Cognitive, Motor, and Behavioral Development of Orphans of HIV/AIDS in Institutional Contexts

  • Kim T. Ferguson
  • Melody J. Lee
Part of the Specialty Topics in Pediatric Neuropsychology book series (STPN)


This chapter describes the cognitive, motor, and behavioral development of sixty 2- to 35-month-old infants living in institutional settings in Malawi. This assessment is critical given the growing number of orphaned infants in sub-Saharan Africa due to the HIV/AIDS pandemic (Malawi National Statistical Office and UNICEF, Malawi Multiple Indicator Cluster Survey (MICS) 2006: Preliminary report. Zomba: Malawi National Statistical Office, 2007). As a result, infant orphanages are becoming increasingly common in this region (Beard, J Community Health Nurs 22:105–115, 2005), yet little is known about the quality of care provided in these institutions nor about the developmental outcomes of the children living in them. We found that children’s cognitive and motor development appeared to be less optimal, while their behavioral development was more optimal, than representative US samples. These findings are discussed in relation to available comparative African and institutional data and related to a general analysis of the caregiving and environmental context. Recommendations for future systematic assessments of the quality of the physical and social environment, as well as of children’s health (including HIV status) and nutrition, are outlined. This research is critically needed to inform orphan-care providers and policy makers in sub-Saharan Africa as to the current developmental functioning of institutionalized children.


Behavioral Development Proximal Process Institutionalize Child Developmental Functioning Mental Developmental Index 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Anne B. Giordani, Ph.D., ELS, provided editorial assistance.


  1. Achenbach, T. M. (1992). Manual for the child behavior checklist/2-3 and 1992 profile. Burlington, VT: Vermont Department of Psychiatry.Google Scholar
  2. Ames, E. W. (1990). Spitz revised: A trip to Romanian “orphanages”. Canadian Psychological Association Developmental Psychology Section Newsletter, 9, 8–11.Google Scholar
  3. Baltes, P. B., Staudinger, U. M., & Lindenberger, U. (1999). Lifespan psychology: Theory and application to intellectual functioning. Annual Review of Psychology, 50, 471–507.PubMedCrossRefGoogle Scholar
  4. Bayley, N. (1969). Bayley scales of infant development. New York: Psychological Corporation.Google Scholar
  5. Bayley, N. (1993). Bayley scales of infant development (2nd ed.). San Antonio, TX: The Psychological Corporation.Google Scholar
  6. Bayley, N. (2006). Bayley scales of infant development (Administration Manual 3rd ed.). San Antonio, TX: The Psychological Corporation.Google Scholar
  7. Beard, B. J. (2005). Orphan care in Malawi: Current practices. Journal of Community Health Nursing, 22, 105–115.PubMedCrossRefGoogle Scholar
  8. Benedict, R. (1934). Patterns of culture. Boston: Houghton Mifflin.Google Scholar
  9. Berry, J. W. (1971). Ecological and cultural factors in spatial perceptual development. Canadian Journal of Behavioral Science, 3, 324–336.CrossRefGoogle Scholar
  10. Berry, J. W. (1974). Radical cultural relativism and the concept of intelligence. In J. W. Berry & P. R. Dasen (Eds.), Culture and cognition: Readings in cross-cultural psychology (pp. 225–229). London: Methuen & Co Ltd.Google Scholar
  11. Berry, J. W. (1976). Human ecology and cognitive style: Comparative studies in cultural and psychological adaptation. New York: Sage.Google Scholar
  12. Berry, J. W. (1984). Towards a universal psychology of cognitive competence. International Journal of Psychology, 19, 335–361.CrossRefGoogle Scholar
  13. Berry, J. W. (2001). Contextual studies of cognitive adaptation. In J. M. Collis & S. Messick (Eds.), Intelligence and personality: Bridging the gap in theory and measurement (pp. 319–333). Mahwah, NJ: Lawrence Erlbaum.Google Scholar
  14. Berry, J. W. (2004). An ecocultural perspective on the development of competence. In R. J. Sternberg & E. L. Grigorenko (Eds.), Culture and competence: Contexts of life success (pp. 3–22). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  15. Berry, J. W., Van de Koppel, J. M. H., Senechal, C., Annis, R. C., Bahuchet, S., Cavalli-Sforza, L. L., et al. (1986). On the edge of the forest: Cultural adaptation and cognitive development in Central Africa. Lisse: Swets & Zeitlinger.Google Scholar
  16. Bhargava, A., & Bigombe, B. (2003). Public policies and the orphans of AIDS in Africa. BMJ, 326, 1387–1389.PubMedCrossRefGoogle Scholar
  17. Boivin, M. J., & Giordani, B. (2009). Neuropsychological assessment of African children: Evidence for a universal brain/behavior omnibus within a coconstructivist paradigm. Progress in Brain Research, 178, 113–135.PubMedCrossRefGoogle Scholar
  18. Boivin, M. J., Gladstone, M. J., Vokhiwa, M., Birbeck, G. L., Magen, J. G., Page, C., Semrud-­Clikeman, M., Kauye, F., & Taylor, T. E. (2011). Developmental outcomes in Malawian children with retinopathy-positive cerebral malaria. Tropical Medicine & International Health, 16, 263–271.CrossRefGoogle Scholar
  19. Bronfenbrenner, U. (1974). Developmental research, public policy, and the ecology of childhood. Child Development, 45, 1–5.CrossRefGoogle Scholar
  20. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and by design. Cambridge, MA: Harvard University Press.Google Scholar
  21. Bronfenbrenner, U., & Ceci, S. J. (1994). Nature-nurture reconceptualized in developmental perspective: A bioecological model. Psychological Review, 101, 568–586.PubMedCrossRefGoogle Scholar
  22. Bronfenbrenner, U., & Crouter, A. C. (1983). The evolution of environmental models in developmental research. In W. Kessen (Series Ed.) & P. H. Mussen (Vol. Ed.), Handbook of child psychology: Vol. 1. History, theory, and methods (4th ed., pp. 357–314). New York: Wiley.Google Scholar
  23. Bronfenbrenner, U., & Evans, G. W. (2000). Developmental science in the 21st century: Emerging theoretical models, research designs, and empirical findings. Social Development, 9, 115–125.CrossRefGoogle Scholar
  24. Bronfenbrenner, U., & Morris, P. A. (1998). The ecology of developmental processes. In W. Damon & R. M. Lerner (Eds.), Handbook of child psychology (Theoretical models of human development 5th ed., Vol. 1, pp. 993–1028). New York: Wiley.Google Scholar
  25. Castle, J., Groothues, C., Bredenkamp, D., Beckett, C., O’Connor, T., Rutter, M., & The E.R.A. Study Team. (1999). Effects of qualities of early institutional care on cognitive attainment. American Journal of Orthopsychiatry, 69, 424–437.PubMedCrossRefGoogle Scholar
  26. Caudill, W., & Weinstein, H. (1969). Maternal care and infant behavior in Japan and America. Psychiatry, 32, 12–43.PubMedGoogle Scholar
  27. Chisholm, K. (1998). A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages. Child Development, 69, 1090–1140.Google Scholar
  28. Cole, M. (1996). Cultural psychology: A once and future discipline. Cambridge, MA: The Belknap Press of Harvard University Press.Google Scholar
  29. Cole, M. (1999). Culture in development. In M. H. Bornstein & M. E. Lamb (Eds.), Developmental Psychology: An advanced textbook (4th ed., pp. 73–84). Mahwah, NJ: Lawrence Erlbaum Associates.Google Scholar
  30. Cole, M., & Bruner, J. S. (1971). Cultural differences and inferences about psychological processes. The American Psychologist, 26, 867–876.CrossRefGoogle Scholar
  31. Cole, M., Gay, J., Glick, J. A., & Sharp, D. W. (1971). The cultural context of learning and thinking: An exploration in experimental anthropology. New York: Basic Books.Google Scholar
  32. Cole, M., & Scribner, S. (1974). Culture and thought: A psychological introduction. New York: Wiley.Google Scholar
  33. Dawes, A., & Donald, D. (2000). Improving children’s chances: Developmental theory and effective interventions in community contexts. In D. Donald, A. Dawes, & J. Louw (Eds.), Addressing childhood adversity (pp. 1–25). Cape Town: David Philip.Google Scholar
  34. Dennis, W., & Najarian, P. (1957). Infant development under environmental handicap. Psychological Monographs, 71, 1–13.Google Scholar
  35. Dunn, A., Jareg, E., & Webb, D. (2003). A last resort: The growing concern about children in residential care. London: International Save the Children Alliance.Google Scholar
  36. Erny, P. (1973). Childhood and cosmos: The social psychology of the Black African child (A. Mboukou, Trans.) Washington, DC: Black Orpheus Press. (Original work published 1968).Google Scholar
  37. Fenson, L., Pethick, S., Renda, C., Cox, J. L., Dale, P. S., & Reznick, J. S. (2000). Short-form versions of the MacArthur-Bates Communicative Development Inventories. Applied PsychoLinguistics, 21, 95–115.CrossRefGoogle Scholar
  38. Ferguson, K. T. (2002). Attachment patterns and corresponding mental and motor development and behavioral tendencies of infants and toddlers at infant homes in southern Africa. Unpublished honors thesis, Knox College, Galesburg, Illinois.Google Scholar
  39. Ferguson, K. T. (2003). Attachment patterns and corresponding mental and motor development and behavioral tendencies of infants and toddlers at infant homes in Southern Africa. Paper presented at the 27th annual conference of the New York African Studies Association: Transnational Discourses in the African World, Ithaca, NY.Google Scholar
  40. Ferguson, K. T. (2008). Infant health and development in Malawian orphanages: A case study in understanding African child development in ecological context. Invited talk in the International Neurologic and Psychiatric Epidemiology Program, Michigan State UniversityGoogle Scholar
  41. Ferguson, K. T. (2010). Infant development in the context of Malawian orphanages. Poster presented at the XVIIth Biennial international conference on infant studies, Baltimore, MD.Google Scholar
  42. Ferguson, K. T., Casasola, M., & Ferguson. T. M. (2005). Effective assessment of institutionalized infants’ and toddlers’ language development in Malawi: The development of assessments in English and Chichewa. Poster presented at The Xth international congress for the study of child language, Berlin, Germany.Google Scholar
  43. Ferguson, K. T., Kim, P., Dunn, J. R., & Evans, G. W. (2009). An ecological model of urban child health. In N. Freudenberg, S. Klitzman, & S. Saegert (Eds.), Urban Health and Society: Interdisciplinary approaches to research and practice (pp. 63–91). San Francisco: Jossey-Bass.Google Scholar
  44. Ferguson, K. T., & MacAllister, J. (2009). Infant development in the context of Malawian ­orphanages. Poster presented at the unite for sight 6th annual global health conference, Yale University, CT.Google Scholar
  45. Fisher, L., Ames, E. W., Chisholm, K., & Savoie, L. (1997). Problems reported by parents of Romanian orphans adopted to British Columbia. International Journal of Behavioral Development, 20, 67–83.CrossRefGoogle Scholar
  46. Freeman, M., & Nkomo, N. (2006). Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers. AIDS Care, 18(40), 302–310.PubMedCrossRefGoogle Scholar
  47. Giese, S., & Dawes, A. (1999). Child care, developmental delay, and institutional practice. South African Journal of Psychology, 29, 17–22.Google Scholar
  48. Gladstone, M., Lancaster, G. A., Umar, E., Nyirenda, M., Kayira, E., van den Broek, N. R., et al. (2010). The Malawi Developmental Assessment Tool (MDAT): The creation, validation, and reliability of a tool to assess child development in rural African settings. PLoS Medicine, 7(5), e1000273. doi: 10.1371/journal.pmed.1000273.PubMedCrossRefGoogle Scholar
  49. Gottlieb, G. (1998). Normally occurring environmental and behavioral influences of gene activity: From central dogma to probabilistic epigenesis. Psychological Review, 105, 792–802.PubMedCrossRefGoogle Scholar
  50. Gottlieb, G. (2007). Probabilistic epigenesis. Developmental Science, 10(1), 1–11.PubMedCrossRefGoogle Scholar
  51. Greenspan, S. I. (2004). Greenspan social-emotional growth chart: A screening questionnaire for infants and young children. San Antonio, TX: Harcourt Assessment.Google Scholar
  52. Groza, V., & Ileana, D. (1996). A follow-up study of adopted children from Romania. Child and Adolescent Social Work Journal, 13, 541–565.CrossRefGoogle Scholar
  53. Hannesdottir, H., & Einarsdottir, S. (1995). The Icelandic child mental health study. An epidemiological study of Icelandic children 2–18 years of age using the Child Behavior Checklist as a screening instrument. European Child & Adolescent Psychiatry, 4(4), 237–248.Google Scholar
  54. Harwood, R. L., Miller, J. G., & Irizarry, N. L. (1995). Attachment, culture, and behavior. In S. Harkness & C. M. Super (Eds.), Culture and attachment: Perceptions of the child in context (Culture and human development: A Guilford series, pp. 138–146). New York: The Guilford Press.Google Scholar
  55. Holding, P. A., Taylor, H. G., Kazungu, S. D., Mkala, T., Gona, J., Mwamuye, B., Mbonani, L., & Stevenson, J. (2004). Assessing cognitive outcomes in a rural African population: Development of a neuropsychological battery in Kilifi District, Kenya. Journal of the International Neuropsychological Society, 10, 246–260.PubMedCrossRefGoogle Scholar
  56. Kambalametore, S., Hartley, S., & Lansdown, R. (2000). An exploration of the Malawian perspective on children’s everyday skills: Implications for assessment. Disability and Rehabilitation, 22, 802–807.PubMedCrossRefGoogle Scholar
  57. LeVine, R. A. (1970). Cross-cultural study in child psychology. In P. Mussen (Ed.), Carmichael’s manual of child psychology (pp. 559–612). New York: Wiley.Google Scholar
  58. LeVine, R. A. (1973). Culture, behavior, and personality. Chicago: Aldine.Google Scholar
  59. LeVine, R. A. (1977). Child rearing as cultural adaptation. In D. S. Palermo (Series Ed.), P. H. Leiderman, S. R. Tulkin & A. Rosenfeld (Vol. Eds.), The child psychology series: Experimental and theoretical analyses of child behavior. Culture and infancy: Variations in the human experience. (pp. 15–28). London: Academic Press.Google Scholar
  60. LeVine, R. A., Dixon, S., LeVine, S., Richman, A., Leiderman, P. H., Keefer, C. H., & Brazelton, T. B. (1994). Child care and culture: Lessons from Africa. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  61. Li, S. (2003). Biocultural orchestration of developmental plasticity across levels: The interplay of biology and culture in shaping the mind and behavior across the life spand Psychological Bulletin, 129(2), 171–194.PubMedCrossRefGoogle Scholar
  62. Liddell, C. (2002). Emic perspectives on risk in African childhood. Developmental Review, 22, 97–116.CrossRefGoogle Scholar
  63. Louw, J., Donald, D., & Dawes, A. (2000). Intervening in adversity: Towards a theory of practice. In D. Donald, A. Dawes, & J. Louw (Eds.), Addressing childhood adversity (pp. 244–260). Cape Town: David Philip.Google Scholar
  64. Malawi National Statistical Office. (2005). Integrated household survey 20042005: Vol. I. Household socio-economic characteristics. Zomba, Malawi: Malawi National Statistical Office.Google Scholar
  65. Malawi National Statistical Office & UNICEF. (2007). Malawi Multiple Indicator Cluster Survey (MICS) 2006: Preliminary Report. Zomba: Malawi National Statistical Office.Google Scholar
  66. Maleta, K., Virtanen, S. M., Espo, M., Kulmala, T., & Ashorn, P. (2003). Childhood malnutrition and its predictors in rural Malawi. Paediatric and Perinatal Epidemiology, 17, 384–390.PubMedCrossRefGoogle Scholar
  67. McCall, J. (1999). Research on the psychological effects of orphanage care: A critical review. In R. B. McKenzie (Ed.), Rethinking Orphanages for the 21st Century (pp. 127–150). Thousand Oaks, CA: Sage Publications.Google Scholar
  68. Mead, M. (1928). Coming of age in Samoa. New York: Morrow.Google Scholar
  69. Mead, M., & Macgregor, F. C. (1951). Growth and culture: A photographic study of Balinese childhood. New York: G. P. Putnam’s Sons.Google Scholar
  70. Miller, C., Gruskin, S., Subramanian, S., Rajaraman, D., & Heymann, S. (2006). Orphan care in Botswana’s working households: growing responsibilities in the absence of adequate support. American Journal of Public Health, 96(8), 1429–1435.PubMedCrossRefGoogle Scholar
  71. Molteno, C., Woods, D., & Hollingshead, J. (1995). A 5-year follow-up study of full term small for gestational age infants in Cape Town. Developmental Brain Dysfunction, 8, 119–126.Google Scholar
  72. Moreno-Vega, M. (2004). MacArthur-Bates communicative development inventories. Retrieved November 4, 2004, from
  73. Munroe, R. L., & Munroe, R. H. (1975). Cross-cultural human development. In L. Dorman & F. Rebelsky (Series Ed.), Life-span human development series. Monteroy, CA: Brookes/Cole Publishing Company.Google Scholar
  74. Nsamenang, A. B. (1992). Human development in cultural context: A third world perspective. Newbury Park, CA: Sage.Google Scholar
  75. Nsamenang, A. B. (2004). Cultures of human development and education: Challenge to growing up Africand New York: Nova Science Publishers.Google Scholar
  76. Nsamenang, A. B. (2005). The intersection of traditional African education with school learning. In L. Swartz, C. de la Rey, & N. Duncan (Eds.), Psychology. Oxford: Oxford University Press.Google Scholar
  77. Nsamenang, A. B. (2006). Human ontogenesis: An indigenous African view on development and intelligence. International Journal of Psychology, 41(4), 293–297.CrossRefGoogle Scholar
  78. Nsamenang, A. B., & Dawes, A. (1998). Developmental psychology as political psychology in sub-Saharan Africa: The challenge of Africanisation. Applied Psychology: An International Review, 47, 73–87.CrossRefGoogle Scholar
  79. Odum, E. (1953). Fundamentals of ecology. Philadelphia: W. B. Saunders.Google Scholar
  80. Ogbu, J. U. (1981). Origins of human competence: A cultural-ecological perspective. Child Development, 52, 413–429.CrossRefGoogle Scholar
  81. Okumu, C. (1999). The social ecology of Malawi orphans. Unpublished master’s thesis, University of Victoria, Victoria, British Columbia, Canada.Google Scholar
  82. Reich, D. (1990). Children of the nightmare. Adoption and Fostering, 14, 9–14.CrossRefGoogle Scholar
  83. Reynolds, C. R. (1983). Test bias: In God we trust: All others must have data. Journal of Special Education, 17, 242–260.CrossRefGoogle Scholar
  84. Richter, L. M., & Grieve, K. W. (1991). Home environments and cognitive development of black infants in impoverished South African families. Infant Mental Health Journal, 12, 88–102.CrossRefGoogle Scholar
  85. Sawadogo, G. (1995). Training for the African mind. International Journal of Intercultural Relations, 19(2), 281–293.CrossRefGoogle Scholar
  86. Segall, M. H., Dasen, P. R., Berry, J. W., & Poortinga, Y. H. (1990). Human behavior in global perspective: An introduction to cross-cultural psychology. Elmsford, NY: Pergamon Press.Google Scholar
  87. Smith, L. B. (2005). Cognition as a dynamic system: Principles from embodiment. Developmental Review, 25, 278–298.CrossRefGoogle Scholar
  88. Smith, L. B., & Thelen, E. (Eds.). (1993). A dynamic systems approach to development: Applications. Cambridge, MA: MIT Press.Google Scholar
  89. Subbarao, K., & Coury, D. (2004). Reaching Out to Africa’s Orphans: A Framework for Public Action. Washington, DC: The World Bank.Google Scholar
  90. Super, C. M., & Harkness, S. (1986). The developmental niche: A conceptualization at the interface of child and culture. International Journal of Behavioral Development, 9, 545–569.CrossRefGoogle Scholar
  91. Super, C. M., & Harkness, S. (1997). The cultural structuring of child development. In J. W. Berry, Y. H. Poortinga, & J. Pandey (Eds.), Handbook of cross-cultural psychology (Theory and method, Vol. 2, pp. 1–40). Boston: Allyn & Bacon.Google Scholar
  92. Thomas, A., Chess, S., Birch, H., Hertzig, M. E., & Korn, S. (1963). Behavioral individuality in early childhood. New York: New York University Press.Google Scholar
  93. Thomas, J. M., & Guskin, K. A. (2001). Disruptive behavior in young children: What does it mean? Journal of the American Academy of Child & Adolescent Psychiatry, 40(1), 44–51.Google Scholar
  94. UNAIDS. (2009). 2009 Fact Sheet on Sub-Saharan Africa. Retrieved March 13, 2011, from
  95. UNICEF (1993). Romania’s children. Bucharest: AuthorGoogle Scholar
  96. UNICEF. (2006). Malnutrition. Retrieved March 25, 2006, from
  97. United Nations. (2008). Malawi: Economic indicators. Retrieved March 13, 2011, from
  98. Valsiner, J. (1987). Culture and the development of children’s action: A cultural-historical theory of developmental psychology. New York: Wiley.Google Scholar
  99. Virtual Linguistics Lab. (2005). Child multilingual questionnaire.Google Scholar
  100. Vygotsky, L. (1986). Thought and language (Rev. ed.) (A. Kozulin, Trans.). Cambridge, MA: The MIT Press.Google Scholar
  101. Weisner, T. S. (1996). The 5-to-7 transition as an ecocultural project. In A. J. Sameroff & M. M. Haith (Eds.), Reason and responsibility: The passage through childhood (pp. 295–326). Chicago: University of Chicago press.Google Scholar
  102. Whiting, J. W. M. (1977). A model for psychocultural research. In D. S. Palermo (Series Ed.), P. H. Leiderman, S. R. Tulkin & A. Rosenfeld (Vol. Eds.), The child psychology series: Experimental and theoretical analyses of child behavior. Culture and infancy: Variations in the human experience. (pp. 211–143). London: Academic Press.Google Scholar
  103. Whiting, J., & Child, I. (1953). Child training and personality. New Haven, CT: Yale University Press.Google Scholar
  104. Whiting, B., & Whiting, J. (1973). Children of six cultures: A psychocultural analysis. Cambridge, MA: Harvard University Press.Google Scholar
  105. Wolff, P. H., & Fesseha, G. (1998). The orphans of Eritrea: Are orphanages part of the problem or part of the solution? American Journal of Psychiatry, 155, 1319–1324.Google Scholar
  106. World Bank Group. (2005). WDI Data Query. Retrieved August 24, 2005, from
  107. World Health Organization. (2007). WHO Statistical Information System (WHOSIS): Core health indicators. Malawi. Retrieved July 13, 2007, from Scholar
  108. Zimmerman, I. L., Steiner, V. G., & Pond, R. E. (2002). Preschool language scale (4th ed.). San Antonio, TX: The Psychological Corporation.Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of PsychologySarah Lawrence CollegeBronxvilleUSA

Personalised recommendations