Self-awareness and Depression among HIV-Affected Children in India

In India, HIV-infection is majorly a psychosocial risk which demands not only physical treatment but also psycho-social intervention because of the inhumane stigma and discrimination exist in HIV-affected individual’ own family and community [1]. So that, the average life span of a HIV-affected individual in India is considerably lower than the life span of HIV-affected individuals in developing countries. Since the social intervention failed to alleviate the stigma and discrimination towards HIV, the charitable organizations and government provide special accommodation and support for them. Because of the community living and the presence of passionatecaretakers (who volunteers himself), they enjoy the social security and community life. But, the psychological trauma or symptoms again worsen their subjective well-being [2]. They are extremely troubled by psychological symptoms like depression, anxiety, suicidal behaviour, PTSD and poor subjective well-being [3,4].


Introduction
In India, HIV-infection is majorly a psychosocial risk which demands not only physical treatment but also psycho-social intervention because of the inhumane stigma and discrimination exist in HIV-affected individual' own family and community [1]. So that, the average life span of a HIV-affected individual in India is considerably lower than the life span of HIV-affected individuals in developing countries. Since the social intervention failed to alleviate the stigma and discrimination towards HIV, the charitable organizations and government provide special accommodation and support for them. Because of the community living and the presence of passionatecaretakers (who volunteers himself), they enjoy the social security and community life. But, the psychological trauma or symptoms again worsen their subjective well-being [2]. They are extremely troubled by psychological symptoms like depression, anxiety, suicidal behaviour, PTSD and poor subjective well-being [3,4].
It was reported that about 70,000 children under 15 years old were living with HIV and an estimated 21,000 children were infected with HIV every year in India. The major reason of transmission in infants was vertical infection, parent -to -child [5]. Since 2013, India has watched over the WHO's recommendation to use antiretroviral drugs for the prevention of HIV-infection, especially for pregnant adult females and young children (WHO, 2014) and provides ART drugs at no cost to people surviving with HIV [6]. Through pediatric the interventions, the number of HIV-infections reduced considerably and HIV-affected children live longer than before. This gives raise to new challenges when these kids reach middle childhood and adolescence [7].
Among HIV-affected children, the impact of physical and psychosocial risk factors are detrimentally higher than HIV-affected adults. The primary reason is parents' death at the early stage of their development [8] or inability to take care of children. Studies have found development delays among these children. This delay is partially explained by lack of proper care from parents and neurological abnormalities. The after-effects are deficit or delay in gross and fine motor skills, cognitive impairments, language delays, and emotional and behavioral problems [9]. In India 60% of children who infected HIV through vertical transmission experience mental health problems such as anxiety disorders followed by ADHD, conduct disorders, oppositional defiant disorders and mood disorders [10]. Studies report that the mental health problems are higher among orphaned children with AIDS in both developed and developing countries [11]. The The rampant internalized problems among HIV-affected children are depression and anxiety [14,15]. A study conducted in southern part of India, found that compared to orphans without HIV, orphans with HIV has significantly higher level depression [16]. But, there is very less evidence about how HIV relates to Anxiety and Depression. Studies conducted among African children have found out that, in orphanages, the monitoring about HIV and psychosocial development are rarely happening [17].
The psychological process of depression is explained by Selfawareness theory [18] which says that loss of important sources of selfworth resulting from a discrepancy between actual and desired states of self. This creates a negative affects and depressive self-focusing style yielding to more and more negative effects. The current study proposes that among HIV-affected children increasing self-consciousness leads to the discrepancy between their actual self and desired self leading to depression. When they become older they become more aware of the physical and social risk and impact associated with HIV such as physical complaints, and stigma and discrimination associated with HIV and lack of adequate support and care from parents or caretakers. This may lead to thinking negatively and being anxious. In the light of Self-discrepancy theory proposed by Higgins [19], the assumption become much relevant and strong. According to Self-discrepancy theory, experiencing discrepancy between actual self, and ideal self and ought self, leads to disappointment, dissatisfaction and sadness. Keeping the support of Self-awareness theory and Self-discrepancy theory as the background, the current study checks two assumptions (1) increasing self-consciousness of HIV-affected children widens the gap between their actual self, and ideal and expected self; and (2) the

Abstract
The objective of the present study is to understand the relationship between self-consciousness and depression among HIV-affected children. Self-consciousness and depression among 70 HIV-affected children are assessed by using Self-conscious scale Revised and Depression self-evaluation scale for children respectively. Statistical analysis conducted by using Spearman's Rank correlation show that at that place are significant positive correlation between Age, self-awareness and depression among HIV-affected children. The multiple regression analysis shows that both self-awareness and age predicts depression among HIV-affected children.

Methods
The present study conducted in among HIV-affected children from four orphanages located in Begaluru, Karnataka, India. The ethical guidelines were recommended and approved by both the authorities of orphanages and Ethical research committee at Christ University, Bengaluru. The data collection was done with the consent of caretaker and children.

Sample size and selection of participants
A sample of 70 orphaned HIV-affected children belongs to the age group of 10 years to 16 were selected from orphanages run by four Non-Governmental Organizations (NGOs) located in Bengaluru, Karnataka, India. With the help of caretaker and orphanage authorities, the researcher collected 20-40 children were selected from four orphanages located. These children could understand the languages Kannada and Tamil and have spent minimum one year in the orphanage. All these children were pursuing their education in different standards ranging from 6 to 9 grades.

Data collection
First, the researcher earned the consent for each participant from their caretaker/guardian. Then, he approached the participants for their voluntary participation and established rapport. The researcher collected data from a group of 20-20 children and the children took 45-60 min minutes to give their responses. After their response session, each participant received a nominal gift as token for their support for the study.

Measures
Depression self-rating scale for children [20] measured depression among HIV-affected Orphan children exploring symptoms related to sleep appetite, pain, interest and mood. This 18 item rating scale has three response options yielding minimum zero and maximum two. The total score was calculated by adding up the items' score. The score equal or greater than 13 indicates the presence of depression. Validity and Reliability have been established for children 7-13 years of age [21].
The self-conscious scale Revised (SCSR; [22]) is a 22 item measure of self-consciousness which includes three sub-scales, namely; Private self-consciousness, Public self-consciousness and Social anxiety and carry four response options for every item ranging from Not at all like me (Score=0) to A lot like me (score=3). For the present study the selfconsciousness is the sum of scores of all sub-scales of self-conscious scale. The maximum possible score on this scale is 66 and the minimum possible score is zero. A higher score indicates a high level of selfconsciousness. This scale has reported adequate reliability and validity among adolescence and children [23,24].

Discussion
The objective of the present study was to understand the relationship between self-consciousness and depression among HIVaffected children and adolescents belong to the age group of 10years to 16 years. The correlation analysis found that not only self-consciousness (r s =0.65**) but also the age (r s =0.69**) of the HIV-affected children are positive related with their depression. The positive correlation between age and self-awareness (r s =0.57**) shows that as the children become older and older they become more self-aware. The multiple regression analysis found that not only self-awareness (β=25*), but also the age (β=0.56**) positive and predict (R 2 =0.55, F (2, 67) = 41.65, p<0.000) depression among HIV-affected children. These findings supports the assumptions which are based on Self-awareness theory [18] and self-discrepancy theory [19] Among HIV-affected children, the self/ consciousness/self-awareness growing out of knowing more about their Illness and illness effect, physical absence/ lack of parents, and stigma of social world; create a gap between desired (Ideal/expected) and actual self. This unsatisfied self might have led to lack of self-worth and selfdissatisfaction. Another notable phenomenon is that increasing age is also positive contributing to depression. This might be the indication of increasing self-awareness/ self-consciousness with age. The positive correlation between age and self-consciousness and depression, would be an indication of that.
But there are studies which reports resilience among HIV-affected children [25,26]. A study on HIV-affected reported gradual decrease in depression, negative self-esteem, and feeling of ineffectiveness [27]. Another study among high risk low-income adolescents found that the despite of the additional risk factors such as physical abuse, sexual abuse, and mal-treatment from own family members, the adolsecnets showed decreased anxiety and depression. This questions the role of age and self-consciousness alone in predicting depression. The protective factors such as social support, trusting relationship with care givers and individual coping skills may also be playing an important role [27]. In the present study the absence of these protective factors might have been additional risks for the participants for their increment level of depression along with age and self-consciousness, since the children were institutionalized due to the death of parents or lack of resourceful parents.