A qualitative analysis of parental loss and family separation among youth in post-conflict Liberia.

Between 1989 and 2003, the Republic of Liberia experienced a brutal civil war. In 2008, the population was approximately 3.5 million people, and there were an estimated 340,000 orphans. Nearly 6000 more children were orphaned by the Ebola epidemic from 2014-2015. The goal of this research was to explore the impact of parental loss, identify moderating factors, and consider interventions that could help vulnerable youth in post-conflict societies following the loss of a parent. Seventy-five young people (age 13-18 years) in Monrovia, the capital city of Liberia, were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically. The loss of a parent or other primary caregiver had a significant impact on psychosocial and emotional health. The timing of the loss, strength of connection with the deceased parent, and relationship with surviving parent or substitute caregiver were all relevant factors. Children separated from living parents were functioning better than those whose parents were deceased. The case of Liberian children underscores the importance of early caregiver relationships and the difficulties children face when such relationships are disrupted. Children who did not experience stable early relationships suffered disconnection from their families and communities.

Introduction

There are approximately 132 million orphans worldwide (UNICEF, 2015); sub-Saharan Africa (SSA) alone has an estimated 56 million orphans (UNICEF, 2013), nearly half the global total. There is a large body of literature describing the needs of orphans in SSA, the majority of which has focused on children orphaned by the HIV epidemic. Children who lost one parent before the age of 18 are considered orphans, and those who have lost both parents are referred to as ‘double orphans’. A recent review of qualitative studies found that orphans in SSA experience neglect, abuse and exploitation at the hands of substitute caregivers (Morantz et al., 2013). These exposures put orphans at risk for mental health problems, including depression and suicidal ideation (L. Cluver, Gardner, & Operario, 2007; L. D. Cluver, Gardner, & Operario, 2008; L. Cluver & Orkin, 2009). Orphans were negatively impacted when they perceived a lack of caring, particularly when they received inferior treatment compared with the caregivers’ biological children (Ansell & Young, 2004; L. Cluver & Gardner, 2007). A study of children orphaned by HIV in Uganda found that orphanhood was associated with psychological ill health among the males (Kaggwa & Hindin, 2010). Male double orphans and male maternal orphans had a significantly higher level of hopelessness than their non-orphaned counterparts. Lower parent/guardian connectedness, having a chronically ill adult in the household and ill treatment in residence, were associated with a higher level of depression, especially among the males. School attendance was found to be protective.

The study of attachment has illuminated the critical role of early caregiving relationships in fostering healthy development and forming a basis for future relationships (Ainsworth, Blehar, Waters, & Wall, 2015; Bowlby, 1988; Freud & Burlingham, 1943; Lyons-Ruth, 1996; Lyons-Ruth, Zoll, Connell, & Grunebaum, 1986). The loss of a parent is a hardship for any child, but the availability of care from other sources can have a meaningful impact upon recovery and ongoing development. Studies conducted in Romanian orphanages demonstrated a significant lag in intellectual and social development in institutionalized children compared with those reared in families (Smyke et al., 2007). Those who formed secure attachments with their foster families were protected from developing anxiety and depression (McLaughlin, Zeanah, Fox, & Nelson, 2012). Relationships with peers and other caring adults outside the home have also been found to be protective in children who face early adversity and disruptions in their caregiving relationships (Betancourt & Khan, 2008; Werner, 1989).

Post-conflict societies struggle to reestablish order while also addressing the consequences of the trauma experienced by their populations. Orphans in these settings face challenges that are unique from those orphaned by HIV, and these have not been well-characterized. One study of war orphans in South Sudan found that they were concerned with survival, stigma, the psychological impact of trauma exposure and access to education. They were attending an orphan school, which they valued for the educational opportunities and the social support it provided (Muller, Munslow, & O’Dempsey, 2015). Factors related to the relationship with the deceased caregiver and the relationship with the substitute caregiver were not explored.

None of the studies referenced earlier included data from Liberia. Between 1989 and 2003, the Republic of Liberia experienced a brutal civil war characterized by ethnic killings, sexual violence and the use of child soldiers. The war displaced more than 800,000 people, of a total population of 3.5 million (LISGIS, 2009). Moreover, it destroyed the productive capacity and physical infrastructure of the country and eroded family and community ties (UNDP, 2006). In 2008, five years after the war ended, there were an estimated 340,000 orphans in Liberia, 18% of the total child population of the country (LISGIS, 2009). It is estimated that nearly 6000 more children were orphaned by the Ebola epidemic from 2014 to 2015 (Collins, 2015).

This study was undertaken as a follow-up to the Liberia Needs Assessment Survey, which was conducted in 2009 to characterize and quantify the mental health burden of the war on the children of Liberia (Borba et al., 2016). Key informants were asked to describe the most emotionally disturbing events or experiences to have affected young Liberians in the past 20 years and how best to help specific vulnerable groups, including orphans, homeless children, former child soldiers, criminals and children with severe mental illness. Youth were perceived to be experiencing significant adverse emotional, behavioral and functional outcomes related to exposure to war and its aftermath (Levey et al., 2013).

The findings presented in this article were obtained from in-depth interviews with Liberian youth designed to assess their postwar experience and identify factors impacting resilience. Resilience was defined as evidence of daily functioning, ability to make realistic plans for the future and presentation of an overall consistent and coherent narrative. A number of individual characteristics were found to be protective in the overall study population, including emotion regulation, cognitive flexibility, agency, social intelligence and, in some cases, meaning-making (Levey et al., 2016). Here, we focus specifically on resilience and recovery following the loss of a parent, identify factors that moderate the impact of the loss and consider interventions that could help vulnerable children following the loss of a parent.

Methods

Study procedures and participants

A qualitative research design was used with a purposive sample of 75 participants. In-depth interviewing was chosen as the data collection method in order to best capture the personal narratives of individual children (Hennink, Hutter, & Bailey, 2011). The interview guide was designed and implemented by the researchers using both a deductive and an inductive conceptual framework. The initial interview guide was developed deductively and was rooted in the existing literature. Prompts were developed to assess factors that had already been identified to be associated with resilience, including agency, self-esteem, altruism, hope, spirituality and meaning-making. Revisions were made after each interview to refine and deepen the questions. Oversight, guidance and approval were provided by the University of Liberia Institutional Review Board (ULIRB) and the Partners Human Research Committee.

Participants were recruited from 13 February to 1 March 2012 and 4 to 21 December 2012. The initial group was recruited from three schools and the subsequent group of children not attending school was recruited from the neighborhoods in Monrovia, the capital city of Liberia, and the surrounding area. All children aged 13–18 years were eligible to participate. Children in this age range were 4–9 years old when the war ended, so they were old enough to have some memory of it, and 10 years later, they were adolescents approaching adulthood, when the consequences of childhood trauma can begin to manifest as mental illness (Chapman et al., 2004; Colman et al., 2013; Schilling, Aseltine, & Gore, 2007). An effort was made to recruit both males and females.

The Republic of Liberia’s Ministry of Education identified three large, well-attended schools in three distinct areas within Monrovia. The participating schools included two government schools (a junior high school and a senior high school) and a private senior high school. These schools were chosen in order to capture distinct age and socioeconomic groups. At each school, the principal notified the students of the opportunity to participate in the research study. Children under 18 years of age had to obtain consent from a parent or guardian and then give their assent to participate. Those who were 18 consented for themselves. Those students who returned signed consent forms first were interviewed. Interviews were conducted over a 3–4-day period at each school.

The research team then recruited and interviewed children not attending school. They were identified in two different communities in Monrovia, with the help of community leaders. Both communities had high rates of poverty, crime, substance use and low rates of school attendance. The leaders went to a few areas in their communities where youth commonly gathered and explained that there was an opportunity to participate in a research study. They distributed printed information and consent forms and told the young people when and where the interviews would take place. They helped to organize a loose schedule with approximate days and times for each child to come. The leaders were present outside the building while the interviews were conducted but were not present in the room during the interviews.

The initial compensation for study participants was a 5 USD phone card, which was approved by the ULIRB. After the initial phase of recruitment, the research team observed that this was a significant inducement to participate. With the approval of the IRB, the research team changed the compensation to 2 USD. Any child identified as having acute psychiatric needs was referred to the study physician, a Liberian child psychiatrist.

Data collection

Primary data were collected using semi-structured interviews averaging 1 hour in length. The interview guide was developed to capture basic demographic information, family composition, adverse experiences, response to adversity and future outlook (see Supplementary Material). Interviews were conducted by the principal investigator together with a Liberian medical student, who acted as both a linguistic and cultural interpreter. The interviews were conducted in a private area. Student participants were interviewed on school grounds. The participants not attending school were interviewed in an office where the community leader worked. Interviews were digitally recorded, and notes were taken by the interviewers regarding participants’ affect and nonverbal communication during the interview. The interviews were transcribed verbatim by Liberians living in the US.

Analysis

A directed content analysis was used because there was an existing body of literature about both resilience and orphanhood, but there was insufficient data about resilience among post-conflict Liberian orphans (Hsieh & Shannon, 2005). Coding was performed by four coders who worked separately and sequentially over the course of two years, beginning six months after data collection was initiated. While coding the first five interviews, the coders met after each interview to compare their findings. There was a discussion about topics that were raised by multiple participants and whether they were saying the same thing or articulating distinct themes. Codes developed and used by multiple coders were then added to the codebook. When there was a discrepancy, coders explored it in an effort to uncover the deeper meaning at the heart of the theme. Discussion continued until a consensus was reached. Coders then met after every five interviews to further refine the codebook. Once there was a consensus as to the codes and definitions being used, all interviews were recoded. Then the themes and definitions were further refined.

Both inductive and deductive approaches were used (Hennink et al., 2011). First, manifest content was grouped thematically. Thematic groupings were then labeled, and these group labels were used to generate broad themes. These broad, overarching themes were divided into subthemes. Within each theme and subtheme, the researchers drew comparisons, looking for overlap and differences, as well as newly emerging topics and patterns. Themes identified included violence, death, sadness, fear, uncertainty and family and community relationships. Responses were reviewed to identify each theme and subtheme. The analysis was conducted using grounded theory, memoing and coding (Hennink et al., 2011). NVivo was employed for data management (QSR, 2015).

Results

Descriptive data

A total of 75 children were interviewed (see Table 1). They ranged in age from 13 to 18 years, with an average age of 16.4 years. Females comprised 51% of the sample. The rate of school attendance was 61.4%. Many children were orphaned by the war or lost one of their parents. Many more were sent to live with substitute caregivers. Sometimes this was done for their protection during the war or to give them greater educational opportunities. It was also done to decrease the burden of caring for many children in large families while providing household help to relatives without children.

Table 1.

Overall demographics of all study participants.

Number of participants	75
Average age (years)	16.4 (SD 1.8)
Females, N (%)	38 (51)
Males, N (%)	37 (49)
Private school, N (%)	11 (14.7)
Government school, N (%)	35 (46.7)
Dropped out of school, N (%)	29 (38.7)

SD = standard deviation.

Of the 75 children interviewed, none were living in institutions. They were either with their families, with other caregivers, living alone or homeless. If one parent was living but the child did not stay with the parent, the child was more likely to be with another caregiver, whereas if both parents died, the child was more likely to be on his/her own. Twenty-four of 26 children living with a caregiver had a living parent; just 8 of 14 children living on their own had a living parent (see Table 2). Fourteen children had no caregiver; eight of them had one or two living parents. One was male. He was living alone but attending school with some support from his uncle. Seven of the eight were females, and only one was attending school (see Table 3).

Table 2.

Current living situation and parental status for participants, aggregated and by gender (N).

	Both parents living	Father deceased	Mother deceased	Both parents deceased
All participants
Living with parent(s)	28	5	2	N/A
Other caregiver	15	4	5	2
No caregiver	4	2	2	6
Male
Living with parent(s)	14	3	1	N/A
Other caregiver	7	3	3	0
No caregiver	1	0	0	4
Female
Living with parent(s)	14	2	1	N/A
Other caregiver	8	1	2	2
No caregiver	3	2	2	2

N/A = not applicable.

Table 3.

School attendance by living situation and parental status (N, %).

	Both parents living	Father deceased	Mother deceased	Both parents deceased
Any school attendance
Living with parent(s)	21, 75	4, 80	2, 100	N/A
Other caregiver	11, 73	4, 100	1, 20	1, 50
No caregiver	1, 25	0	1, 50	0
Government school attendance
Living with parent(s)	14, 50	2, 40	1, 50	N/A
Other caregiver	10, 67	4, 100	1, 20	1, 50
No caregiver	1, 25	0	1, 50	0
Private school attendance
Living with parent(s)	7, 25	2, 40	1, 50	N/A
Other caregiver	1, 7	0	0	0
No caregiver	0	0	0	0

N/A = not applicable.

Twenty participants lost one parent. Eleven lost fathers, and nine lost mothers. Of the 11 who lost their fathers, five were living with their mothers and four were with their caregivers. Nine were attending school (see Table 3). By contrast, just two of the nine participants who lost their mothers were living with their fathers, and four were attending school. Eight participants lost both parents. Six of them were on their own and had no caregiver. None of those six were attending school. Of the two participants living with caregivers, only one was attending school. Of the 11 participants interviewed who were attending private school, 10 lived with one or both parents, and one lived with a caregiver. All had at least one parent living, and none were on their own.

Analyzed data

In our analysis, we considered the themes of the impact of the loss of a parent, the importance of understanding the loss, the timing of the loss, the relationship with the deceased parent, the relationship with the surviving parent or substitute caregiver and the difference between death and separation. We found that the loss of a parent or other primary caregiver had a significant impact on psychosocial and emotional health. Understanding the cause of death did not mitigate the negative impact of the loss for these study participants. The timing of the loss did have an impact; children who lost their parents at a younger age (10 years old or younger) generally struggled more than those whose parents died when they were older in the postwar context. Experiencing a strong connection with the deceased parent and the surviving parent or substitute caregiver were both important factors in supporting recovery. Many children were separated from their parents and sent to live with other relatives; they typically found themselves in more supportive situations than children who were living with relatives after the death of their parents.

Impact of the loss of a primary caregiver

The impact of the death of a parent or other primary caregiver was experienced emotionally and also impacted daily functioning and future opportunities. Some children had ongoing difficulty coping with the loss and turned to substance use. Many also lost support for their education and experienced uncertainty about the future.

A 17-year-old girl who had been attending school and living with her sister dropped out and started using drugs after her sister died. She had lived with her sister since she was young. She could have gone back to live with her parents, but she did not, she explained ‘because I was used to her’. Other children expressed this feeling of being ‘used to’ someone, usually about their parents, as compared to other caregivers, but for this girl, she felt very close to her sister and was used to her life with her in the city. Rather than go back to her family, she sought comfort from other children around her. She described her path of following them into drug use:

[My sister] was taken to the sick bush and died there, so my mind got disturbed. I started to follow behind friends, and that’s how friends involved me into smoking. When I think about my sister … she used to send me to a very good school. So after she died, it played on me. First I involved into drinking. After that I started to smoke the grass. When I smoke the grass it makes me to eat and sleep, and then I don’t think too much.

Children who had lost a caregiver also expressed uncertainty about their future. Some were forced to leave school because they had no one to sponsor their education. Others remained in school but worried that they might have to leave at any time and abandon their career plans. One boy who lost his father explained:

He knew about [my plan to study engineering]. He was going to encourage me because, as I learned, he loved me when I was small. But now, I come home from school, I will study. Nobody tell me to study. I don’t have, yet some other people have their fathers, telling them to do this, telling them to do that other thing… I don’t have a father to tell me to do this or that. My mother is old now.

The child’s understanding of the cause of death

While participants clearly tried to explain the deaths of their loved ones, in most cases they were left without a satisfactory explanation; the narratives they did construct did not seem to help them recover from these losses. Children described the concept of ‘African science,’ a curse placed by one person on another to cause misfortune and sometimes death. Seventeen reported that a family member had been poisoned by a jealous relative or neighbor, which reinforced their belief that their parent was envied by others and gave them a way of understanding their death.

One girl lost her father and sister following gastrointestinal illnesses, so she believed they were poisoned by African science. For her, this was less an explanation than a label for something unexplainable. She wanted to study Western medicine and become a nurse, which she viewed as a path to greater understanding:

For me I prefer to do the hospital medicine. For the native medicine I don’t have idea on it. For people who are wise they the one who have idea on it. Some people will put medicine in your food so the native doctor will know what kind of leaf to use for that food to come out, but for me I don’t know it … If I feeling sick I will choose to go to the hospital. Because if I have headache, I will go to the hospital then the people will check me and tell what is happening to me.

African science was used to explain death by a mysterious illness but not death due to war violence. Superficially, those whose parents were killed in the war had an understanding of why their parents had died because they witnessed them being brutally killed. And yet it was clear that losing their parents in this way was still very disorganizing. There was a need to make meaning out of it and, in some cases, take back control by seeking revenge. An 18-year-old boy lost both parents when rebel forces attacked his village. When the government troops arrived, he joined them. He wanted to avenge his parents’ death. This led him on a path to violence and drug use:

I did not go anywhere. I lived in the town until the men captured the town. They wanted to kill me, and one of them said no. So when they went in the house and saw my parents’ bodies they decided to take me with them. So when I started to grow up I just feel that I don’t have any family in my life. I can feel like paying back and doing bad things to other for what they did to my parents. I don’t have mercy on people because at the times I did not know who kill my parents so anyone I see, I executed them.

Having an explanation was not helpful, but believing that they could have done something to save their parents made the grieving process even more complicated. A 13-year-old boy lost his father after the war from an asthma attack that this boy witnessed when he was about 6 years old: ‘That day he fell down inside, and they carried him to the hospital. They said he stopped breathing … I feel bad when I think that I couldn’t do anything [to save him]’. Every year on the anniversary of his father’s death, he was overcome by this feeling of helplessness. At multiple points during the interview, he said he was doing ‘nothing’. He conveyed a lack of self-worth and a sense that he did not have control over his life.

Timing of the loss

Some children lost both parents together. Some lost one parent during the war and the other years later. Some children were so young when their parent died that they had no memory of that parent, while for others it was much more recent. In the worst cases, children lost both parents amid the chaos of the war, without the presence of extended family or community support to step in, and they were left with nowhere to go. A 17-year-old boy who lost both parents during the war dropped out of school after 7th grade and supported himself by stealing. He was addicted to drugs. He could identify no sources of support and saw no way to stop using:

So the rocket killed my father and my mother instantly right in the house along with other two or three families. After that, my sister did not have anything to cater to me. So I started to go from place to place and stealing. I was shocked, because I used to love my father and mother, to hear that they were dead. After the war, the drugs and cocaine and everything just polluted the market and at that time to get the drugs, it was very easy.

A girl who lost her father as an adolescent, after the war, explained her experience. He was ill, and her mother was caring for him and the rest of the family when he died. This left her with a sense of order and security:

He was sick. His sickness was somebody that witched him. Sitting by himself all day, not doing nothing, somebody that is not old and yet … he is not cripple, he can’t walk. Yeah, … my mother was there, she used to take care of him, feed him, and that’s how he died.

Relationship with deceased caregiver

As discussed, participants who lost parents at younger ages were generally more negatively impacted. The timing of the death was significant because these children were too young when their parents died to have developed an enduring connection with them. They were unable to hold on to the memory of their parents. The quality of the relationship was also significant. Children who had a strong connection with their deceased parent were more likely to continue on a productive path and recruit other supportive adults.

A 17-year-old girl with two children of her own was already an adolescent when her father died. She suffered from the loss, but she was working and providing for her children and had connected with a neighbor who was able to help her with childcare:

When I delivered, my father did not give me chance to sit home for long, and he paid my school fees. He sent me to one school in the area and one big-sized girl was at the house so when I come from school at 12:00, I will stay with my son and then the girl will go to school. That was how we used to do it but since he died, things turned upside down.

Children who did not have strong attachments to their parents while they were living had more difficulty after they died. One girl had a mother who was mentally ill, and three of her siblings died as infants. Then her mother died, and she was not able to make sense of the loss: ‘She was sick. She used to talk by herself, like to say the person going mad. You [can]not hold her, she goes by herself. So one morning we just see her body lying down in the house’. She was sent to stay with an older brother, who then sent her to live with his mother-in-law. The mother-in-law died, and the girl was on her own. She had no consistent relationship with any reliable caregiver. Her brother was pressuring her to marry for financial reasons, but she wanted to finish school first. She broke down crying as she explained this: ‘My mother not living. So I live with my brother … He ain’t care about me … Everything I can do it for myself’.

Relationship with surviving caregiver

After the death of a parent, children turned to the other parent, if they could, or to another caregiver. A consistent, supportive relationship with a surviving parent allowed a child to continue to grow and develop and to plan for the future. Under the best circumstances, this parent shared with the child memories of the deceased parent. The surviving parent saw the best qualities of their deceased spouse in their child and spoke openly about their pride in and affection for the child. Of the 26 children living with a nonparent caregiver, 11 were able to make use of another caregiver, but the rest did not feel cared about or supported by the other caregiver. Children living with other caregivers were more likely to report neglect, inferior treatment to the caregiver’s biological children, and exploitation.

A 13-year-old boy not attending school was living with his aunt after the death of his mother. He explained that his aunt treated him like her own child. She wanted to send him to school but did not have the money, and she was not sending her own children to school either: ‘When she goes out and see anything, she will buy for her son and buy something for me’. Feeling cared for by his aunt, he was able to develop a coherent narrative and plan for the future. He maintained an interest in returning to school and wanted to become a social studies teacher.

Some families fell apart following the loss of a parent, even if the other parent remained alive. This was particularly true after the loss of the mother. Of the nine children who lost their mothers but not their fathers, five were sent away because their fathers felt incapable of caring for them, and two had no caregivers. After marital separation or spousal death, single fathers were more likely to take another wife, which meant the child was faced with the complexity of dealing with a stepmother. Children reported that they were treated differently than the stepmother’s biological children. They were spoken to harshly, punished more severely, and sometimes abused and exploited. In contrast, children did not report the presence of a stepfather after the death of their father.

A 15-year-old boy attending government school was living with his father and stepmother after his mother died. Initially, he described them both as caring, but then he spoke about the uncertainty he felt about whether he would be able to continue his education. After his mother died, he began to worry about his father dying, although he was healthy, which was a fear that many children reported after the loss of one parent:

[My father] just behind me to put strong because I don’t know when he will be leaving, so I should put strong and get what I want from him because anytime God can take him away, so I should put strong when he spend more time behind me to go to school.

He also spoke about the differences between his mother and his stepmother: ‘We can’t eat together and also she can’t wash my clothes. And when my mother was living she do all, she wash my clothes, draw water, do all the other work’. There was no longer anyone looking out for him; he had to take care of himself in a way that left him alone.

A 15-year-old girl, whose mother died near the end of the war, was sent to live with her mother’s sister, who treated her brutally. She had sporadic contact with her father, who visited when he could and provided financial support until he died two years prior to the interview. Her aunt had always been dismissive and harsh, but after her father died, she began encouraging the girl to engage in prostitution:

She can want me to follow my friends on the road to go and hustle. I can tell her I am not able to do that. So when I say I am not able to do that sometimes she gets mad … She forces me. She cut my hair, and she put the dye there. And then when the girls were going on the road at night she told me to follow behind them.

Family separation

It might be expected that having living parents and not living with them would signal problems, and sometimes that was the case, but having a living parent usually meant that children fared better, even if they were living with another caregiver. Having a living parent meant that a child was more likely to find a caregiver and that the caregiver was more likely to take better care of the child. In some cases, their parents had made arrangements for them to live with another adult. Others did not have the benefit of their parents having made specific arrangements in this way, but they described secure connections with their parents and were able to form other connections themselves. Once a child was with a caregiver, the parents’ ongoing involvement effected how the child was treated by the caregiver.

A 16-year-old girl attending government school was sent to Monrovia by her parents, who were in the interior, to live with her uncle and attend school. Her parents made these arrangements for her and prepared her for the trip. While some children complained about restrictions from their caregivers, she liked the restrictions placed by her uncle because she felt that he would protect her from getting into trouble or getting pregnant before she was ready:

My parents advised me that when I come here, I should be good. I should respect the people I live with … When you living with your born people, you can get [bad] idea, you can put [bad] something in your head, but when you living with different person, you will be scary. All the one you used to do you will leave it, you change, you put different way in you.

Although she rarely saw her parents, she retained a sense of connection to them: ‘I can resemble [my father] … The only thing I bring that my mom’s way is she like plenty people, she loves to see people’. With support from her uncle and connection to her parents, she conveyed confidence and a clear, balanced sense of herself and ability to connect with others: ‘When I get vexed, I get vexed, but I like playing fun, I like laughing, I like joking, and I love people’.

While having living parents was generally better, it was not sufficiently protective in all cases. There were children with two living parents who were living on their own without a caregiver. One boy was attending school, working to support himself, maintaining a relationship with his family and making supportive connections in the community. The rest were not attending school, and all appeared to be struggling. Although both of their parents were alive, they had lost an important caregiving relationship or experienced a trauma from which their caregiver could not protect them.

An 18-year-old girl began engaging in prostitution after she was raped during the war. Her parents were unable to protect her from this event, and she found no use for their rules after the war: ‘The soldier boys started to beat us, and I was raped. That’s how I got in life, and them there we came back. Since we came back, that’s the life I’m living [prostitution]’. After the war, she left home because she did not like the rules imposed by her parents. She explained that living with her family was ‘nothing bad, except that we used to go to bed [early]’.

Discussion

The loss of a parent posed particular challenges to youth in this post-conflict setting. There were a number of factors that moderated the impact of the loss, including timing, relationship with the deceased parent and the relationship with the surviving parent or caregiver. Understanding the cause of death did not have a meaningful impact on the participants’ ability to recover from the loss. Among orphans in Uganda, being orphaned by HIV was worse than losing their parents due to another cause (Kaggwa & Hindin, 2010). In our study population, however, participants seemed to recognize that they were facing circumstances beyond their control, whether they watched their parents be killed by gunfire or believed they were poisoned by a jealous neighbor. When participants believed they could have done something to save their parent, this complicated their grieving process.

From the attachment literature, we know that children learn to believe in their own capacities in the context of their relationship with parents who believe in them (Bowlby, 1988; Freud & Burlingham, 1943), and these early relationships in the first few years of life form the template for future relationships (Ainsworth et al., 2015; Lyons-Ruth, 1996; Lyons-Ruth et al., 1986). Our findings were consistent with this insofar as children who lost their parents later generally fared better. This differs, however, from another study which suggested that children who lost their fathers during the war in Croatia were less negatively impacted if they were very young (under two years) when the loss occurred (Plasc, Poljarevic, Loncar, & Henigsberg, 2011). This may be explained by the fact that we were comparing children who lost their parent in early or middle childhood (10 years old or younger) with those whose parent died during adolescence. It may be that early and middle childhood are the most difficult times for such a loss to occur. Also, when parents died after the war, there was more support available through the extended family and the community.

The study had eight participants who lost both parents; only one was attending school and all were struggling significantly. Among participants who lost one parent, there was more variation. When the relationship with the deceased parent had been positive, children had confidence in themselves and their ability to relate to others, which continued to support their functioning even after that parent died. The relationship with the surviving parent or caregiver was also important. When the mother was the surviving parent, children were more likely to live with her and be enrolled in school. This is consistent with the finding that maternal orphans typically fare worse, experiencing more depression and hopelessness than paternal orphans (Kaggwa & Hindin, 2010). Children living with nonparent caregivers often received inferior treatment, compared to the caregiver’s biological children. They were forced to do more work and their education was not prioritized. In some cases, they were overtly exploited to earn money for the caregiver, including forced prostitution. This differential treatment is similar to what have been described among orphans in other sub-Saharan African countries (Morantz et al., 2013).

For those children who were living on their own, forming a connection with an adult in their community was extremely valuable. These relationships were typically formed with a neighbor who was an elderly woman without children, or whose children were grown. Sometimes children were able to make extra money by helping these women with chores. What was emphasized most, though, was being able to talk with these women about their problems and rely on them for emotional support. Other research on high-risk youth has found that such extra-familial relationships can be crucial (Werner, 1989), but this has not been well described in orphans. Some studies of orphans have found that access to schools and other institutions is helpful because it creates opportunities for supportive relationships with teachers and staff, but the focus of these studies has not been on the relationships themselves (Hermenau, Eggert, Landolt, & Hecker, 2015; Morantz et al., 2013; Muller et al., 2015).

In the literature, male orphans in SSA have been reported to suffer greater depression and hopelessness than female orphans (Kaggwa & Hindin, 2010). Our findings suggest that while male orphans do indeed suffer, particularly double orphans, female children in the low-income post-conflict setting of Liberia face unique risks even if their parents are living. We found that while there were both boys and girls who were living on the streets without caregivers, boys were in this situation only if both of their parents were deceased. In contrast, several girls had left home despite having one or two living parents. This finding was a surprise but has multiple potential causes. Girls described restrictions imposed on them for their protection; some left home because they were angry about these restrictions over where they could go, when and with whom. On the other hand, girls living with other caregivers were sometimes pressured to engage in sexual relationships with older men, or outright prostitution, to offset their expenses. Some girls also experienced unwanted sexual advances and sometimes frank abuse from older men living in the same household.

The prevailing view is that orphans are best served in the community setting, and not in institutions (Communique, 2008). Recent research has challenged this view. A qualitative study of war orphans in South Sudan found that those attending an orphan school felt that their needs were being better met there than with their families (Muller et al., 2015). A study of 2837 orphans across five low- and middle-income countries found that those living in institutions fared as well or better than those living in the community, based on measures of physical health as well as cognitive and emotional functioning (Whetten et al., 2009). None of the participants in our study were living in institutions, but many found that their environments were not meeting their needs. Orphans in particular had unmet needs including basic physical care, stable and safe home environment, education and emotional care. The type of setting that could best meet those needs and is feasible in Liberia will need to be carefully considered.

There were a number of limitations of this study. Participants were recruited from Monrovia only. Children in other parts of Liberia were not included, and the data may not be representative of their experiences. Interviews were conducted at a single time point, so resilience could not be assessed over time. No collateral information was obtained from teachers or family members. This allowed the children’s voices to come through, but it also meant that we were not able to obtain a complete picture of their circumstances. Some may have chosen, for a variety of reasons, to minimize the difficulties they were facing, while others may have chosen to magnify them. There is also the possibility of selection bias, as children who chose to participate may be different from those who did not.

Conclusion

The case of Liberian children underscores the importance of early caregiver relationships and the difficulties children face when such relationships are disrupted. In a country that endured 14 years of brutal civil war, followed by a devastating Ebola outbreak, many children have experienced deprivation, violence and uncertainty. Orphans in particular suffered painful losses, and their supports were compromised. Those who were connected to their communities fared better. There was a divide such that children were either connected to multiple community institutions, like school and church, or they were totally disconnected from the larger community and instead were part of a subculture of substance use and criminal activity.

Further research is needed to evaluate interventions to support orphans in post-conflict settings. Our findings suggest that helping orphans to reintegrate into existing community institutions would be an important next step. This would require financial assistance, ongoing emotional support and personal contact. Orphans who are not reached by this type of effort may have more significant needs that would be better addressed by an institution designed specifically for them. Some children who were attending school suffered excessively at the hands of harsh caregivers, and they might also benefit from access to an institutional setting where they could interact with multiple caregivers and find protection from exploitation and abuse.

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