Adverse childhood experiences, psychosocial well-being and cognitive development among orphans and abandoned children in five low income countries

The plight of orphans^a and abandoned children (OAC) is an increasing global problem that is particularly pervasive in Southeast Asia and sub-Saharan Africa [1]. Improving the educational attainment of the 153 million orphans and other vulnerable children worldwide is a key goal for development policymakers and practitioners. International declarations such as the Millennium Development Goals and the Education for All Movement indicate that the educational attainment of vulnerable children has become a global priority. Most recently, the 2011 Political Declaration on HIV/AIDS targeted increases in school attendance of orphans as an important and measureable indicator of progress [2].

To understand which policies can improve educational attainment for OAC, decision makers must first understand the determinants of and barriers to these outcomes. However, there are mixed results regarding which factors, including orphanhood itself, are significantly associated with educational attainment. Previous research shows that the loss of a parent can lead to a series of developmental disadvantages resulting in poor education [3–7], such as lags in grade for age and school attendance relative to non-orphans [3, 7, 8]. In contrast, other studies find little negative impact of parental death on child education [9–11] and instead find that alternative factors such as wealth, age, or the child’s relationship to the head of household are better predictors of education outcomes [12]. Importantly, many of these studies are restricted to single country analyses, rendering results arguably context specific.

Additionally, few studies examining the educational attainment of orphans move beyond outcomes such as school enrollment, grade for age, and attendance to disentangle what factors contribute to a child’s learning [13, 14]. Other outcomes may provide more meaningful information. A recent study showed that tests of cognitive development can be a useful measure in understanding OAC learning and educational experience across settings. In particular, cognitive development was found to be positively associated with increases in exposure to formal education [15].

One factor that may offer some insight into the development of OAC is mental health. Previous research, though not focused on orphans, highlights the role of adverse childhood experiences in life outcomes [16]. Cumulative effects from multiple risk factors have been shown to be more predictive of compromised early cognitive development among vulnerable children than any one risk factor alone [17]. In the research on orphans, the role of psychosocial status on multiple outcomes has been studied, though not specifically in relation to learning outcomes. Research on OAC in low and middle income countries found that orphaned children are more susceptible than non-orphans to exposure to potentially traumatic events due to lack of adequate adult protection [18–21]. A recent study found that OAC anxiety and emotional difficulties increased with additional exposure to potentially traumatic events [22]. Another recent study found associations between orphan risk of psychosocial difficulties and subsequent risk of HIV infection [23].

While there is a clear need for mental health interventions among OAC, few investigators have examined the role of mental health in predicting OACs’ cognitive development [24–26]. To our knowledge, no study has attempted to do a cross-country analysis of community based OAC to address these questions. Through these analyses, we aim to understand better the linkages between emotional difficulties and a child’s ability to participate in and gain from education in a context where children are particularly vulnerable to adverse events and subsequent emotional difficulties. In this manuscript, we employ within-country and cross-country analyses to examine associations between exposure to adverse childhood events, the emotional difficulties that OAC face, and their cognitive development.

This is the first cross-country study to examine the relationship between orphans’ emotional difficulties and their learning. Moreover, conducting such an analysis on a unique sample of vulnerable children who are susceptible to multiple instances of adversity, including trauma, provides evidence of the nature of this relationship within a context of heightened adversity and potentially higher risk of mental health difficulties. This analysis showed that OAC exposure to potentially traumatic events is an important predictor of emotional difficulties, thus supporting previous literature that the number of adverse events matters for risk of mental health difficulties.

The most salient finding was a negative and significant relationship between a child’s emotional difficulties and his/her cognitive development, within and across five of six study sites. Rates of exposure to adverse childhood events among the orphaned and abandoned children in this study were high, and exposure to adverse events, in addition to male gender, and lower household wealth, was associated with significantly higher rates of emotional difficulties. Interestingly, orphan status was only significantly associated with emotional difficulties in some sites and was not predictive of cognitive development, although the negative and significant relationship between emotional difficulties and cognitive development held within each orphan subgroup. These findings may suggest that when a child is more vulnerable to a number of adverse events, it is the context in which a child loses a parent, rather than the loss of a parent alone, that better explains mental health outcomes. Children who are vulnerable from orphaning and have experienced other adversity are at heightened risk of increased emotional difficulties, which is associated with lags in cognitive development. These findings offer insights into the relationship between vulnerable children’s mental health and their ability to participate in and benefit from education.

In the context of multiple adversity, the loss of a parent, or orphan status, does not show statistical significance in the hypothesized relationship between mental health and learning. Nevertheless, the overall findings still underscore the importance of mental health intervention for children who are especially vulnerable. It is likely that the effect of parental loss is further affected by the additional adverse events to which the child is even more vulnerable. No trauma or potentially traumatic event happens in isolation.

Although causality cannot be inferred from this analysis, the results offer insight into the relationship between emotional difficulties and educational outcomes. The fixed effects model controls for unobserved time-invariant differences between children that may be correlated with emotional difficulties and may influence cognitive development. Consequently, the results in Table 4 give us an unbiased estimate of the relationship between a child’s emotional difficulties and his/her cognitive development, controlling for these differences. The consistency of the association between these two factors across multiple contexts and measures and within different subgroups is striking. This underscores the importance of providing trauma support and focusing on the psychosocial development of vulnerable children as a means to alleviate strains inhibiting a child’s learning.

Additionally, the associations found between wealth and emotional difficulties may indicate that interventions aimed at easing households’ resource constraints could help alleviate emotional difficulties in some contexts. One may hypothesize that in less stable, resource poor settings, children who were exposed to trauma may be less likely to recover from emotional difficulties. Interventions on both the child and family levels may work in tandem to improve education outcomes for orphans. If policies and programs can improve economic and emotional stability for both children and families, orphans may have a greater chance of pushing past the challenges of losing a parent and the additional traumas to which orphanhood exposes them. While economic support does not treat mental health difficulties, it may provide families with the resources needed to keep children in school, which may aide their psychosocial development. Such support may improve a child’s chances of overcoming the emotional challenges that are associated with lags in cognitive development. We acknowledge several limitations.

Children’s cognitive development is described by only two measures, an aggregated score summarizing children’s performance on three nonverbal KABC II subtests plus a measure verbal memory and attention based on the CVLT. While ability is likely not to change over time, the child’s performance on the KABC II tests is not only an indication of the child’s ability, but also a variety of other factors associated with motivation, self-confidence, response to authority and the child’s developed non-verbal skillset [1]. We may interpret the association of test scores with the child’s emotional difficulties to be related to changes in these additional factors. While this measure may not singularly isolate the child’s cognitive development, knowledge of the critical role of emotional difficulties in the child’s learning and subsequent academic attainment is an important insight for policies on global support for vulnerable children, including but not limited to those vulnerable due to parental death.

Further, the available data do not offer adequate statistical power to describe the temporal association between the variables of interest, and therefore cannot rule out possibilities of reverse causality. It is possible that the observed relationships are circular and that, even if higher emotional difficulties impede cognitive development, lags in cognitive development in turn may heighten emotional difficulties. With adversity, psychosocial manifestations, and cognitive delays spanning much of the life span of the children in this study, the three year follow-up period does not offer sufficient within-child variation to disentangle these effects. Regardless of the direction of causality, if we know that children who are exposed to more trauma also report more emotional difficulties and perform lower on tests of cognitive ability, interventions to provide emotional support for children living in adversity will help at least one or more of these difficulties. Even though we do not know whether emotional difficulties are driving lags in cognition or the other way around, we still need to address the emotional difficulties, specifically targeting potentially traumatic events.

Finally, the study findings may not be generalizable, as there are many other groups of OAC, including street children, institution-based orphans, and those that live in countries with widely different contexts than those in our sample. These associations may differ in those samples. The variability in the observed associations across the six study sites suggests that associations between trauma, emotional difficulties and cognitive development, and appropriate interventions, are likely context-specific. Nevertheless, this analysis offers new insight into the relationship between psychosocial factors, exposure to adverse childhood experiences, resource constraints and the cognitive development of orphans in wide variety of contexts and diverse settings in Southeast Asia and sub-Saharan Africa.

This study suggests that increased reports of exposure to potentially traumatic events among orphans and abandoned children are associated with higher emotional difficulties, and increases in emotional difficulties are associated with lags in cognitive development. Hence, exposure to trauma and emotional difficulties comprise important barriers to educational attainment for all such vulnerable children, including orphans. Higher socioeconomic status and better educated caregivers may offer buffers to these difficulties, since they are associated with fewer emotional difficulties and higher performance on tests of cognitive development. Interventions targeting both the psychosocial development of the child, vis a vis their exposure to adverse childhood events, and the socio-economic status of the caregiver may work in tandem to improve educational outcomes for vulnerable children in a more holistic sense. Further, family based interventions to stabilize socioeconomic conditions or increase caregiver education may help overcome psychosocial challenges that otherwise would present as barriers to the child’s educational advancement. Most importantly, psychosocial status may be an important actor in a child’s ability to profit from and stay in school, and one factor that influences this status is a child’s exposure to traumatic and other adverse experiences. These findings may provide a guide to developmental strategies for those working to improve education outcomes for children in less wealthy areas.

^aWhile the definition of “orphan” varies across cultures and settings, UNICEF provides a commonly accepted definition for orphan as “a child who has lost one or both parents” (UNICEF 2004).

^bFor more information, see sdqinfo.org.

^c“Hearing about a family member who has died”, “had a brother or sister die”, “seeing a dead body in town”, and “having a painful or scary medical treatment,” were excluded from the trauma count variable. Almost all children had lost a family member, hence the first event did not add to the variation in the count. For the second event, it was not clear whether the child witnessed the event themselves. For the third event, in some sites, burials are open-casket so all kids had seen these events. For the latter event, event description was not specific enough. It seemed that for some children, this included blood draws or like events that were scary to the child but not comparable to the other categories.

^dData was compiled from a variety of country specific DHS data sets. See references for further information on data used.

^eConstants in linear regression models represent the estimated mean value for the (hypothetical) reference group for whom the values of all variables in the model are zero.