |
<.0001 |
|
Current employment status |
|
|
|
|
<.0001 |
|
Legal job, paying
income taxes |
15.6 |
15.5 |
10.8 |
18.7 |
|
|
Legal job, paid "under
the table" |
13.6 |
13.0 |
12.3 |
15.6 |
|
|
Illegal job |
0.9 |
1.3 |
1.0 |
0.8 |
|
|
Receives public assistance |
32.5 |
54.1 |
36.9 |
25.5 |
<.0001 |
|
* Information on parental status is missing for 8
participants.
Custodial parents were most likely to be cohabiting with a
primary partner, whereas nonparents and noncustodial
parents modally reported no primary relationship.
Custodial parents had a mean ± SD of 1.7 ± 1.0
coresident minor children (women: mean ± SD, 1.8 ±
1.0; MSM: mean ± SD, 1.1 ± 0.3; heterosexual men:
mean ± SD, 1.5 ± 0.9; women had significantly more
than MSM, P < .05, by Scheffé’s test).
HIV-Related Health Status and Medical Care Adherence
HIV-related health indices are shown in Table 2. Consistent
with the more recent spread of the US epidemic among women
and heterosexual men than among MSM, both groups of
parents had learned their serostatus more recently
than nonparents. The groups did not differ
significantly on HIV-related symptom counts (mean ±
SD, custodial parents: 12.4 ± 5.9; noncustodial
parents: 12.3 ± 5.9; nonparents: 12.6 ± 5.5).
However, although differences were modest, both groups of
parents reported greater distress than nonparents
because of HIV symptoms.
Table 2. Medical Status and Health Care
Utilization among Adults Living with HIV by Parental Status (N =
3810)*
|
Characteristic |
Total Sample |
Custodial Parents of Minor Children (n = 401) |
Noncustodial/Parents of Grown Children (n =
1319) |
Nonparents (n = 2090) |
P Value |
|
|
|
Years since learned HIV
serostatus, mean ± SD |
8.4 ± 4.7 |
7.7 ± 4.1 |
8.1 ± 4.5 |
8.8 ± 4.8 |
<.0001 |
|
Last self-reported CD4
count <200 |
20.4% |
15.1% |
20.7% |
21.2% |
.0309 |
|
Last viral load detectable
(self-report) |
59.3% |
54.7% |
58.1% |
61.0% |
.0377 |
|
HIV-related symptom count,
mean ± SD |
12.4 ± 5.7 |
12.4 ± 5.9 |
12.3 ± 5.9 |
12.6 ± 5.5 |
.3145 |
|
Distress due to HIV-related
symptoms, mean ± SD |
2.8 ± 0.5 |
2.9 ± 0.5 |
2.9 ± 0.5 |
2.8 ± 0.5 |
<.0001 |
|
Currently taking
antiretrovirals |
74.7% |
72.6% |
73.7% |
75.7% |
.2378 |
|
Adherent to all
medications, past 3 days |
63.7% |
53.0% |
63.5% |
65.8% |
.0002 |
|
Any missed medical
appointments, past 3 months |
47.7% |
53.0% |
48.9% |
46.1% |
.0418 |
|
* Information on parental status is missing for 8
participants.
Rated
1 (doesn’t bother at all) to 4 (bothers a great deal).
Custodial parents were significantly less likely than
noncustodial parents and nonparents to report that
their last CD4 count was <200 or that their viral
load was detectable. However, custodial parents were
also significantly less likely to report 100% antiretroviral
medication adherence over the past 3 days (adjusted odds
ratio 0.60, 95% CI, 0.44, 0.82) and more likely to
report missing medical appointments over the
preceding 3 months.
Mental Health and Psychosocial Adjustment
Relationships between mental health and parental status are
shown in Table 3. Although the difference was modest,
custodial parents scored significantly lower than
nonparents on positive states of mind. However,
neither significant main effects of parental status
nor significant interactions of parental status with
other demographic or clinical variables were observed for
anger burnout (32.8% of the total sample scoring >2),
moderate/severe depression (39.9%), antidepressant
(30.8%) or other psychiatric medication use (11.7%),
mental health visits in the past 3 months (39.2%), or
perceived stress (mean ± SD, 18.8 ± 7.0).
Table 3. Crude and Adjusted Associations of
Mental Health and Adjustment Measures with Parental Status (N =
3810)*
|
Measure |
Total Sample |
Custodial Parents of Minor Children (n = 401) |
Noncustodial/ Parents of Grown Children (n =
1319) |
Nonparents (n = 2090) |
Adjusted Odds Ratios or Regression Coefficients
(95% CI)
|
|
Custodial vs. nonparents |
Noncustodial vs. nonparents |
|
|
|
Beck Depression Inventory
score, mean ± SD |
12.9 ± 9.0 |
13.1 ± 9.3 |
13.0 ± 9.1 |
12.8 ± 8.8 |
|
|
|
|
MSM |
|
|
|
|
0.88 (–2.15, 3.90) |
0.60 (–0.48, 1.69) |
|
|
IDU |
|
|
|
|
13.10 (6.64, 19.57) |
1.43 (–0.58, 3.44) |
|
|
Women |
|
|
|
|
–0.66 (–2.12, 0.80) |
–0.75 (–2.03, 0.52) |
|
|
Heterosexual men |
|
|
|
|
0.33 (–1.76, 2.42) |
1.12 (–0.19, 2.43) |
|
|
Frequentsubstance use (%) |
31.6 |
22.7 |
33.2 |
32.4 |
|
|
|
|
African American |
|
|
|
|
0.63 (0.43, 0.92) |
0.87 (0.68, 1.13) |
|
|
Hispanic |
|
|
|
|
0.46 (0.21, 0.98) |
1.40 (0.94, 2.09) |
|
|
White |
|
|
|
|
0.84 (0.51, 2.72) |
1.52 (1.03, 2.25) |
|
|
Other ethnicities |
|
|
|
|
0.87 (0.65, 1.16) |
1.06 (0.58, 1.94) |
|
|
Substance abuse treatment,
past 3 months (%) |
46.1 |
41.7 |
59.1 |
38.7 |
|
|
|
|
MSM |
|
|
|
|
1.06 (0.46, 2.43) |
1.51 (1.14, 2.01) |
|
|
IDU |
|
|
|
|
3.52 (0.39, 31.62) |
2.49 (1.35, 4.59) |
|
|
Women |
|
|
|
|
0.47 (0.32, 0.69) |
1.24 (0.88, 1.75) |
|
|
Heterosexual men |
|
|
|
|
0.93 (0.54, 1.61) |
1.36 (0.64, 1.26) |
|
|
STAI score, mean ± SD |
36.3 ± 11.0 |
37.2 ± 11.4 |
36.0 ± 10.7 |
36.3 ± 11.1 |
|
. |
|
|
African American, no
current employment income |
|
|
|
|
4.40 (2.60, 6.20) |
2.19 (1.00, 3.38) |
|
|
African American,
current employment income |
|
|
|
|
1.34 (–1.04, 3.72) |
1.68 (0.62, 3.99) |
|
|
STAI score >42 (%) |
26.5 |
29.8 |
25.8 |
26.3 |
|
|
|
|
African American |
|
|
|
|
2.20 (1.51, 3.22) |
1.60 (1.21, 2.10) |
|
|
Hispanic |
|
|
|
|
0.46 (0.21, 0.98) |
1.40 (0.94, 2.09) |
|
|
White |
|
|
|
|
0.84 (0.51, 2.72) |
1.52 (1.03, 2.25) |
|
|
Other ethnicities |
|
|
|
|
0.49 (0.15, 1.62) |
1.06 (0.58, 1.94) |
|
|
Currently taking
anti-anxiety medication (%) |
19.7 |
19.2 |
17.1 |
21.5 |
|
|
|
|
No current welfare
income |
|
|
|
|
0.85 (0.53, 1.35) |
0.99 (0.77, 1.28) |
|
|
Current welfare income |
|
|
|
|
1.79 (1.10, 2.92) |
1.01 (0.70, 1.46) |
|
|
Positive States of Mind
Scale, mean ± SD |
12.9 ± 3.5 |
12.9 ± 3.6 |
13.0 ± 3.6 |
12.9 ± 3.4 |
–0.48 (–0.89, –0.07) |
–0.24 (–0.51, 0.03) |
|
|
Coping self-efficacy, mean
± SD |
6.6 ± 1.8 |
6.7 ± 1.8 |
6.7 ± 1.8 |
6.6 ± 1.8 |
|
|
|
|
African American, MSM |
|
|
|
|
–0.94 (–1.59, –0.28) |
–0.56 (–0.82, –0.30) |
|
|
African American, IDU |
|
|
|
|
–1.40 (–2.80, 0.00) |
–0.85 (–1.32, –0.38) |
|
|
Hispanic, women |
|
|
|
|
0.46 (0.01, 0.91) |
0.55 (0.18, 0.92) |
|
|
White, women |
|
|
|
|
0.37 (–0.22, 0.93) |
0.51 (0.13, 0.89) |
|
|
Other ethnicities, MSM |
|
|
|
|
–1.00 (–2.04, 0.03) |
–0.57 (–1.05, –0.10) |
|
|
Other ethnicities, IDU |
|
|
|
|
–1.47 (–3.10, 0.16) |
–0.86 (–1.46, –0.27) |
|
|
* Information on parental status is missing for 8
participants.
Defined
as alcohol > daily, any other drug > 4 times weekly, or
any injection in the past 3 months.
Interactions of Parental Status with Demographic
Characteristics
Significant interactions of parental status with ethnicity,
behavioral risk group, and income sources were observed on
the BDI, STAI, substance use, substance abuse
treatment, and coping self-efficacy.
On the BDI, custodial IDU fathers were significantly more
depressed than nonparental MSM. Custodial mothers
were less likely to utilize substance abuse services,
whereas noncustodial MSM and IDU fathers were more
likely.
African American and Hispanic custodial parents displayed
significantly decreased odds of frequent substance
use, whereas white noncustodial parents demonstrated
significantly increased odds, compared with African
American nonparents.
Coping self-efficacy was significantly lower among African
American MSM and IDU fathers, particularly those with
custody, than among African American MSM nonparents.
It was also significantly lower among noncustodial
MSM and IDU fathers of "other ethnicities," but
higher among both noncustodial and custodial Hispanic and
noncustodial white mothers. In other behavioral risk and
ethnic groups, the estimated regression coefficients
(95% CI) were statistically nonsignificant, ranging
from –1.47 (–3.10, 0.16) for custodial IDU fathers of
other ethnicities to 0.47 (0.00, 0.93) for
noncustodial Hispanic heterosexual men.
Anxiety was significantly higher among both groups of African
American parents who did not, and among noncustodial
African American parents who did, have employment
income, than among African American nonparents. For
other subgroups defined by ethnicity and income, the
estimated regression coefficients (95% CI) were
statistically nonsignificant, ranging from –2.20
(–5.91, 1.50) for white custodial parents with, to 3.95
(–1.30, 9.21) for custodial parents ofother ethnicities
without, current employment income.
Associations with
Primary Relationship Status
Primary relationship did not interact with parental status in
association with mental health variables. However, being
in a primary relationship was independently
associated with lower BDI and STAI and higher
Positive States of Mind Scale scores, particularly
among respondents who cohabited with their primary
partners. Primary, cohabiting relationships were also associated
with lower utilization of antidepressants, other
psychiatric medications, substance abuse treatment,
and mental health visits, but higher odds of frequent
substance use. Primary, noncohabiting relationships
were associated with higher odds of substance abuse
treatment and higher coping self-efficacy.
Associations between
Number of Offspring and Response Variables
Not shown here but available on request, Spearman rank-order
correlations between total number of offspring and
continuous response variables did not differ from
zero. In the sample as a whole, current antianxiety
medication was associated with fewer (Wilcoxon rank
sum 2
= 10.95, df = 1, P = .0009), and
substance abuse treatment with more offspring (Wilcoxon rank
sum 2
= 107.85, df = 1, P < .0001). Among custodial
parents, frequent substance use was associated with
fewer (Wilcoxon rank sum 2
= 4.51, df = 1, P = .0336), and substance abuse
treatment (Wilcoxon rank sum 2
= 3.93, df = 1, P = .0475) and current
antidepressant medication (Wilcoxon rank sum 2
= 5.70, df = 1, P = .0170) with more
offspring. Number of minor offspring residing with
custodial parents was not significantly associated
with any response variables.
Discussion
To our knowledge, this study is among the first to examine
mental health, psychosocial adjustment, and substance
use among a large, diverse, HAART era sample of HIV+
custodial parents, noncustodial parents, and
nonparents. Parenthood is associated with substantial
role responsibilities and potential stressors. Unexpectedly,
however, there were few differences by parental status in
mental health, substance abuse, or treatment
utilization. Most associations that we observed
identified parents, especially custodial ones, as
more distressed than nonparents, and indicated that custodial
parents had particular difficulty with medication
adherence and attendance at medical appointments.
However, these differences were relatively modest.
In the case of substance abuse, caring for young children may
be protective, because substance abuse is more prevalent
among noncustodial than custodial parents. This may
reflect the increased propensity for parents with
serious substance use problems to lose or relinquish
custody and perhaps to seek treatment as part of the
process of getting the children back. Similarly,
custody of children may be an incentive for parents to abstain
from substances.59
Consistent with previous studies of risk factors for
psychological distress, many of the disadvantages
exhibited by parents were moderated by other
variables that are often markers of socioeconomic
disadvantage, such as African American ethnicity, lack of
current employment income, and injection of drugs
over the preceding 12 months.60
Being in a primary relationship did not moderate
associations with parental status, either to reduce distress
or to increase positive adjustment. In addition, neither
total number of offspring nor number of minor
children living in the home was associated with most
psychological measures.
African American and Hispanic custodial parents were less
likely to report frequent substance use; both
custodial and noncustodial Hispanic mothers, as well
as white noncustodial mothers, endorsed greater
coping self-efficacy, whereas African American MSM and
African American IDU fathers, and IDU fathers of
ethnicities other than African American, Hispanic,
and white, reported less. The lower odds we observed
for frequent substance use among custodial African
American and Hispanic parents are compatible with
previous epidemiologic studies that identify lower prevalence
in ethnic minority groups.61–63
However, the higher scores |
