An estimated 24.8% of South Africa's population are HIV+, with 4.7 million infected by 2001 [1
]. Numbers of children parentally bereaved by AIDS in South Africa are expected to rise from 1.1 million in 2003, to 3.1 million by 2010 [2
], peaking at 5.7 million in 2015. Even with the proposed full administration of anti-retroviral therapy, estimates remain at 1.15 million maternal orphans by 2015 [3
Orphaned children in South Africa have traditionally been cared for within the extended family [4
], often by elderly grandparents [5
]. There are concerns that this support system is weakening as orphan numbers and HIV prevalence increase [6
]. There are few reliable data on numbers of orphans living in non-kin fostering arrangements, institutions, child-headed households and as streetchildren [7
Most work on orphans concentrates on basic needs. This is understandable as AIDS-affected households are characterised by economic deprivation, often exacerbated by medical costs [6
]. Orphans frequently lack sufficient food, shelter, schooling and medical care, and are at risk of abuse and economic exploitation [8
There is little available research, but increasing concern, regarding the psychological well-being of orphans in Africa. Children orphaned by AIDS are exposed to multiple stressors which may compound and complicate the grieving process. They may have cared for and witnessed the death of parent/s with a debilitating illness, loss of bodily functions, and sometimes AIDS-related mental illness [11
]. AIDS can cause multiple losses, for example of mother, father and perinatally-infected younger siblings. Caregivers of orphans have been found to suffer poor psychological health themselves [13
]. South African orphans report that stigma and secrecy surrounding AIDS causes social isolation, bullying, shame, and a lack of opportunity to openly discuss their loss [15
]. Poor levels of AIDS-related knowledge and communication can lead to children being ignorant of the cause of death, or fearing that they will also be infected [16
Searches of literature on mental health for orphaned children found 10 unpublished studies and 6 published studies to date. Of these, 6 lacked a control group and 9 compared children parentally bereaved by AIDS with some kind of controls. There may be difficulties translating US studies to an African context, with differing support systems and characteristics of HIV-infected groups. There is also danger in assuming that studies conducted in one part of Africa are transferable to the South African context. This is the first quantitative study known to be completed in South Africa.
Studies in Africa
Sengendo and Nambi (1997) [17
] interviewed 169 orphans under the education sponsorship of World Vision in rural Uganda, and a comparison group of 24 non-orphans. On a non-standardised scale, orphans experienced more depression than non-orphans. Makame et al. (2002) in urban Tanzania, used a scale based on the Rand Inventory and items from the Beck Depression inventory, and found increased internalising problems and suicidal ideation in orphans (n = 41) compared with non-orphans (n = 41). Manuel et al. [13
] used a questionnaire based on Makame et al in rural Mozambique, and found orphans (n = 76) more likely than controls (n = 74) to be depressed and bullied, and less likely to have a trusted adult or friend. Carers of orphans showed more depression and less social support. Poulter (1996) interviewed carers in 22 Zambian households with orphans, 66 with HIV+ parents, and 75 controls. On the Rutter scales, carers reported orphans as more unhappy and worried than children with HIV+ parents, who were more so than controls. No clear link was found between distress and poverty, and there was no evidence of conduct problems [18
]. Wild, Flisher, Laas and Robertson [19
], in the Eastern Cape of South Africa, used standardised questionnaires with orphans (n = 80) and both other-orphan and non-orphan control groups, and found that children orphaned by causes other than AIDS reported more depression, anxiety and lower self-esteem than non-orphans, with children orphaned by AIDS falling between the two groups. In rural Uganda, Atwine, Cantor-Graae and Banjunirwe [20
], used standardised questionnaires (Beck Youth Inventory) with 115 orphaned children and 110 matched non-orphaned children. Orphans had greater risk of anxiety, depression and anger.
Two further, unpublished, studies found in Africa, were unable to be accessed. A mention of Gelman [21
], in Zimbabwe, reports only the finding that existing Western psychometric tools could not be validated. An interim report of Elmore-Meegan et al (ongoing) in Kenya, describes a multi-centre study using an adaptation of the Achenbach CBCL. Preliminary results suggest more depression and stress amongst orphans.
Non-controlled studies in Africa include Foster, Makufa, Drew, Mashumba & Kambeu, (1997) in rural Zimbabwe. In focus-groups, orphaned children (n = 40) reported anxiety, fear, stigmatisation, depression and stress. Nampanya-Serpell [22
] used structured interviews with families of rural and urban Zambian orphans, and found emotional disturbance related to separation from siblings and increased family size. Volle et al. [23
] interviewed 788 orphans in Zambia. 89% reported unhappiness, and 19% running away from their new homes. Makaya et al. (2002), used clinical interviews with 354 Congolese orphans, and found 20% experiencing psychological difficulties, including depression, anxiety and irritability (34%), fugue, offending and hyperactivity (27%), and PTSD (39%).
Studies in the USA
In New York, orphans (n = 30) reported more peer and externalising problems on standardised instruments, than children with HIV+ parents (n = 29) [24
]. Another New York study [25
], using longitudinal assessments with standardised instruments, found that bereaved children reported more emotional distress and problem behaviours than children whose parents were alive and HIV+.
The Family Health Project [27
] used standardised instruments with 20 maternal orphans and 40 non-orphans. Affected children were assessed pre-orphanhood, and at 6 months after bereavement. Children of HIV+ mothers showed more internalising and externalising problems, and lower cognitive and social competence than controls. 6 months after orphanhood, there were non-significant improvements, and authors suggested that this may be related to increased stability and wealth amongst new caregivers. However, at 2 years, orphans showed higher levels of internalising (but not externalising) problems. Hirsch [29
] compared 16 maternal orphans by AIDS and 18 'other' orphans, and found higher depression, anxiety and conduct problems, on standardised scales, amongst children orphaned by means other than AIDS.
The limited research suggests the possibility that orphans may be experiencing higher levels of internalising and, to a lesser extent, externalising problems. These studies, combined with qualitative research on orphan well-being, also hint at more specific areas of difficulty. Makaya (2002) reported high levels of PTSD amongst Congolese orphans, and studies have linked childhood PTSD to traumatic parental death, especially the witnessing of that death [30
] Orphans have reported difficulty concentrating at school, due to worries, sadness or tiredness [27
]. Concentration problems may be linked to post-traumatic stress, as could anecdotal reports of recurrent nightmares. Literature also suggests somatic symptoms [34
], which may be a useful indicator of distress amongst children in South Africa [35
]. Finally, friendship difficulties related to stigma have been found in both qualitative [9
] and quantitative studies [13
This study was conducted at the request of the Cape Town Child Welfare Society. Little is known about the effects of orphanhood in urban South Africa. Studies show multiple stressors of violence and poverty common to all township children, but there may be additional difficulties for parentally bereaved children in these communities. Furthermore, there is a clear need for further studies using both matched non-affected control groups, and standardised instruments, to test hypotheses suggested by the literature to date.
We hypothesised that children who were orphaned by AIDS would show a higher incidence of psychological difficulties than a non-orphaned control group from the same community. Specific areas derived from the literature include difficulty with concentration, friendships, traumatic and somatic symptoms.