HIV/AIDS orphans in South Africa: NGO interventions supporting transitions to alternative care

Abstract

By 2015, an estimated 2.3–4.8 million children will be orphaned due to AIDS-related illness. Limited information is available on the emotional and behavioral problems that AIDS-orphaned children experience. This qualitative study explores 49 orphaned children who were observed in a non-governmental organization group setting in a small, rural village located in Eastern Cape, South Africa. Of the children in this study, 20 were orphaned due to AIDS. However, 19 children were orphaned due to parental death with an undeclared cause, but the deaths are believed to have resulted from AIDS.

Keywords

Emotional and behavioral HIV/AIDS non-governmental organizations orphans parental loss South Africa

Introduction

In 2011, the residents of a small, rural village in the Eastern Cape, South Africa (SA), informed the staff of the local non-governmental organization (NGO) about several orphaned children who required services. The NGO developed and implemented services for the orphaned children and their caregivers. Later in 2011, a social work practicum exchange student from a Midwest university in the United States (Midwest U) together with the NGO staff recorded information regarding these children. The data collected were the children’s demographic information (e.g. age, grade, gender, and date of birth) and current caregiver information (e.g. relationship to child and place of employment). Additional information was gathered regarding family history (e.g. parental cause of death, current living situation of child and caregiver, and information about the orphan child’s living relatives). Data collectors recorded the orphaned children’s stated feelings and observed behaviors for the purpose of programming within the NGO.

This article puts forth a literature review of issues that orphaned children in SA might face. The qualitative methodologies of observational data collection and analysis of the data, along with qualitative findings, are included. The issues addressed in this research, although they may not be new to practitioners working with orphans, point out the importance of working in connection with communities, caregivers, and orphans. The needs of the orphans are stability with caregivers, socialization, education, and economic and emotional stability, along with socially acceptable behavior.

Literature review

Thousands of children in SA lose a parent due to tragic deaths such as murders, accidents, or suicide every year. However, a high prevalence of parental deaths is related to illnesses, specifically AIDS. The HIV/AIDS pandemic has left millions of children in SA orphaned. In 2011, 2.01 million children were orphaned as a result of AIDS-related deaths (Statistics South Africa, 2011). The Eastern Cape Province has the second highest number of orphans in SA at 26 percent, while KwaZulu-Natal leads the country with the highest rate of orphans at 27percent (Meintjes and Hall, 2012). Without interventions, between 3.6 and 4.8 million children in SA will be orphaned due to HIV/AIDS-related illnesses by 2015 (Bradshaw et al., 2007).

No universal definition for the term ‘orphan’ is used in SA. For the purpose of this research, the term ‘orphan’ will be defined as follows:

A child under the age of 18 years old.

Maternal Orphan: A child whose mother has died, but the father is still living.

Paternal Orphan: A child whose father has died, but the mother is still living.

Double Orphan: A child whose mother and father have both died. (Meintjes and Hall, 2012: para. 2)

The emotional distress of parental death for children is extensive. However, the literature supports the argument that parental death related to HIV/AIDS has an even greater impact on the children. Research related to the mental health consequences for South African children or any child orphaned by HIV/AIDS has not been investigated extensively (Cluver et al., 2012). The research is limited to a 2-year period post-parental death, and the lasting psychological distress is not well documented (Cluver et al., 2012). However, Cluver et al. (2012) discovered that orphaned children, as a result of parental death due to AIDS, had higher rates of depression and posttraumatic stress disorder (PTSD) compared with children who were not orphaned or children orphaned due to factors other than AIDS. Likewise, these findings were supported by Kirkpatrick et al. (2012), who found that children left parentless due to HIV/AIDS have higher rates of depression, anxiety, and anger.

In addition, children experience higher rates of stress as a result of parental death, along with environmental factors such as community and individual poverty, numerous children in the home, and limited access to school fees, medical care, and basic daily necessities. Orphaned children in SA are generally cared for by extended family members following the death of one or both parents or when the whereabouts of their remaining parent is unknown. Frequently, the orphaned children are cared for by a grandmother who is elderly and experiencing health complications of her own or has limited financial resources (Kiggundu and Oldewage-Theron, 2009).

The financial burden experienced by the caregiver is extensive and the children may not have access to basic needs, such as food and clothing (Freeman and Nkomo, 2006). The unemployment rate in the Eastern Cape is extremely high. The South African government provides social security in the form of Foster Care or Child Support Grants, which are dispersed to caregivers to alleviate some of the economic difficulties associated with raising orphaned children. Despite these limited funds, poverty remains a serious factor that affects orphaned children not only after a parent’s death but also prior to the death of a parent. HIV/AIDS-infected families frequently have higher rates of medical costs and debt related to parental convalescence. Andrews et al. (2006) reported families affected by HIV/AIDS have more economic difficulties due to the mounting medical costs. In addition, HIV/AIDS-related families spent four times more income on medical expenses than households not infected with HIV/AIDS (Andrews et al., 2006). The children may be more likely to drop out of school to help care for an ailing parent or obtain employment to assist in household expenditures.

Furthermore, orphaned children who live in poverty and have lost a parent due to HIV/AIDS-related illness are more likely to have decreased coping mechanisms. AIDS-orphaned children living in poverty may experience higher rates of grief related to parental death (Cluver et al., 2009b). In their research, Cluver and Gardner (2007) also found that poverty was highly correlated with the risk factors for emotional and behavioral anguish among participants.

The South African government has attempted to ease the burden by offering caregivers Child Support and Foster Care Grants to help ease the costs associated with caring for an orphaned child (Ardington et al., 2009). According to the South African Government Services (SAGS, 2013a), Child Support Grants are allotted to a person who is the children’s primary caregiver and can provide an identity document along with the child’s birth certificate. Child Support Grants are approximately R290 per month (SAGS, 2013a).

Caregivers may also receive a Foster Care Grant for a child who has been abused, neglected, orphaned, abandoned, or is at risk (SAGS, 2013b). The amount caregivers receive for Foster Care Grants is significantly higher at R800 each month (SAGS, 2013b). Foster Care Grants and Child Support Grants may offset some of the burden associated with caring for an orphaned child, yet it may not be sufficient to save orphaned children and caregivers from poverty. In addition, it may be difficult to obtain the grants due to the need to supply the child’s birth certificate, the caregiver’s identification documents, or the parents’ death certificates, which may not be readily available if they were not registered with the government’s Department of Home Affairs.

The significance of this research is multidimensional; frequently, NGOs are faced with crises that require immediate attention with little time to formally develop, plan, and implement interventions. It is important in these situations that the NGOs develop interventions with local communities, orphans, and their caregivers. The NGO in this study developed intervention strategies, which included listening to community members and assessing the needs of the orphans and caregivers.

Purpose

This research analyzed archival data from the NGO that were collected in 2011 by NGO staff and a social work practicum student. This qualitative research was completed in an attempt to discover risk and protective factors provided by the data collected in order to assist the NGO in the development of services that best meet the needs of orphaned children.

The purpose of this qualitative study was to address the impact of parental death/absence on orphaned children, with emphasis on those who experience parental death/absence due to HIV/AIDS-related death. This study evaluated the effectiveness of the NGO’s programs through an analysis of the historical data, observational behaviors, and reported emotions of the 49 orphans. An assessment of the caregiver relationship for the orphaned child and the means of financial support for the child (e.g. Foster Care Grants, Child Support Grants, Old Age Pensions, employment) were also explored.

NGO’s intervention strategies

Due to the rising number of orphaned children in the community, the NGO recognized the need for a different approach that addressed the needs of the orphaned children. Therefore, a specialized intervention model was developed and utilized by the NGO due to the complexity of the orphaned children’s needs compared with other children involved in the organization. This intervention model was developed by the NGO director and staff through individual meetings with each orphaned child and his or her caregiver to gain an understanding of the child’s, as well as the family’s, specific needs. This systematic approach not only led the organization to the individual needs of the child and family, but also created a roadmap of the educational needs of the caregiver, as well as the community. Through the NGO’s assessments and interviews, the staff observed that a majority of the children exhibited socialization challenges. As the observations data demonstrate, the children were on a continuum, which ranged from isolation and interpersonal withdrawal to acting out aggressive behaviors. Following staff observations and interviews with the children and caregivers, the data collected and recorded consisted of children’s behaviors, answers to the interview questions, and answers solicited within the group settings. The children’s questions focused on the topics listed below. Some of the children were unable to answer the questions, in which case the caregiver provided the answers. The children’s’ assessment questions focused on the following:

demographic information (name, age, and location of home);

reasons for parental death;

safety (child’s feelings of safety in the home, school, NGO, and community);

child’s hygiene;

schooling (child’s last attended grade);

general health and specific health issues, such as being tested for tuberculosis (TB) and HIV.

Along with the children’s assessment, the NGO staff assessed the caregivers through interviews, which were recorded by staff. The caregivers’ assessment covered the following areas:

demographics of the people living in the home;

how the caregiver became responsible for the orphan and the length of time;

whether the caregiver had applied for grant monies to care for the orphan;

illness the orphans might have experienced and care received;

the caregiver’s income or household income;

the level of safety in the home and community felt by all members of the home;

the caregiver’s worries for the orphan(s).

After reviewing the orphans’ and caregivers’ aggregated responses, the NGO director searched the literature for programming that would address the individual child’s needs, the orphans as a whole, as well as the caregivers’ needs and the provision of education to the community at large.

The director assigned staff to meet with the children on an individual basis. These meetings focused on the child’s basic necessities such as food, clothing, safety, and other developmental needs. In addition to the individual interviews with staff, each orphaned child attended group programming. The director divided the orphans into age-related groups for the purpose of cognitive functioning and age-specific interventions. The groups followed the program, which was modified by Dr Beverly Killian from Dr Kurt Madorin’s original manual. Dr Killian’s manual is entitled ‘A Structural Group Therapy Programme for Vulnerable Children Affected by HIV/AIDS, Poverty and Violence’ (n.d.). The caregivers also attended weekly psychoeducational group meetings and received a package of food each week. Community educational meetings were held monthly to increase awareness of the growing number of child orphans within the community and community engagement as change agents to assist with not only the orphaned children’s needs, but also their psychoeducation on topics such as AIDS, sexually transmitted diseases, increasing violence, community participation, and resources. These educational meetings provided were curriculum based with the desired outcome of acceptance for the children who were orphaned, as well as increased community awareness of the events leading to the crisis of the increasing number of orphaned children.

Research methodology

In May 2011, the NGO learned from community members that services were needed for 49 orphaned children in their village. In order to facilitate the development of programming and the most appropriate intervention strategies, the NGO recognized the importance of collecting information about the children first.

In August 2011, the social work practicum student and NGO staff collected historic information, reasons for parental death or absence, and caregiver demographics, and began observations of the 49 orphaned children’s behavior and emotions during support group sessions. The children were divided into the NGO’s program intervention groups based on age and observable social behavior. There were five intervention groups: the first group had seven participants from the ages of 4 to 7 years. The second group had 12 participants; the ages were 7 to 9 primarily, with two siblings under the age of 7 due to attachment issues. The third group consisted of 14 participants with 9- to 13-year-olds. The fourth group with 11 participants was composed of 11- to 12-year-olds. There was an overlap in ages between the third and fourth group. This age overlap was based on the children’s individual behavior, trauma-related anxiety (separation anxiety associated with siblings), and the children’s cognitive abilities. The fifth group had five members and consisted of 15- to 16-year-olds. Ultimately, these five different support groups ran for 8 weeks. The 8-week curriculum consisted of individual behavior within orphans’ environments. The topics covered bullying, peer empathy, homework, hygiene and basic day-to-day life skills, violence, AIDS, and altruism. The orphans attended the groups after school twice a week for 3 hours, which included supper. Some of the orphans were involved in sports and other activities such as football (soccer), netball, sewing, dance, leadership, and religious interests.

Information about each child and the current caregivers was collected as part of the group work process. Post-intervention observational data were recorded for the remaining 2 weeks during the last group sessions. These observational data were then analyzed in order for them to develop the final intervention plan for each child.

The NGO requested additional data analysis of the collected information in 2012. The researchers removed any identifying information of each participant’s historical information and observational data to ensure that the information could not be traced back to the participants. A description of the findings follows.

Findings

Researchers conducted this study using an interpretative phenomenological analysis (IPA) process (Smith et al., 2009), which was used to investigate the observation and historical data of the orphaned children. The IPA method explored the impact of parental death on orphaned children and was used systemically to discover and separate the themes within qualitative data by identifying the similarities and differences among the children. The findings of this research were not used to analyze individual responses; rather, key words or partial sentences were analyzed. The researchers sought to understand the historical information in conjunction with observational data to determine level of adjustment to the loss of the parent(s).

Through the use of IPA, the researchers discovered marked differences between the 20 children whose parents died of AIDS, along with the 19 whose parents died of undeclared causes (believed to be AIDS-related), in comparison with the 10 whose parents died of other known causes (not AIDS-related). The 39 children whose parent’s death was either known to be from AIDS or believed to be AIDS-related displayed more emotional stress in the initial observations than the other 10 children whose parents had died from non-AIDS-related causes.

Participants

Based on gender, there were 24 males and 25 females ranging from 4 to 16 years of age, who resided in a small, rural township (also known as an informal settlement) in the Eastern Cape (Table 1). The children were considered orphans due to the death of their mother or father (92%), parental abandonment or unfitness to care for child (6%), and ‘other’ (2%). Of these 49 orphans, 17 female children’s parents had died of either AIDS or undeclared causes. Of the total 24 male children, 22 had parents who had died from AIDS or undeclared causes.

Table 1.

Gender of orphaned children.

Gender	Frequency	Unknown parental death	AIDS parental death	Abandonment or other known causes of parental death
Female	25	7	10	8
Male	24	12	10	2
Total	49	19	20	10

The mean age of participants was 9.28 years. The highest rate of participants was between the ages of 8 and 10 years (36.73%, n = 18). Participants from 5 to 7 and 11 to 13 years of age were statistically equal at 24.49 percent (n = 12). The ages of three orphans were unknown (Table 2).

Table 2.

Age of child during sampling.

Age of child (years)	Frequency	Unknown parental death	AIDS parental death	Abandonment or other known causes of parental death
4	1	0	0	1
5–7	12	2	6	4
8–10	18	5	9	4
11–13	12	7	2	3
14–16	3	1	2	0
Unknown	3	1	2	0
Total	49	16	21	12

Table 3 illustrates the orphaned children’s current education level. The children’s ages varied within a specific grade level. For example, one 9-year-old child was in Grade 1, while another 9-year-old was in Grade 4. Of the 49 orphaned children, 20 children’s current grade status was unknown. Of the 20 children whose grade is unknown, 10 did not know why their parents had died and 6 of the children’s parent(s) had died of AIDS. Of the two children not attending school, one child had an unknown parental death and the other child’s parent(s) had died of AIDS. One child was expelled from school, and their parental death was unknown to them.

Table 3.

Current grade of orphaned children.

Grade	Frequency	Unknown parental death	AIDS parental death	Abandonment or other known causes of parental death
Preschool	6	2	2	2
Grade 1	10	1	6	3
Grade 2	6	2	2	2
Grade 3	2	1	1	0
Grade 4	1	1	0	0
Grade 6	1	0	1	0
Not attending	2	1	1	0
Expelled	1	1	0	0
Unknown	20	10	6	4
Total	49	19	19	11

Extended family members were identified as the primary caregiver after parental death to the orphaned children. Grandmothers (36.71%) and aunts (34.67%) have provided the highest rates of care (71.38%) to orphaned children after parental death. NGO staff were caregivers to 12.24 percent of the orphaned children (Table 4).

Table 4.

Current caregivers’ relationship to child.

Caregiver’s relationship to child	Frequency	Percentage
Mother	1	2.05
Father	1	2.05
Uncle	1	2.05
Cousin	1	2.05
Sibling	2	4.09
Foster mother	2	4.09
NGO staff	6	12.24
Aunt	17	34.67
Grandmother	18	36.71
Total	49	100.00

NGO: non-governmental organization.

A child is considered to be a paternal orphan or a maternal orphan when one of the parents is deceased. For example, one child whose mother had died from AIDS was living with their father and another whose father had died from AIDS was living with their mother. In both cases, these children were in need of additional support.

Cause of parental death/absence

Of the 49 children and 98 biological parents (two parents per child), 47 children had at least one deceased parent (two of these children were double-orphaned, equalizing 49 deceased parents). At least one parent had abandoned their child in 12 cases, 34 children had unknown fathers, and 3 children had at least one parent absent from their life.

A total of 47 children had at least one deceased parent (two children were double-orphaned) and 42 children had experienced maternal deaths. Of the 42 maternal deaths, 38.78 percent (19) had died of HIV-related illness, 28.58 percent (14) of an unknown illness, and 10.20 percent (five) due to a tragic death (i.e. suicide, murder, or fire). The maternal statuses related to the orphaned children are displayed in Table 5.

Table 5.

Maternal status related to orphaned child.

Mother’s status	Frequency	Percentage
Mother not deceased	1	2.04
Absent	4	8.16
Maternal tragic death	5	10.20
Maternal abandonment	6	12.24
Unknown illness-related death	14	28.58
HIV-related death	19	38.78
Total	49	100.00

Table 6 illustrates the results of paternal death. Paternal whereabouts were unknown for 34 (69.39%) out of the 49 orphaned children. Six (12.24%) of the children had a known father, but the father had no contact with the child. Of the 49 children who had at least one deceased parent, two children were double-orphaned and seven (14.29%) children had experienced paternal death. Of the seven paternal deaths, one (2.05%) father had died due to HIV-related illness, five (71.43%) of an unknown illness, and one (2.05%) as result of a tragic death (e.g. suicide, murder, or fire).

Table 6.

Paternal status related to orphaned child.

Father’s status	Frequency	Percentage
HIV-related death	1	2.05
Paternal tragic death	1	2.05
Father lives with child	2	4.09
Unknown illness-related death	5	10.20
Father has no contact with child	6	12.24
Father’s whereabouts unknown	34	69.37
Total	49	100.00

Themes

Researchers identified four themes within the observations and historical data. These themes included the following:

Expressed and observed bereavement of parent’s death/absence was displayed by 29 (59.18%) of the respondents.

An increased need for physical or tactical attention was observed in six (12.24%) of the orphans.

Negative behavior was observed in 35 (71.43%) children at the beginning of the NGO interventions.

A total of 34 (69.39%) of the children demonstrated improvement at the end of NGO intervention.

Children’s observed behavior in the beginning of NGO intervention

Table 7 illustrates the children’s observational and expressed bereavement of parental death/absence. NGO staff recorded 29 (59.18%) out of the 49 orphans’ feelings related to maternal and/or paternal death. Some of the children discussed more than one emotion, therefore the total number of recorded emotions is 85 for 29 children. Results showed that 17 (58.62%) children displayed sadness when asked or they talked about the death or absence of the parent(s) (‘Child is sad about the loss of his/her mother’). Eight (27.59%) children cried when discussing parental death (‘Child cries when you ask him/her about mother and appears to be very sad’).

Table 7.

Bereavement of parental death/absence.

Orphans’ feelings regarding parental death	Unknown parental death	AIDS parental death	Abandonment or other known causes of parental death
Sadness	5	7	5
Cried	3	5	0
Not aware of parental death	1	3	0
Guilt	2	1	0
Refusal to talk about parental death	3	4	2
Denial	1	3	1
Angry	5	7	7
Worried	1	0	2
Haunted	0	0	1
Scared	0	1	1
Ran away from caregiver	1	1	0
Blames others	1	0	0
Shyness	0	4	2
Isolation	3	1	1
Total	26	37	22

Results identified that four (12.05%) of the children were not aware of his or her parent’s death (‘Child doesn’t understand that the child lost his/her mother, child thinks his/her sister is the child’s mother’). Three of the four children’s parent(s) died of HIV and the remaining child’s parent(s) died of unknown causes.

Three (9.38%) children displayed guilt over parental death (‘Child has guilt he/she holds within him/herself for not moving home with child’s mother when she was sick and letting her die alone’). Of the children who expressed extreme guilt, two children’s parent(s) died of unknown causes and one died of AIDS.

Refusal to speak about parental death was a factor for nine (31.03%) of the children (‘When asked about his/her mother, child will state that his/her mother is dead, but will not talk about it’). The parents of seven of the nine children who refused to speak of parental death had died of either unknown causes or AIDS. Five (17.24%) children were in denial about their parent’s death (‘Child was in denial about his/her mother’s death’). Of the children who denied parental death, four parents had died of either AIDS or unknown causes.

Nineteen (65.52%) of the children’s emotional reaction to parental death was anger (‘Child was angry after father died; now is moody’). Seven children expressed anger toward others whose parents had died of unknown causes and HIV. Worry was displayed by three (10.34%) children (‘At first, child was worried and sad he did not get new clothes’). A house fire haunted one (3.45%) child (‘The accidental fire was haunting Child 1’). Feeling scared was the emotion of two (6.90%) children (‘Child was scared; he doesn’t really interact with other children’). Two (6.90%) children ran away from current placement (‘Child would run away from her father’s house’). One child whose parent had died of an unknown cause blames other people for parental death. Five children frequently isolated themselves or withdrew from the other children. Four of these five children’s parents had died of either unknown causes or AIDS. Six children displayed extreme shyness. Four of these children’s parent(s) had died of AIDS.

Touch and affection

The NGO staff noted or observed that at least six (12.24%) out of the 49 children required more physical or tactical attention in the form of hugs and other types of touching (‘Child enjoys personal interactions like hugs and communication’). Of the six children, 33.33 percent of their parents had died of HIV and one of a communicable disease, TB, making a total of 50 percent. Three (50%) out of the six children needed affirmation that they are loved (‘Child likes knowing you love him/her’). At least one child was concerned that his favorite NGO staff member would worry about him or her while the child was away from the group (‘If child misses group at NGO, child worries NGO worker will wonder where he/she is’).

Satisfaction with current caregiver

Orphaned children verbalized that they were happy with their current caregiver in eight (16.33%) out of the 49 children. Of the eight children, many expressed different types of happiness for a total of 10 different ‘happiness emotions’. At least two (27.2%) of the eight children living with NGO staff reported being happy (‘Within the foster home, child is happy’). One (1.0%) of the eight children expressed happiness in his or her current home because child enjoyed washing clothes and doing chores (‘Child enjoys helping his/her granny, he/she likes to fetch water and wash the socks’). Six (60.0%) of the eight children verbalized they were happy because of the relationships within the home (‘Child is showing signs of happiness now that child lives with NGO staff’). In addition, one (1.00%) child expressed happiness because he/she felt a sense of security in foster care (‘Child always shows signs of happiness now that he/she is staying at NGO; child has a sense of security’). There appears to be no connection between children orphaned due to AIDS or unknown causes and satisfaction living with current caregiver. Of the eight children who reported being happy, only two were had experienced AIDS-related parental death, three parental deaths were unknown, and three parental death causes were known.

Child improvement with NGO intervention

The NGO interventions consisted of cognitive behavioral strategies at small group and community levels. In the small groups, the NGO provided age-appropriate psychoeducation instruction on topics such as individual behavior within the home, school, and community environments. The small group facilitators developed group activities, which focused on domestic violence, community safety, bullying and peer empathy, AIDS, completion of school assignments, age-appropriate community involvement, and altruism. Altruism was addressed through the establishment of each child’s development of individual responsibility to family, peers, and community members. At the community level, the caregivers were provided with psychoeducational instruction on issues that the orphans may have to address at school or within the community. The psychoeducation information focused on the education of the caregivers on topics such as the rights and financial benefits of the orphans and caregivers, advocacy skills, dietary needs of the orphans and provision of additional food for the caregiver’s family, fiscal management, domestic violence, education and awareness of HIV/AIDS, and age-appropriate child discipline that shifted away from corporal punishment.

The post-intervention observations were recorded from 30 October to 15 November 2011. The researchers recognize that this 2-week post-observation is short in duration. However, the observations were completed over 4–5 hours per day for 2 weeks. The observer had limited access to the children and only was able to complete post-observation after the interventions had been implemented. The post-intervention observations found that 35 out of 49 (71.43%) orphaned children had shown signs of improvement with the NGO’s interventions. At least 14 (28.57%) children interacted and played in group activities (‘Child likes to play with other children and participates in all group activities’). Expression of self was displayed by 14 (28.57%) of the 35 orphaned children (‘Child is getting better and being able to express him/herself through words and play’). Seven (14.29%) children reportedly ‘behaved’ well in a group (‘Child has good behavior in the group; child is friendly to other children’).

Discussion

Grief and loss

Parental death is emotionally traumatic for a child, despite the cause of death. On average, a child’s intense grieving process may continue for 2 years (Black, 1998). While a majority of children will experience emotional distress related to parental death, most are able to adjust to and cope with parental death after a grieving process (Webb, 2010). The literature suggests children orphaned due to HIV/AIDS have higher rates of psychological, emotional, and behavioral problems than non-AIDS orphaned children (Cluver and Gardner, 2007; Cluver et al., 2012; Kirkpatrick et al., 2012; Lester et al., 2006). This research supports the concept that children orphaned by AIDS or unknown causes initially have greater difficulty coping than children who have been orphaned by known causes of parental death. The grieving process lasts longer for children orphaned due to AIDS (Watts et al., 2010). Orphaned children in this study illustrated high rates of grief and loss associated with the death of his or her parent(s) through mood changes, aggressive behaviors, and observed bereavement. According to the literature, the children’s behavior is a normal reaction to parental loss. Still, the literature recommends that children who have suffered parental loss will benefit from grief support group membership (Wood et al., 2006). The literature also confirms that children who live in poverty, lack support within the educational system, or have limited access to basic health care experience prolonged grief and emotional instability (Cluver and Orkin, 2009).

Attachment of orphaned children

A majority of the orphaned children in the study were under the age of 13 at the time of data collection (87.56%). Children suffering the loss of a parent at an early age are at increased risk of attachment disorders (Papalia et al., 2009). Children whose parents die as a result of an HIV/AIDS-related illness are more likely to develop behavioral, emotional, and psychological problems (Watts et al., 2010). Approximately half of the 49 orphaned children (55.10%) experienced parental death before 8 years old. In addition, six of the children in the study had a parent who died due to a traumatic event, and one child experienced dual parental death as a result of a home fire. Domestic violence was witnessed by two of the six children before the maternal death, and murder or suicide of the mother was witnessed by three of the orphaned children. Three of the orphaned children experienced an additional death of the second caregiver (i.e. the mother died, and the grandmother, who was the primary caregiver after maternal death, died at a later date).

Attachment is a vital element of child development and helps shape relationships into adulthood (Papalia et al., 2009). Inadequate or loss of attachment in the early stages of development may alter a child’s perception of interactions throughout their life (Van der Kolk, 2005). Secure attached children develop a trust of individuals and the surrounding environment he or she may rely on (Papalia et al., 2009; Van der Kolk, 2005). Children with a secure attachment are more likely to have the ability to develop a healthy sense of self, trust in responsiveness of others, stable relationship bonds, and discuss his or her feelings appropriately with his or her own words (Fairchild-Kienlen, 2001; Van der Kolk, 2005).

Children with insecure attachments (i.e. avoidant, resistant/ambivalent, or disorganized–disoriented attachment) are more likely to exhibit mistrust issues; be more fearful; have higher levels of stress and higher rates of fight/flight/freeze responses; exhibit an unhealthy sense of self, aggression, and an inability to properly express emotions; and express dissociative behaviors (Papalia et al., 2009; Van der Kolk, 2005). Individual treatment and/or small groups may be beneficial for orphaned children. In addition, high rates of NGOs, educational systems, and social services in SA and other countries terminate the helping relationship when the adolescent is viewed as an adult (Cluver et al., 2012).

Education

The average age of orphan participants in this study was 9.28 years. The average grade of participants who were attending school was Grade 1, with a mean grade of 1.65. Approximately 42.86 percent of orphaned children’s current grade was unknown. The average age of South African children starting Grade 1 is 6 years (Statistics South Africa, 2009). The mean age of participants in Grade 1 in this study was 8.18 years. Children who have parents who die or are absent from the home have high rates of falling behind academically or dropping out (UNICEF, 2006). The children often fall behind educationally before parental death is experienced. Children who have ill parents, specifically HIV/AIDS-related illnesses, may need to drop out of school or fall behind due to caring for an ailing parent (Andrews et al., 2006).

Children also leave school due to the AIDS stigma, need for additional household income, or to provide child care to younger children in the household (Bicego et al., 2003). Further research has shown that orphans are less likely to be enrolled in school or in the age-appropriate grade level than children who are not orphaned (Kurzinger et al., 2008). Educating caregivers on providing a learning atmosphere at home for the orphaned children might help the child stay up to date with schoolwork (Loening-Voysey and Wilson, 2001).

Economic growth and household progression is obtained through a child’s education (Bicego et al., 2003). Without a proper education, orphaned children may be at higher risk of poverty and may be less knowledgeable about the impact of AIDS and the need for protection. Assisting in helping the caregivers to understand the importance of continued education could help improve the child’s attendance and completion rate in school.

Studies have shown that as HIV/AIDS-orphaned children age and move into adolescence and adulthood, psychological problems heighten and intensify (Cluver et al., 2012). Supplying orphaned children as they age with access to support groups may be a way to alleviate some of the surfacing emotional issues and curve any self-destructive behaviors or deviance that may result from the surfacing emotions.

Environment changes may be difficult for children to adjust to in their new surroundings. Children often have to move from their home to a new family home, adapt to different patterns of living and new schedules, and may need to adjust to additional children within the home context (Pharoah et al., 2004). Furthermore, children who move to new families may be moving into an environment that is more impoverished; the child may not have access to the necessities they had before the parental death (Cluver et al., 2009b). They may have better coping mechanisms when provided with caregivers who are responsive for the child’s needs and a nurturing environment (Ogina, 2012). Helping children cope with the new adjustments and environment could help the child fit into the family setting more effectively. In addition, educating the caregiver on providing a nurturing environment for the child could help alleviate stressors within the family unit.

PTSD-related trauma associated with orphanhood

SA has one of the highest rates of violence in the world. A report by the Overseas Security Advisory Council (OSAC, 2012) stated that several cities in SA (e.g. Johannesburg, Cape Town, and Pretoria) are rated on a scale from ‘low’ to ‘critical’ in reference to crime. Children in SA who are exposed to violence within the community and to family violence have higher rates of PTSD (Cluver et al., 2009a).

Six children (12.24%) in this study experienced the traumatic death of a parent. Two of the female orphans show signs of PTSD within play. Both children illustrate anger and aggression toward boys in the group during periods of playing house. This may be the child’s way of reenacting the trauma the child experienced related to the parental death. All six of the children displayed one or more symptoms of PTSD such as anger, refusal to talk about the event in group, aggression, sleep disturbances, and/or emotional distress related to the event (Suliman et al., 2005).

Satisfaction with current caregiver

Eight of the 49 orphaned children expressed feelings of happiness and/or safety in their current living environment. The remaining 41 orphaned children may be having difficulty adapting to the current environment and/or the environment may need additional support for the child. For an orphaned child to reach optimal development, he or she needs to be supplied with a support atmosphere (Pharoah et al., 2004). If a child is in a setting he or she does not view as nurturing or supportive, the child may be more likely to view the environment as uncaring and/or threatening (Pharoah et al., 2004). In addition, a child needs to have a strong connection with the mezzo system and have an outlet for help within the family and/or community (Pharoah et al., 2004). Providing outside community support can help the child understand that he or she is cared for and social isolation may be avoided.

Strength-based perspective

The HIV/AIDS orphan epidemic appears to be the responsibility of those at a community level. Community individuals and NGOs are typically the response team for orphaned children (Pharoah et al., 2004). Among the most effective interventions for orphaned children, especially children affected by HIV/AIDS, are groups supplied to the children by NGOs (Loening-Voysey and Wilson, 2001). Social service agencies tend to take long periods of time to help orphaned children (Pharoah et al., 2004), resulting in NGOs taking on most of the burden for orphaned children. The NGO in this research supplies orphaned children with support groups, provides caregivers with food vouchers every month, helps find temporary foster parents for orphaned children with no family, and provides support groups for children and caregivers who are infected with HIV/AIDS (NGO Director, personal communication, 15 December 2012).

This study shows positive involvement among NGO staff, orphaned children, and peer interactions. The NGO staff continue to build on the strong foundation with the orphans. Recommendations are for NGOs to teach the children to recognize positive characteristics within current relationships with staff, caregivers, peers, and community members. Children who are able to recognize the positives in current relationships may identify and apply knowledge learned to future relationships. It is important for NGOs to teach orphaned children to identify negative characteristics in relationships to protect themselves from future harm. The longer period of time the children can stay involved with NGOs, the greater the likelihood that the child will develop more effective coping mechanisms. NGOs provide a stable and supportive environment, which helps children continue to prosper and to cope with the grief related to parental death.

Conclusion

In conclusion, the NGO in this research project provides several groups that focus on helping children develop healthy life styles, providing leadership skills, teaching activities of daily living skills, education, and enhancing self-esteem. The ‘Findings’ section demonstrated that the destructive or low self-esteem behaviors declined for the majority of the children who participated in the ‘orphan groups’ over a 6-month period. These positive observations illustrate the strengths of the NGO interventions. As the literature reveals, children who are orphaned due to AIDS, trauma, or unknown causes often require a variety of social, educational, and psychological interventions for a number of years. It is vital that as the children grow and develop, NGOs continue to work with the orphans’ caregivers to assist them in creating a healthy and loving environment that will focus on reattachment issues, along with providing the caregivers with consultants to problem-solve issues that may arise.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

Tiffany Ann Breckenridge completed her BSSW and MSW at Minnesota State University, Mankato. Ms. Breckenridge’s professional experience includes, but is not limited to, domestic violence advocate, child protection assessor and on-going case manager and medical social worker. She has completed multiple research in the areas of program for orphans and housing needs in South Africa.

Christine Black-Hughes is an Associate Professor at Minnesota State University, Mankato. Dr. Black-Hughes has deep ties with the University of Fort Hare in South Africa and has completed multiple research projects since 2007 in South Africa. Dr. Black-Hughes research areas include international social work education across continents, as well as orphans, housing needs, and student motivations for social work careers in South Africa.

John Rautenbach is the Head of Department of the Department of Social Work and Social Development at the University of Fort Hare in South Africa. He is on the Executive Committee of the Association of South African Social Work Education Institutions (ASASWEI) and a Board Member of the International Association of Schools of Social Work (IASSW). Dr. Rautenbach has historically been involved in agency evaluations and the partnership with Minnesota State University, Mankato since 2007.

Michele McKinley completed her BSSW at Minnesota State University, Mankato. Ms. McKinley finished her practical requirements in South Africa and NGO. She volunteered in Thailand and the Peace Corps. Ms. McKinley plans to devote her professional career to assisting underprivileged children throughout the world.

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