A case study of school support and the psychological, emotional and behavioural consequences of HIV and AIDS on adolescents

Abstract Various studies have reported a huge increase in the numbers of orphaned adolescents in Sub-Saharan Africa and its effects on their psychological, emotional and behavioural development. Yet, their needs are seldom recognised or adequately addressed in policy and programmes.This article uses a qualitative study to report the experiences of 11 orphaned adolescents (5 boys and 6 girls aged between 15 and 18 years) affected by HIV and AIDS in a secondary school (in Atteridgeville, Pretoria, South Africa) and the school support provided by them. The primary data-generation strategies were informal interviews and the Beck Youth Inventories-II (BYI-II) (adopted to measure the participants’ level of emotional, behavioural and psychological problems). All interview transcriptions with the participants were thematically analysed. BYI-II data were subjected to T scores (in percentages) to know the participant's psychological, behavioural and emotional problems in order to compare it with their perceptions on the degree of support provided by the school. Result shows that participants have a high prevalence of psychological, behavioural and emotional problems and that the school support provided to them (teachers’ support, the general school environment and the degree of discrimination, labelling and bullying that exists in the school) was not sufficient. The participants, however, reported a high level of support from the principal. In conclusion, we have suggested the urgent need for teachers to acquire and possess basic knowledge and skills in caring and paying attention to learners affected by HIV and AIDS and for government agencies and NGOs working with HIV-and AIDS-affected children, to focus on proposals that address the psychological, behavioural and emotional problems in such affected adolescents.


Introduction
HIV and AIDS have been prevalent in the world since being discovered some years ago. According to Thupayagale-Tshweneagae and Mokomane (2013), the HIV and AIDS pandemic has claimed many lives and has not only had a direct influence on the growth and development of many countries but has also led to increasing numbers of orphaned children and adolescents. Worse still, HIVand AIDS-affected adolescents (either sick themselves, with sick parents or orphaned as defined by Andersen 2012) are particularly vulnerable to poor nutrition, mental and physical health, sexual abuse and poverty which consequently tend to have a negative impact on their school enrolment and academic progress (Gregson & Nyamukapa 2007;Malindi & Machenjedze 2012;Mugurungi & Gregson 2007). Moreover, compounding the challenges of losing a parent is the loss of adult guidance and protection, and the likelihood that such children may be at increased risk of emotional, psychological and behavioural problems. This possibility is supported by the UNICEF report (2013) that despite the millions invested in programmes supporting HIVaffected children, many of such children continue to face enormous economic, emotional and social challenges. Findings from the study of Ntaote (2011) also showed that orphaned and vulnerable adolescents are severely affected by the stigma of the disease as they are often teased, bulled and gossiped about by other learners and some of their teachers and also experience discrimination and isolation from the members of their extended families. Other studies also confirm that orphans suffer more vulnerability than non-orphans in terms of education (Foster & Williamson 2000;Grassly & Timaeus 2003;Walraven et al. 1997). This has been a serious concern especially in Sub-Saharan Africa, which continues to have the highest percentage of the global HIV and AIDS crisis (as evident in the UNAIDS World Report 2011).
However, despite the escalation in the numbers of orphaned and vulnerable adolescents in Sub-Saharan Africa and its effects on their psychological, emotional and behavioural development, their needs are seldom recognised or adequately addressed in policy and programmes. According to Thupayagale-Tshweneagae and Mokomane (2013), the focus tends to be on the orphans and vulnerable children instead of on the adolescents. Meanwhile, several factors have been identified that emphasise the importance of creating a supportive environment for orphaned adolescents. For instance, as emphasised by UNICEF (2012), orphaned and vulnerable adolescents often lack role models and social support systems vital to healthy, social, emotional, psychological, behavioural and educational development. In addition, Niang and Van Ufford (2007) found that the challenges faced by affected adolescents contribute to a school environment characterised by distress, anxiety, confusion and lower teaching efficiency. Manuel (2002) also found that in Mozambique, orphans have higher depression symptoms, were easily bullied and less likely to have trusted friends than non-orphans. Also, the study of Wild, Flisher, Laas and Robertson (2006) that was conducted in South Africa reported that other orphaned children exhibited higher signs of depression and anxiety than non-orphaned children, while children whose parents died of AIDS showed intermittent scores. In another study carried out by Atwine, Cantor-Graae and Bajunirwe (2005) in Uganda, using the Beck Youth Inventories TM , children whose parents died of AIDS were found to have significantly higher scores for anxiety and depression than non-orphaned children. However, the study of Cluver, Gardner and Operario (2007) showed a conflicting result as it was reported that more AIDS-orphaned children than nonorphaned children met clinical disorder cut-off points for depression, anxiety, peer problems and post-traumatic stress.
The study of Cluver and Gardner (2006) in South Africa also showed no significant differences between the two groups. These conflicting findings show that studies on the psychological consequences of HIV and AIDS are inconclusive.
In addition, studies by Selesho and Modise (2012) showed that most learners (68%) indicated that becoming an orphan as a result of AIDS is a shocking and sudden change of role in one's life. This sudden change of roles damages them emotionally as many of them have become responsible for taking care of both their siblings and their HIV-infected parents. Also, according to Xu, Yan, Duan, Wang, Rou and Wu (2010), reports show that adolescents living with HIV-positive parents have emotional disturbances including fear and low self-esteem. Orphans and vulnerable children growing up without parental guidance and support may later develop behavioural problems such as depression, isolation, anxiety, difficulty in making friends, low self-esteem, alcohol and drug abuse (UNAIDS 2004;UNICEF 2000). The findings of Fainstein (2010) that most of such adolescents often experience problems with attachment formation, and other facets of emotional and behavioural development further confirm this statement. This explains why the emotional needs of HIV-/AIDS-affected adolescents are still an important issue to be researched further. Weeks (1998) categorised behavioural problems into more serious behaviour (juvenile delinquency and sexual child abuse); serious problems (truancy or bullying) and behavioural problems of a minor nature (lying and not being punctual which are temporal). Chimbenga (2002) also pointed out that problem behaviour in the classroom frustrates teachers' efforts during the teachinglearning process, thereby interfering with the classroom learning activities of the learner. Makame, Ani and Grantham-McGregor (2002) carried out a study using an adapted version of the Rand Mental Health and Beck Depression Inventories and found that orphaned children showed markedly higher internalising problems, increased suicidal ideation, often went to bed hungry and were more likely to be out of school. In addition, according to Jacobs (2011), HIV-and AIDS-affected learners from disrupted societies and those left homeless by HIV, AIDS and poverty, in contrast with their more affluent peers, join gangs rather than youth groups to attain a sense of belonging and to escape their loneliness. Furthermore, Cluver and Gardner (2006) found that adolescents affected by HIV and AIDS were less likely to have close friends, more likely to lose their temper quickly, exhibit difficulty concentrating and have somatic symptoms and nightmares. In addition, Nyamukapa et al. (2008) found that in their need for emotional security, HIV-and AIDS-affected adolescents may lack the ability to explore and make choices and may show signs of aggression, helplessness, sadness, depression and negative self-concepts.
A major challenge facing many schools in Sub-Saharan Africa, especially in South Africa, is therefore how to protect adolescents who are affected by physical, psychological and emotional risks. Provision of a safe and supportive environment with adequate and well-trained teachers, adequate resources and appropriate teaching conditions in order for such adolescents to achieve their full potential and quality education continues to challenge South African secondary schools. This statement is supported by the UNICEF (2009) conclusions on the need to create a supportive school environment with schools focussing on the child's needs as a whole: their health, safety, security, nutritional status and psychological well-being. Also, according to UNICEF (2009), such schools must be a place of play and healthy interaction, preventing and confronting harassment and antisocial behaviour, abuse, bullying, sexual exploitation, violence, stigma and discrimination. According to Attig and Hopkins (2006), these types of psychosocial support measures have proved successful in integrating orphans and vulnerable learners into the school community, resulting in improved mental health, reduced behavioural problems as well as dropout and higher school completion rates. Findings in the study of Ntaote (2011) also showed that many teachers were faced with the increasing burden of teaching children affected by the HIV and AIDS pandemic and, as a result, they are at times called names, stigmatised and even discriminated against.
Another important aspect of a school's supportive environment is how effectively the principal manages the school. According to UNESCO & ESART (2009), school principals in the worst HIVand AIDS-affected areas are often faced with serious managerial problems caused by the pandemic, which not only affect their managerial skills, but also impede their ability to attain successful self-actualisation because of managerial stress and in such an environment, HIV-affected learners dare not disclose their problems. Kganare (2001) found that HIV-and AIDS-affected learners have feelings of inferiority and frustration, which impact negatively on their self-actualisation and also lead to disciplinary and absenteeism problems in school management, which, in turn, leads to problems with quality control and classroom management, disrupting curriculum coverage. This results in poor academic achievement and therefore principals of such schools are faced with almost insurmountable difficulties in delivering quality education. This explains why school principals need to be trained to create caring environments in their schools. A good school with a competent teacher can develop the selfesteem of orphans and vulnerable children as well as facilitate better job opportunities and economic independence (Save the Children 2011).
However, although schools can be an invaluable source of support for children by providing stability and institutional affiliation (Murray 2010), reducing levels of stigma (Brown, Macintyre & Trujillo 2003) an important resource for successful coping (Skovdal, Ogutu, Aoro & Campbell 2009)  . These findings reflect the findings of Govender (2004) that the quality of teaching and learning in Sub-Saharan African schools is under severe threat as the number of orphaned and vulnerable children escalates. According to him, the consequences of such problems are seen in the classroom as teachers struggle to balance the already challenging teaching-learning business with the additional demands imposed by the increased levels of anxiety, limited concentration spans, severe trauma, heightened discrimination and stigma, as well as increased poverty experienced by these orphans. In Western Europe, a cross-sectional study of children and adolescents living with HIV-positive parents found that HIV-positive children had significantly more reports of discrimination than HIV-negative ones (Nostlinger, Bartoli & Gondillo 2006). In Benin, a cross-sectional study of orphans and vulnerable children (including those affected by HIV and AIDS) with a control group showed that orphans and vulnerable children were more likely to be rejected or isolated at school than the control group children (GECA 2005). In addition, a large qualitative study conducted in India (Loudon, Bhaskar & Bhutia 2007) of HIV-affected children (with an HIV-positive parent or orphaned by AIDS) reported in certain cases that teachers actively discriminated and even mistreated affected children in the classroom by neglecting or abusing them. In a Namibian study by UNESCO & ESART (2009), which examined the educational needs of HIV-positive learners, a school counsellor in a focus group said she feels inadequate as she may not give the needed help or deal with learners' issues in the correct way. She felt she needed training in dealing with the stigma and discrimination.
According to Andersen (2012), more in-depth qualitative research from HIV-affected children and adolescents is needed in order to understand their needs and how they feel about the ways schools support them to cope with adversity in their everyday lives. It is very important to create an enabling environment of supportive teachers, principals, peer groups, friends and an environment that will help ensure that their full range of rights and needs are respected and fulfilled. The major focus of this study is therefore to investigate the school climate as a mediator for the well-being of orphaned adolescents affected by HIV and AIDS in order to become psychologically, behaviourally and emotionally well-developed so that they can enjoy full access to education.

Research settings and study design
This study employed the qualitative approach to data collection. Qualitative research is particularly appropriate for this study as it can give an in-depth account and details of the phenomena that are otherwise difficult to convey with quantitative methods and it seeks to gain rich, comprehensive data from a small number of participants (Creswell 2005). The research data collected from the field not only provided descriptive data essential in this study, but also made it possible for the researchers to triangulate data from the participants for the purpose of reporting the study findings. The population of interest was orphaned South African adolescent learners who are affected by HIV and AIDS. The UN definition of orphanhood was used in this study; that is, loss of one or both parents (UNAIDS 2004).
Recruiting participants for the study was purposive in nature, guided by the information provided by the school support team coordinator. The participants were 11 orphaned adolescents (males ¼ 5, females ¼ 6; mean age ¼ 16) who are affected by HIV and AIDS and are learners in Grades 8 -10 in a Secondary School in Atteridgeville, Pretoria, South Africa. Atteridgeville is an urban, historically disadvantaged post-apartheid township comprised of informal dwellings with mainly indigenous black Africans and situated west of Pretoria. The school has a total population of 1100 learners, 36 educators and a teacher -learner ratio of 1:47. The particular school was chosen because it was suggested by a Gauteng district official and largely due to the fact that it is located in a community where there are many HIV-and AIDS-affected households (HRSC Survey 2014; Shisana et al. 2005;Statistics, South Africa 2004).
The choice of the study was also determined by practical considerations, namely the location of the researchers which is a convenient means of recruiting and collecting data from the participants within a short period. To be eligible to participate, participants were required to be in grade 8 -10, 15-18 years of age, orphaned by HIV and do not live with both parents. Adolescents aged 15 -18 years were targeted as participants because at this age, their cognitive development allows them to be aware of their problems and can interpret and assess the degree of supportive environment provided in the school. Participants may not be HIV-positive. No testing or documentation was used to confirm the status of the participants but the researchers relied on the selection done by the school's support team coordinator who has privileged information of some of the learners due to her relationship and background knowledge of them as they shared their problems with her (Although, this selection was not done until the researchers gave full assurance of confidentiality and information anonymity about the participants).
Ethical approval was first obtained from the Gauteng Department of Education and secondly from the Ethics Committee of the College of Education at the University of South Africa. Consent forms, developed in English, were given to participants to be signed by them and their wards. The form gave detailed information about the research. The participants were allowed to participate in the study only after the form was signed. All the participants were informed about the study and its goals as well as the protection of their privacy and sensitivity. Participation in the research was voluntary and participants were informed of their right to terminate their participation. Great care was also taken to ensure that social, political and human implications of the study did not cause any harm. In order to protect the privacy as well as respect the confidentiality of the participants' status, the researchers were alert and conscious of statements and actions (overt or covert) that could cause them harm. The learner's rights to information, privacy, dignity and respect were safeguarded at all times. The researchers were also sensitive to participants' needs at all times.

Data collection
The researchers made use of informal interviews and the Beck Youth Inventories-II (BYI-II) as data-generation strategies. The interviews were based upon multiple activities aimed at generating thick, rich, detailed descriptions of the adolescents' experiences (Terre, Blanche & Durrheim 1999). Literature from child-friendly schools by Attig and Hopkins (2006) on how the school can assist in supporting children affected by HIV and AIDS was used to structure the open-ended interview schedule. These structured questions were used to gain insights into the various ways in which orphaned adolescents affected by HIV and AIDS, who are stakeholders in this study, see the problem from their various individual perception. Although the researchers are psychologists, there was no attempt to analyse these activities from either a research or psychological perspective. In this regard, the main aim was to create data-generation sessions (interviews) that were non-threatening and stimulating for the participants as a means to possibly reduce anxiety and encourage a safe research environment for the adolescents. All sessions were tape-recorded and transcribed. Each set of interviews took about 35-40 minutes (during the break and in the school support team coordinator's second office). Owing to the qualitative nature of the study, the researchers did not adhere to a formal observation schedule.
The Beck Youth Inventories TM (BYI-II), developed by Beck, Beck, Jolly and Steer (2005), was adopted to measure the participants (adolescents) level of emotional, behavioural and psychological problems. The BYI-II is a set of norm-referenced diagnostic scales designed to assess children and youth between the ages of 7 and 18 with regard to depression, anxiety, anger, disruptive behaviour and self-concept. Each of the inventories consists of 20 items that are self-rated on a 4-point scale of 0 to 3. It has internal consistency of Cronbach's alpha coefficient that ranged from .91 to .96 for ages 15 -18 across all five scales and a convergent validity measure of .72. Completion of the questionnaire took about 20 minutes.

Data analysis
All interview transcriptions with the participants were thematically analysed. The information from the structured interviews was read through and re-read to enable coding to be done in order to identify emerging themes and their relationship to the study objectives. This thematic content analysis method enabled the researchers to identify and also acknowledge the opinions of the participants. The steps consisted of open coding using the participants' own words and phrases and without preconceived notions or classification; examining language used by each participant; categorising the information from all the interviews and finally theoretical coding in which open codes and categories were compared to generate an analytic schema and to interpret the findings (Miles, Huberman & Saldaña 2014). BYI-II data were subjected to T scores (in percentages) to know the participant's psychological, behavioural and emotional problems in order to compare it with their perceptions on the degree of support provided by the school. The 4-point Likert scale ranges from 0 to 3 (Table 1).

Demographics
A total of 11 orphaned adolescents were interviewed and also responded to the BYI-II questionnaire. Participants interviewed were 5 males and 6 females between the ages of 15 and 18 years. Orphanhood was double (63.6%), paternal (36.4%) or

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Journal of Social Aspects of HIV/AIDS VOL. 12 NO. 1 2015 maternal (0.0%). Five (5) of the participants (45.4%) were 15 years old, 2 (18.2%) were 16 years, 2 (18.2%) and another 2 (18.2%) were 17 and 18 years, respectively. Four of them representing (36.4%) the total participants were in grade 8 while two (18.2%) were in grade 9 and three (45.4%) were in grade 10. Six (54.5%) of the orphaned adolescents interviewed stay with their aunts, three (27.3%) stay with their mothers, one (9.1%) stays with her brother while the remaining one (9.1%) stays with his sister and grandmother. The researchers limit reporting the results to four main themes; (1) supportive environment created by teachers, supportive environment created by the principal, (3) general environment of the school and (4) the degree of discrimination, stigmatisation and bullying that existed in the school. In this study, these four themes reflected the most prevalent areas of a supportive school environment. Participants' opinion are rated (as none, little and much) in Table 2. Quotes for each theme, illustrating the feelings of participants, are provided below. When asked how he knows most of the teachers do not like him, his response is expressed in the following quotes:  Principal's degree of friendliness to participants 1(9.1) 1(9.1) 9(81.8) Accessibility of the principal to participants 2(18. . . . When someone doesn't like you, it will show in his approach to you. At times, they shout at me or tell me to come back later when I ask them a question. Meanwhile, they will answer other learners more patiently. In addition, 6 out of the 11 participants reported that the school support team coordinator respects and has a good relationship with them while other teachers often shout at them and, as a result, they always find it difficult to share their problems and needs with them. In Table 2, 9 (81.8%) participants reported that teachers had no relationship with them, while only 2 (18.2%) reported little relationship with teachers and none reported much relationship with teachers. This is expressed in the following quotes: . . . Mostly, it is the school support team coordinator that is nice to us but not all of them have a relationship with me. If I want to talk to some of them, at times they may say they are going to class. Some of them are only close to the learners they know . . . (Participant 2) . . . It is only a few of the women that have a good relationship with me. They communicate with me more than male teachers. The women are more patient and spend more time with me. I give women 90% and men, 10% . . . (Participant 1) . . . Teachers don't have a relationship with me because we are many in class. They don't know all of us. They also don't know our background . . . (Participant 4) Another participant also reported that only a few teachers show her respect and that it is only the female teachers that she has a good relationship. She also complained that teachers do not quickly respond to her needs. The bitter feeling of another learner on this issue is expressed in the quote below: . . . Teachers in my school don't have any respect for me. When I do something wrong, they don't correct me nicely but shout and make fun of me in front of other learners and I feel small and dejected . . . (Participant 9) Thus, while only 2 (18.2%) of the 11 participants reported that teachers have much respect for them, 3 (27.3) of the participants reported little respect and as much as 5 participants reported teachers' lack of respect for them.
On the category relating to how teachers respond to participants' needs and problems, most of them complained that the teachers do not have time for them. An example is shown in the quote below: . . . No quick response. They also have their problems. Most of the time they will tell us to work hard and read our books or we should go and tell our friends our problems . . . (Participant 5) As much as 8 (72.7%) of the 11 participants reported that teachers do not quickly respond to their needs and problems while only 2 (18.2%) reported that teachers do respond quickly.
In addition, 8 (72.7%) participants reported that teachers do not trust nor have confidence in them. An example of such opinion is shown in the quotes below: . . . I can say that teachers don't have confidence in me. It's only very few of them that do so. This does not help me to have confidence in myself. It is only the learners that are doing well that they respect and trust . . . I can score them 3/10. They often shout at me and they don't talk in a friendly way to me . . . (Participant 4)

Theme 2: Supportive environment created by the principal
The level of support the principal gives to orphaned adolescents affected by HIV and AIDS (in terms of how friendly and assessable he/she is to them, the degree of participation he allows in the decision of the school rules, how responsive he is to their needs and the extent to which he gives room for play and co-curricular activities) was shown in this theme. The opinions of the participants are reported in the following quotes: . . . The principal gives us opportunities to participate in making decisions in the school, at times he postpones the date of an event because we learners are going somewhere . . . (Participant 2) On the opportunity given to participants in decision-making, 5 (45.5%) reported that the principal does not give them opportunity to participate in decisions that concerns them. While 2 (18.2%) of the participants reported that he allows a little participation, 4 (36.3%) reported that the principal allows them to participate in such decisions. One of the participants who did not believe that the principal gives them room to participate in decisions reported in the following quotes that: . . . The principal does not give us opportunity to participate. When he is happy, he can smile and listen to us patiently. But when he is not happy, he can shout on the assembly. . . .

(Participant 5)
However, on the issue of how friendly the principal is, while only one participant (representing 9.1%) reported that the principal

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Journal of Social Aspects of HIV/AIDS VOL. 12 NO. 1 2015 was not friendly, another participant (9.1%) reported that he was a little friendly but as many as nine (81.8%) reported that he was very friendly. This is expressed in the following quotes: The principal laughs and smiles with us. I can easily approach him to report any student that is troubling me . . . (Participant 3) . . . I can say that our principal is friendly. He doesn't shout at us, he greets us as a father does to his child. He doesn't shout at us and even on the assembly he doesn't shout at us. Although, I have not gone to him for anything before but I have seen a girl in grade 12 going to him for money and he gave her . . . (Participant 2) He also added that the principal normally gives room for play and that they have opportunity to play football and volley ball: . . . The principal asks us what we wish to eat at times. He also asks us if we are happy. He keeps a smile on his face every morning and he often asks us how we feel . . . (Participant 6) . . . Our principal is friendly. He encourages us on the assembly and tells us how to respect others. He also smiles and cracks jokes. Our principal gives us a lot of opportunities to participate in co-curricular activities . . . (Participant 1) The structured interview on how accessible the principal is to participants shows that while only 2 (18.2%) participants each reported little and no accessibility, more participants (7, representing 63.6%) reported that the principal was very accessible to them. An example of this is expressed in the quote below: . . . He always tells us to come to him any time we have problems and at times he comes to class and asks us if we are okay. The principal always makes sure that everything is okay with us . . . (Participant 6) On the sub-theme regarding how the principal responds to participants' needs and problems, most of the participants (6, representing 54.5%) reported much and quick response of the principal to their problems while five (45.5%) participants and none of the participants reported little and no response, respectively.
Theme 3: General environment of the school As shown in Table 2, structured interviews with participants revealed that inadequate health services, dirty toilets and unattractive environment were a reported problem by all the participants. For instance, while all (100%) participants reported a poor health facility, 7 (63.6%) reported poor and unattractive environment. However, almost all the participants (72.7% and 81.8%) reported a high quality of food services and much space for play and simulation.
The opinions of the participants are reported in the following quotes: . . . The health facility of our school is poor. No clinic, no nurse. They only send us home when we are sick. It is only the food that is sweet. I can score them 100%. It is sweet and it is always enough for everybody. The school is not attractive. Learners drop papers anywhere. The buildings in the school are not fine . . . (Participant 11) . . . The health facility in my school is not adequate. We don't have a clinic and nurse. We only have a first aid box. The food is sweet and it normally goes round. But our school is not attractive because we don't have nice furniture and beautiful flowers . . . (Participant 10) . . . The small room they ask someone who is sick to rest doesn't look like a clinic and there is no nurse. The food is always adequate but I don't like the way they prepare it. They give us tiny fish, with no meat but only cabbage. I can score them 60%. The school is not too attractive because there are not many flowers and no garden. I can score them 50%. . . . (Participant 6) Theme 4: The degree of discrimination, stigmatisation and bullying existing in the school Almost (81.8%, 100% and 63.6%) all the 11 orphaned adolescents interviewed reported a continuous problem of discrimination, bullying and stigmatisation in the school. These opinions are expressed in the following quotes: . . . Some teachers call me names such as 'fool, 'little witch etc. and that they don't sleep in the night each time they remember me . . . And sometimes when I am fighting with another learner, they don't want to know what happened. They just judge me instantly without asking for my opinion. This makes me to feel like a lost person who doesn't have anything . . . (Participant 9) . . . Teachers don't respond to everybody's needs and problems. It is only those they know and like that they care for. Some learners come from poor backgrounds and they don't have uniforms, money etc and nobody cares for them. It is also learners that are doing well that teachers respect and trust . . . (Participant 11) . . . Teachers in my school discriminate a lot . . . Most teachers think I am a crook. So I used to dodge the classes of such teachers. When I tell such teachers that I want to go to toilet, they refuse while they allow other students to go . . . There is also bullying among learners in my school.
There was a time that a learner in grade 9 took the money of another learner in grade 8 . . . (Participant 6) . . . Some teachers prefer some students to others. (Participant 2)

Discussion
This study provides rich insights into HIV and AIDS-orphaned adolescents' experiences in a secondary school in Atteridgeville, Pretoria. It is one of the few studies that focused on exploring the psychological, behavioural and emotional consequences of HIV and AIDS on orphaned adolescents vis-à-vis their opinions of the support from the principal, teachers and the general school environment. The findings of this study indicate that orphaned adolescents did not get support (in terms of love, care, good relationship, respect, trust and confidence from their teachers), as all the participants reported that most teachers do not show love and care to them, neither do they have good relationships with them. No wonder the scores of the participants on psychological, behavioural and emotional problems were very high (as shown in Table 3). As indicated by the participants, the efforts of only one teacher (the school support team coordinator) cannot create a safe environment for orphaned adolescents affected by HIV and AIDS. There is need for other teachers to be trained on how to develop healthier relationships with orphaned adolescents affected by HIV and AIDS. This finding lends credence to the research findings of Van Deventer, Van den Brande, Braat, van den Brink, Versteeg, Bauer et al. (2003) who reported that learners perform better in the classes of teachers they trust and like and where a positive class climate prevails and that the teacher's attitude, personality, appearance, behaviour in class, sense of fairness, discipline and enthusiasm can have a positive or negative influence on the learner's attitude and interest in the learning activity. In another study by McNeeley (2005), the studentteacher relationship was found to be the key predictor of decreased at-risk behaviour. Findings from the study of Cothran, Kulinna and Garragy (2003) and that of Govender (2004) also support the result of this study.
In addition, participants in this study reported a high level of support from their principal, as most of them claimed he was very friendly and responsive to their needs. This finding is contrary to that of Kganare (2001), which found that principals at schools with HIV-and AIDS-affected learners are faced with insurmountable difficulties in delivering quality education because of the disciplinary and absenteeism problems in school management, problems with quality control and classroom management and disrupting curriculum coverage resulting in poor academic achievement.
On the third theme which explored participating orphans' opinions on the general school environment (in terms of health facilities, access to healthy food, neat environment, enough space for play and recreation and attractiveness of the school), most participants reported a generally poor school environment that is unsupportive. This is contrary to the position of UNESCO & ESART (2009) that areas with high HIV prevalence need special hygiene vigilance in schools and preschools to protect children from opportunistic infections and that although clean water supplies, hygienic toilets and the hygienic preparation of school meals are always important in schools, standards need to be particularly high in schools with HIV-affected children.
On the issue of discrimination, bullying and stigmatisation, the findings of this study are supported by results of studies in South Africa and other nations. For instance, in a Western Europe study, HIV and AIDS-affected children had significantly more reports of discrimination than their counterparts who were not affected. In a Nigerian study (in Benin), orphans and vulnerable adolescents were more frequently rejected and isolated at school than the control group children (GECA 2005). This finding is also supported by those of Loudon et al. (2007); UNESCO & ESART (2009);Ntaote (2011); Grassly and Timaeus (2003); Foster and Williamson (2000) and Walraven et al. (1997).
Study findings also revealed that orphaned adolescents affected by HIV and AIDS had high scores of behavioural problems (anger and disruptive behaviour). This could be because such children lack the necessary parental guidance to form habits and identity and become socialised into healthy adults. This reasoning is substantiated by UNICEF (2012), who opined  Sinha and Kumar (2010), who reported that HIV and AIDS cause a range of difficulties including emotional and behavioural disturbances among affected people. Rotheram-Borus, Lin and Lester (2004) also found that HIV-and AIDS-affected adolescents have higher scores in conduct problems than non-affected adolescents. The study also found high scores of psychological problems (anxiety and depression) in orphaned adolescents affected by HIV and AIDS. This is supported by the study of Landis (2002) et al. (2005). However, the studies of Wild et al. (2006) reported a conflicting result. The study of Cluver and Gardner (2006), conducted in South Africa, also found no significant differences between depression and anxiety among orphaned and non-orphaned children.
Another finding in this study is the high emotional (self-concept) scores of participants. This may be due to the poverty and suffering they face as a result of their parents' illness and eventual death. This possibility is substantiated by Mather (2002), who found orphaned adolescents affected by HIV and AIDS had feelings of helplessness about their futures and/as well as negative selfconcept. This study is in agreement with the findings of Fainstein (2010), Doku (2009) and Xu et al. (2010) who also found that adolescents affected by HIV-positive parents have emotional disturbances including fear and low self-esteem. However, the result of this study disagrees with that of Wild et al. (2006).
The limitations of this case study include the limited sample size (only one school included as a case study) as well as the sensitivity with which the study had to be conducted. We reported on the experiences of 11 adolescents who attend school in a specific context. As this is a purposefully selected case study, we acknowledged that findings cannot be generalised to other schools; however, it has theoretical generalisation within the research context. A further limitation was recruiting the participants through the guidance of the school support team coordinator based on privileged background information and relationship with the learners. (Although, getting information directly from participants regarding their parents' cause of death would have been impossible). Furthermore, for the purpose of this specific case study (with a limited sample size), no distinction was made in the analysis of data between the adolescents who were HIV-positive and treated with medication and those who were HIV-negative. In addition, we chose not to distinguish between the orphaned adolescents and the non-orphaned adolescents in the analysis of data. However, the strengths of this study include the use of qualitative methods and conducting qualitative interviews as well as the use of BYI-II to collect data on participants' psychological, emotional and behavioural problems. We believe these strengths enabled this study to provide a rich description of the HIV and AIDS-affected orphaned adolescents' subjective experiences and give an insight into the complexities that may be applicable to many adolescents living in similar circumstances.

Conclusion
The main finding of this study is that orphaned adolescents that are affected by HIV and AIDS have a high prevalence of psychological, behavioural and emotional problems and that the school support provided to them (in terms of the support provided by teachers, the general school environment and the degree of discrimination, labelling and bullying that exists in the school) was not sufficient. The study's findings thus justify the importance of improving the supportive school environment for such orphaned adolescents. Teachers and the principal must be able to assist these orphaned adolescents to have more interests in school and the subjects taught, if indeed they want to maximise their potential in life when compared to their non-affected counterparts. The study also justifies the need for teachers to be prepared for their roles as educators in a world affected by HIV and AIDS. In addition, the findings highlight the need for the principal and teachers to create a friendlier environment free of violence, labelling and stigmatisation, but rather an atmosphere of love, respect and utmost care and concern for learners. The school is therefore in dire need of assistance to create an enabling environment of supportive teachers, friends, principal and an environment free from stigma, labelling and violence in order to help affected adolescents reach their full range of rights and needs, become better equipped psychologically, behaviourally and emotionally as well as enjoy full access to education like their non-affected counterparts.

Recommendations
After conducting this study, the main recommendation is the urgent need for teachers to acquire and possess basic knowledge and skills in caring and paying attention to learners affected by HIV and AIDS, in order that these learners will trust them enough to share their problems and concerns with them. This recommendation is in agreement with the findings of Van Deventer et al. (2003) that learners perform better in the classes of teachers they trust and like/respect. Teachers should also be attentive to individual learners' needs when presenting their subject matter. This is important because findings reveal that most learners affected by HIV and AIDS are often worried about their status and may not be able to fully concentrate in class, but teachers with understanding of individual differences will be of great help to these affected learners. The principal, as the school manager, must also ensure that teachers are effective by having in place the correct management structures in the school. Effective interaction and communication between teachers and learners and among learners themselves that will generate more love and support for these affected learners must be ensured. In agreement with Ansell (2008), there is also a need for schools to go beyond knowledge and provide more comprehensive support for HIV-affected and orphaned children, particularly in the light of the dwindling capacity of struggling households in providing adequate care and support for children in their care. Efforts should also be made by government agencies and NGOs working with HIV-and AIDS-affected children, to focus on proposals that address the psychological, behavioural and emotional problems in such affected adolescents. Further studies are needed to empirically examine larger populations and could also involve multiple informants including caregivers, parents, teachers and other immediate family relatives in generating data to be triangulated.