The death of a parent during childhood is traumatic, with a profound and potentially lasting impact on a child's psychosocial wellbeing (Li et al., 2008
). In addition to the developmental vulnerability normally faced by any child whose parents have died, experience with parental illness and death due to AIDS may create additional cognitive and social challenges. These challenges may further aggravate the grieving process among children who have lost parents or who face the potential of losing parents to HIV/AIDS, and may increase risk for psychological problems. In just 2 years, from 2001 to 2003, globally the number of children orphaned by AIDS (i.e., lost one or both parents to AIDS) increased from 11.5 million to 15 million (UNICEF, 2004
). By 2003, the number of children orphaned by HIV/AIDS worldwide was estimated at 15 million, of whom 12.3 million were living in sub-Saharan Africa (UNICEF, 2004
). The age distribution of orphans was fairly consistent across countries, with ~12% of orphans being 0–5 years old, 33% being 6–11 years old, and 55% being 12–17 years old. UNAIDS and UNICEF estimated that, based on the current trends, the number of AIDS orphans could reach 25 million by 2010 and 40 million by 2020 (Phiri & Webb, 2005
; UNICEF, 2004
Both qualitative and quantitative data from American and sub-Saharan African countries suggest that AIDS orphans (i.e., children who have lost one or both parents to HIV/AIDS) and vulnerable children (i.e., children living with HIV-infected parents) suffer psychological symptoms such as depression, anxiety, fear, anger, loneliness, social withdrawal, and hopelessness (Cluver & Gardner, 2007
; Cluver, Gardner, & Operario, 2007
; Rotheram-Borus, Weiss, Alber, & Lester, 2005
; Sengendo & Nambi, 1997
; Woodring, Cancelli, Ponterotto, & Keitel, 2005
). These symptoms vary in type and severity, but a common theme runs through many of these studies to suggest that negative psychological symptoms arise at the onset of parental diagnosis and persist after the parent's death (please see Cluver & Gardner, 2007
for a comprehensive review). However, it is widely acknowledged in the literature that the psychological health of children orphaned by HIV/AIDS has been under-investigated (Cluver & Gardner, 2007
; Li et al., 2008
). In addition, the geographic locations of the existing studies are disproportionately concentrated in inner cities of America and rural towns in sub-Saharan Africa. The condition of AIDS orphans in Asian countries has received little attention despite the rapid growth of the AIDS epidemic in many Asian nations and regions including China, which has experienced a rapid progression of the AIDS epidemic in the last two decades (Zhao et al., 2007
The China Ministry of Health estimated that there were at least 100,000 AIDS orphans in China by the end of 2004 (Zhao et al., 2007
). Many of the identified AIDS orphans live in Henan Province, an agricultural province in central China with a population of 96.66 million. The HIV/AIDS epidemic in remote areas of Hunan is believed to have originated in the 1980s due to the practice of selling blood for additional income by the farmers to governmental and commercial blood stations/centers in the region. The commercial collection centers pooled the blood of several donors of the same blood type, separated the plasma, and injected the remaining red-blood cells back into individual donors to prevent anemia. Such practices, along with the reusing of needles and contaminated equipment, contributed to the rapid spread of the virus through the local population.
Although many HIV-infected individuals in Henan Province and other HIV-epicenters in China progressed to AIDS and subsequently died, leaving their children orphaned (Ji, Li, Lin, & Sun, 2007
; Yang et al., 2006
; Zhao et al., 2007
), studies regarding the psychosocial adjustment of AIDS orphans and vulnerable children in China are limited. In an attempt to further our understanding of this outcome, we have developed a developmental psychopathology framework () hypothesizing factors leading to the psychosocial wellbeing of children orphaned or made vulnerable by AIDS (Li et al., 2008
Figure 1. Developmental psychopathology framework of psychosocial needs of children affected by HIV/AIDS, adapted from Li et al. (2008)
Culture is likely to influence bereavement and grief experience among children. The Chinese view of death and grief is largely rooted in the traditional Chinese collectivist culture, taking the perspective of the group (e.g., family, community, society) rather than the individual (Nisbett, 2003
). While this greater collectivism might protect Chinese children from the increased risk for trauma exposure observed among children in Western culture, there are certain aspects of the Chinese culture that may exacerbate the trauma of parental loss. These aspects include the greater emphasis in Chinese culture on interdependence, cultural expectation for children to control emotions that are considered to be adverse or disruptive to harmonious social interaction, social disapproval of any excessive expression of grief and mourning, and cultural norms against adoption of orphans by non-family members (Tseng & Wu, 1985
; Zhao et al., 2007
In addition to the general cultural and value orientation of Chinese population, some local characteristics of the AIDS epidemic could also impact the child's psychosocial wellbeing. One such characteristic is the mode of HIV transmission in central China, where the primary cause of AIDS is poverty-driven blood donation/transfusion. The high prevalence of HIV infection in this area due to such a mode of transmission could increase community tolerance of persons with HIV/AIDS and hence place less stigma on these individuals and on the children in their families, as compared with persons acquiring HIV through sex or intravenous drug use. In such instances of lower stigma, children could feel less isolated and distressed. On the other hand, it is equally possible that being from a village with a high rate of distress due to AIDS-related illness and death could heighten the risk of distress among these children.
In addition, the care arrangement for AIDS orphan in China may also affect their psychosocial adjustment. While the extended family (or kinship) care and community-based orphan care are the dominant strategies for orphan care in many African countries (Abebe & Aase, 2007
), China government has recently developed orphanages and small group homes as alternatives in response to increasing numbers of double orphans (West & Wedgwood, 2006
). Small group homes are usually managed by local residents who serve as “house parents” for a small number (four to six) of orphans in family style (e.g., the orphans would refer to house parents as “father” and “mother” and to each other as brothers or sisters). A previous study in China has suggested that children living in small group homes perceived better life improvement and reported greater life satisfaction than AIDS orphans living in AIDS orphanages or kinship care (Zhao et al., in press). Therefore, it is important to examine the impact of AIDS on the psychosocial wellbeing of Chinese children under these unique cultural influences and care arrangements.
Guided by the conceptual framework (), we assembled an array of scales designed to explore each of the putatively important constructs illustrated. Given the complexity of the process leading to the psychosocial outcomes of orphans and vulnerable children and therefore the size of the data required to develop a robust framework for understanding, we explored clusters of these data in a series of manuscripts. In this manuscript, we assess the psychosocial functioning (e.g., adjustment) of these children based on parent status (died of AIDS, alive living with HIV/AIDS, and alive without AIDS or known HIV infection). Future reports from this dataset will explore the developmental stage of these children, their bereavement and grief experience, and putative risk and protective factors.
Accordingly, the current study, utilizing the baseline data from a longitudinal assessment of psychosocial needs of children orphaned or made vulnerable by HIV/AIDS (i.e., facing the potential of losing a parent to AIDS), was designed to compare the psychosocial adjustment of AIDS orphans and vulnerable children with comparison children from the same community. In addition, we explored the differences of psychosocial adjustment between single orphans (children who lost one of their parents to AIDS) and double orphans (children who lost both of their parents to AIDS) as well as the differences by care arrangement (i.e., orphanage, kinship care, and group homes) among double orphans. We hypothesized that AIDS orphans and vulnerable children would have higher levels of psychological problems (e.g., depression, loneliness) and lower levels of psychosocial wellbeing (e.g., self-esteem, positive future orientation) than comparison children. We also hypothesized that care arrangements for double orphans would be associated with children's psychosocial adjustment, with double orphans in government-supported care settings (e.g., AIDS orphanage and small group homes) demonstrating higher psychological functioning relative to double orphans in kinship care.