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W. Elarousy ^1,2 and M. Al-Jadaani ¹

سوء المعاملة العاطفية للأطفال: دراسة في جدة، المملكة العربية السعودية

وفاء العروسي، مرادي الجدعاني

الخلاصة: سوء المعاملة العاطفية للأطفال هو أكثر أشكال سوء معاملة الأطفال سرية وأقلها تقديراً. ويعرض الباحثان لدراسة استكشافية أجريت في المملكة العربية السعودية حول معدل وأنواع سوء المعاملة العاطفية بين الأطفال وارتباطه بمتغيرات منتقاة. وقد اختيرت عينة ملائمة تتكون من 60 طفلاً تتراوح أعمارهم بين 12-18 عاماً من ثلاثة مراكز تسوّق في جدة. وجرى استيفاء استمارة استبيان ذاتية اعتماداً على أسئلة خصوصية للأطفال وبموافقة الوالدين. وعموما أعرب ٪90 من المشاركين عن تعرضهم لشكل واحد على الأقل من أشكال سوء المعاملة العاطفية، وتعرض منهم ٪61.7 شكلا واحداً على الأقل من أشكال سوء المعاملة القائم على التجاهل أو الترويع. وارتبطت الأمراض المزمنة لدى الآباء والأمهات ارتباطاً إيجابياً على نحو يُعْتَد به مع سوء المعاملة العاطفية المثير للترويع. وكان هناك علاقة سلبية يُعتدّ بها إحصائياً بين علاقة الأم مع الطفل وأنواع سوء المعاملة العاطفية القائمة على التجاهل والترويع. ومازال هناك حاجة إلى إجراء المزيد من البحوث حول معدَّل الانتشار المجتمعي، وارتباطات وعواقب سوء المعاملة العاطفية للأطفال في المملكة العربية السعودية.

ABSTRACT Emotional abuse is the most hidden and underestimated form of child maltreatment. We report an exploratory study in Saudi Arabia of the rate and types of emotional abuse among children and its association with selected variables. A convenience sample of 60 children aged 12–18 years was recruited from 3 malls in Jeddah. A specially designed, self-administered questionnaire was completed in confidence by the children with the consent of parents. Overall 90% of participants reported at least 1 form of rejecting emotional abuse and 61.7% at least 1 form of ignoring or terrorizing types of abuse. Chronic illness among parents was significantly positively correlated with terrorizing emotional abuse. There was a statistically significant negative correlation between mothers’ relationship with the child and ignoring and terrorizing types of emotional abuse. Further research is needed about the community prevalence, correlates and consequences of child emotional abuse in Saudi Arabia.

Violence psychologique chez l'enfant : une étude à Djeddah (Arabie saoudite)

RÉSUMÉ La violence psychologique est la forme la plus sous-estimée et cachée de maltraitance chez l'enfant. Nous présentons une étude exploratoire en Arabie saoudite, portant sur les taux et les types de violence psychologique chez l'enfant et son association à des variables sélectionnées. Un échantillon de commodité de 60 enfants âgés de 12 à 18 ans a été recruté dans trois centres commerciaux de Djeddah. Un questionnaire auto-administré spécialement conçu a été rempli de manière confidentielle par les enfants avec le consentement de leurs parents. Globalement, 90 % des participants ont déclaré avoir souffert d’au moins une forme de violence psychologique par le rejet et 61,7  % d’au moins une forme de mauvais traitements impliquant la négligence ou la terreur à leur encontre. Une maladie chronique des parents était significativement et positivement corrélée à la violence psychologique exercée par la terreur. Une corrélation négative statistiquement significative a été observée entre la relation de la mère avec son enfant et les types de violence psychologique impliquant le rejet et la terreur. Des recherches plus approfondies sont requises sur la prévalence dans la communauté, les corrélations et les conséquences de la violence psychologique chez l'enfant en Arabie Saoudite.

¹College of Nursing, King Saud Bin Abdulaziz University for Health Science, Jeddah, Saudi Arabia (Correspondence to W. El-Arousy: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
²Faculty of Nursing, University of Alexandria, Alexandria, Egypt.
Received: 20/05/12; accepted: 25/06/12
EMHJ, 2013, 19(10):869-875

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Introduction

Every child has the right to health and a life free from violence. Each year, though, millions of children around the world are the victims and witnesses of physical, sexual and emotional violence [1]. Emotional abuse does not leave physical injuries and its ongoing nature usually means there is no crisis that would precipitate its identification by the health, welfare or criminal justice systems. For that reason emotional abuse is the most hidden and underestimated form of child maltreatment [2]. The consequences of child emotional abuse can be devastating and long-lasting and include increased risk for a lifelong pattern of depression, anxiety, low self-esteem, inappropriate or troubled relationships or a lack of empathy [3]. The consequences of children abuse are affected by many variables including: the nature, frequency, intensity and duration of abuse [4].Studies conducted in the Arab Peninsula revealed that children there are subjected to all forms of child maltreatment. Child abuse is ignored or may even be tolerated and accepted as a form of discipline [5].

Emotional and psychological abuse involves both isolated incidents, as well as a pattern of failure over time on the part of a parent or caregiver to provide a developmentally appropriate and supportive environment. Acts in this category may have a high probability of damaging the child’s physical or mental health, spiritual, moral or social development. Abuse of this type includes: the restriction of movement; patterns of belittling, blaming, threatening, frightening, discriminating against or ridiculing; and other non-physical forms of rejection or hostile treatment [2]. Rejecting, ignoring and terrorizing are types of emotional abuse. Rejecting means putting down a child or youth's worth or putting down their needs. Ignoring is failing to give any response to or interact with a child or youth at all. Terrorizing is defined as causing a child or youth to be terrified by the constant use of threats and/or intimidating behaviour [6,7].

Research efforts to gain a clear understanding of the origins, nature and risk factors of child emotional abuse are needed. An increased understanding of child emotional abuse is essential before practitioners and policy-makers can begin crafting policy and interventions aimed at addressing child emotional abuse. We report an exploratory study in Saudi Arabia of the level of emotional abuse among a convenience sample of children from malls, to describe the forms of rejecting, ignoring and terrorizing emotional abuse reported by the children and to describe the association between the forms of emotional abuse and selected variables.

Methods

Study design and sample

A descriptive, correlational study design was used [8]. A convenience sample of 60 children were recruited over the 2 months from December 2011 to January 2012 from among families visiting 3 different malls in Jeddah, Saudi Arabia. These malls are among the largest malls in Jeddah and are visited by all different social groups. The inclusion criteria: were male and female children aged 12–18 years who were willing to participate in the study and whose guardians agreed to the child participating. The exclusion criteria were children and their guardians who refused to participate in the study. A total of 100 families were approached but 40 families refused after reading the questionnaire.

Data collection

The questionnaire was developed by the researchers, after a review of the literature. It included 2 parts: demographic data of the child and parents (age, sex, education level) and questions about the forms of emotional abuse. The questions were in the form of statements that reflect rejecting, ignoring and terrorizing types of emotional abuse and the participants responded to each statement by 4 options: usually, sometimes, rarely or never. A pilot study was done by asking 10 children to complete the questionnaire and any necessary modifications were made to the questionnaire. The validity of the questionnaire was determined by asking experts to assess the relevance to and coverage of the topic and necessary modifications were done. Test of reliability showed a Cronbach alpha of 0.78, which is acceptable according to Burn and Grove [9].

The researcher visited the malls at weekends (Thursday and Friday) and introduced herself and the purposes of the study to available children and their guardians in the mall. The researcher distributed a self-administered questionnaire to those participants who were willing to participate, after asking their guardians to sign the informed consent. The form was filled by the child on another table away from the parents in the same food court. To minimize the possibility of bias the researchers ensured that data collection was standardized and that the respondents received standardized instructions on how to complete the questionnaires.

The information of the current study was handled confidentially. All identifying information obtained was coded and kept in a locked file and no one had access to the data except the researchers. Data was presented in aggregated format so that participants’ identification was secured. Children’s guardians signed a consent form for them to participate in the study after learning that participation was voluntary. No other ethical issues were of concern. The study was approved by the College of Nursing research committee.

Statistical analysis

Statistical analysis was carried out using SPSS, version 18.0 software. The data were illustrated using simple descriptive statistics and cross-tabulations. The chi-squared test was used to compare differences and the Pearson test was used for correlations. P-value < 0.05 was considered statistically significant.

Results

Table 1 illustrates the demographic characteristics of the children. Their ages ranged from 13 to 18 years with mean age of 16.0 (SD 1.6) years; 38.3% of the children were males while 61.7% were females. All of them were Saudi nationals. One-quarter (25.0%) of mothers and 38.3% of fathers had university education, while 5.0% of mothers and 6.7% of fathers were illiterate. One-third of mothers (33.3%) had a job, and the remaining two-thirds were housewives, while 85.0% of fathers had a job and 15.0% were not working. A chronic disease was reported by 53.3% of parents.

Table 2 presents the children–parent relationships, as reported by children on a scale that ranged from strong to bad relationship. A strong relationship with the mother was reported by 73.3% of children and with the father by 53.3%, while a weak relationship was reported with the mother by 18.3% and with the father by 25.0%. No relationship (neither good nor bad) was reported by 6.7% of children for the mother and 16.7% of for the father. A few children described their relationship with their mother and father as bad (1.7% and 5.0% respectively).

Table 3 illustrates the percentage distribution of children according to types of emotional abuse. It was found that 90.0% of children reported at least one form of rejecting emotional abuse while 61.7% reported at least one form of ignoring or terrorizing type of emotional abuse.

Table 4 illustrates the percentage distribution of children according to types of emotional abuse. Among the items covering rejecting type of emotional abuse, usually “yelling at me” was reported by 26.7% of children followed by usually “treating me as a child” reported by 21.7%. Usually “criticizing me” was reported by 16.7% and sometimes “criticizing me” reported by 43.3% while only 1 child reported usually “telling me, I am ugly”. In regards to ignoring type of abuse, usually “failing to pay attention to my significant events” was reported by 26.7% followed by “lack of attention to schooling, peers” which was reported by 23.3%, while only 1 child reported “denying me required health care”. Among the items for terrorizing type of emotional abuse, usually “hits my mother in front of me” was reported by 21.7% of children followed by usually “yelling, cursing and scaring me” by 18.3% of them.

More than half of the children aged 16+ years old reported at least one form of rejecting, ignoring or terrorizing emotional abuse. The differences according to the child’s age were statistically significant for rejecting and terrorizing types of emotional abuse. Slightly more females reported the 3 types of emotional abuse than did males but the difference between the sexes was not statistically significant (Table 5).

The Pearson correlation coefficients between parents’ demographic characteristics and children emotional abuse were calculated (Table 6). It was found that chronic illness was positively correlated with terrorizing emotional abuse and the correlation was statistically significant (r = 0.43, P < 0.01). Mothers’ relationship with the child was negatively correlated with ignoring and terrorizing emotional abuse and the correlation was statistically significant for both these types of emotional abuse (r = –0.35, P < 0.01 and r = –0.29, P < 0.05 respectively).

Discussion

Emotional abuse is maltreatment that causes or could cause emotional, behavioural, cognitive or mental disorders [10]. It is a difficult category of maltreatment to document because often it does not involve a specific incident or visible injury. The effects of emotional maltreatment tend to become apparent over time, e.g. impaired cognitive, social and emotional development. This form of abuse may occur with or without physical abuse, but there is often an overlap [11].

In the Canadian incidence study of reported child abuse and neglect over 700 child welfare service providers reported that the incidence of emotional abuse alone in investigated maltreatment children was 15% and of emotional abuse with other types of maltreatment was 16% [11]. In Saudi Arabia, a total of 292 child abuse cases have been registered by the National Family Safety Program; children neglect constituted 41.3% of cases and 27% of neglected children were emotionally abused [12]. In the current study, it was found that about 90% of children reported at least one form of rejecting emotional abuse and 61.7% of children reported at least one form of either ignoring or terrorizing emotional abuse. This is because emotional abuse is the most hidden and underestimated form of child maltreatment. In addition, the previous estimate in Saudi Arabia was based on registered maltreated children. Barlow and MacMillon reported that registered cases of emotional abuse represented just the tip of the iceberg, and that children under child protection comprised only a small proportion of the total number of children actually experiencing abuse of this type [13].

Nguyen and Dunne, studying types of child maltreatment and adolescent mental health, revealed that nearly all children reported having been “yelled at” and having had someone “try to make them feel guilty” [14] compared with the current study in which “yelling at me” was reported by 26.7% of the children.

A retrospective study of cases registered at the Suspected Child Abuse and Neglect (SCAN) programme in Saudi Arabia from 2000–08 reported that 53.4% of cases were males and 46.6% females, regardless the type of maltreatment [15]. A study in Viet Nam in 2009 revealed that females reported more neglect and emotional abuse than males [14]. This is in agreement with the results of the current study as females reported more emotional abuse than males, whether rejecting, ignoring or terrorizing emotional abuse.

Morrison et al. reported that children who are abused and neglected by caregivers often do not form secure attachments to them. These early attachment difficulties can lead to later difficulties in relationships with other adults as well as with peers [16]. Furthermore lack of parent–child attachment and failure to bond is associated with an increased risk of child maltreatment [2]. This is in agreement with the results of the current study, in which mothers’ relationship with their children was negatively correlated with ignoring and terrorizing types of emotional abuse and the correlation was statistically significant for these 2 types of emotional abuse.

The World Health Organization reported many risk factors that increase the incidence of child abuse and neglect, such as poverty, unemployment, lack of parental education, young maternal age, substance abusing parents, parents who were abused as children and parents with psychological diagnoses [2]. In the current study, we did not find a significant correlation between parents’ education and occupation with types of emotional abuse. This is may be due to the small sample size.

The United States Centers for Disease Control and Prevention reported that abuse and neglect can occur in families where there is a great deal of stress. The stress can result from many causes, including chronic health problems. Families that do not have nearby friends, relatives and other social support are also at risk [17]. Furthermore, Trocmé et al. found that at least 1 caregiver was known to have a chronic illness in 9% of children with emotional abuse [11]. This is in accordance with the results of the current study, which revealed that chronic illness among parents was significantly positively correlated with terrorizing emotional abuse.

Among the limitations of the study was refusal by many parents to participate in the study after reading the questionnaire, even to the extent of becoming angry, and this will have affected the study sample as those who are most likely to be abusers were more likely to refuse to participate. Therefore a more comprehensive study is needed.

Conclusions

The study revealed that 90% of children who participated in the study reported at least one form of rejecting emotional abuse and 61.7% of children reported at least one form of either ignoring or terrorizing emotional abuse. There was a negative relation between mothers’ education and occupation and children’s experience of emotional abuse. Chronic illness was positively correlated with terrorizing emotional abuse and the correlation was statistically significant. Mothers’ relationship with the child was negatively correlated with the ignoring and terrorizing types of children emotional abuse and the correlation was statistically significant for ignoring and terrorizing emotional abuse. More research is needed into the community prevalence, correlates and consequences of children emotional abuse in Saudi Arabia.

Competing interests: None declared

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