Eastern Mediterranean Health Journal  | Back to Health Journal  page | Health Journal back issues | Home
 

Child abuse and neglect: mothers' behaviour and perceptions

H.Y. Atta and R.M. Youssef

ABSTRACT Mothers' behaviour relating to child maltreatment, their perceptions of such behaviour and its correlates to parents' characteristics and family background were investigated. Women with at least one child under 18 years were targeted and given an interview questionnaire. A high proportion of mothers reported maltreatment behaviour that constituted emotional (69.0%) and physical (57.1%) abuse as well as neglecting the child's safety (43.8%), education (46.1%) and medical care (53.3%). Mothers tended to perceive neglectful behaviour rather than abusive behaviour as child maltreatment. Child maltreatment was significantly associated with parents' level of education, father's occupation, mother's working status, financial problems, mother's age at the birth of the first child, number of offspring, crowding index and maternal perceptions of maltreatment.

L'enfant maltraité et négligé: comportement des mères et leur perception à cet égard

RESUME On a étudié le comportement des mères relatif au mauvais traitement de l'enfant, leur perception de ce comportement et la corrélation avec les caractéristiques des parents et le contexte familial. L'étude a été ciblée sur les femmes ayant au moins un enfant âgé de moins de 18 ans, auxquelles on a donné un questionnaire d'enquête. Une forte proportion de mères ont signalé un comportement de maltraitance qui constituait un abus affectif (69,0%) et physique (57,1%) ainsi que la négligence vis-à-vis de la sécurité de l'enfant (43,8%), de son éducation (46,1%) et des soins médicaux (53,3%). Les mères avaient tendance à percevoir la négligence plutôt que l'abus comme maltraitance de l'enfant. La maltraitance de l'enfant était associée de manière significative au niveau d'instruction des parents, à la profession du père, au travail de la mère, aux problèmes financiers, à l'âge de la mère à la naissance du premier enfant, au nombre d'enfants, au degré d'occupation du logis et à la perception qu'a la mère du mauvais traitement.

Introduction

Applying the label of "child maltreatment" implies a judgement about social deviance and brings to bear both personal and societal values regarding parenting. Implicit in this process are judgement about circumstances harmful to children, minimal requirements for development and other aspects of the child that are important for society to protect [1].

For centuries child maltreatment has been a societal problem yet clinical reporting started only 30 years ago [2]. In North American and European societies, the number of abused and neglected children continues to rise [3,4]. This increase is attributed to better awareness and recognition of the problem as well as to a real increase in its magnitude [4].

Generally, there is no available literature on the extent of child maltreatment in Arab countries [5]. However, a recent study conducted in Alexandria, Egypt revealed that children are subjected to physical abuse in a disciplinary context [6]. Moreover, school teachers, social workers and physicians do encounter cases ranging from neglect to sexual abuse [7]. Although these studies indicate that child maltreatment exists, they do not reveal the extent and scope of the phenomenon. Accordingly, a community-based study was carried out to elucidate mothers' behaviour relating to child maltreatment, their perceptions of such behaviour and its correlates to parents' characteristics and family background.

Subjects and methods

Women who had at least one child under the age of 18 years constituted the target population of the present study. The modified cluster sample survey of the World Health Organization was adopted to select eligible women. Thirty clusters, the usual chosen number, were identified. The total number of women to be enrolled was estimated using the following equation:

n = [(Z² × p × q)/D²] × 2.

Since the actual prevalence of the behaviour under study was unknown, the probability of its presence was estimated to be equal to its absence (p = q = 0.5) and a value of 0.1 was chosen as the acceptable limit of precision (D). Based on these assumptions, the sample size was estimated to be 192.08. This number was rounded to the nearest figure to be divided by the chosen number of clusters. Accordingly, a total of 210 women, seven from each cluster, was selected.

The women enrolled were given an interview questionnaire which consisted of the following sections:

Section I: social and family background of participants (14 questions)

Section II: behaviour relating to child maltreatment which included 29 questions describing physical (6 questions) and emotional (5 questions) abuse and physical (3 questions), gross safety (5 questions), educational (3 questions) and medical care (7 questions) neglect (Tables 1 and 2).

Mothers were requested to report both their behaviour and their perceptions. Responses included two choices: yes (coded 1) and no (coded 0).

The operational definitions adopted for the present study were as follows.

Child abuse was considered when attempts were made to harm the child physically (physical abuse) or attacks were made on the child's development of self and social competence (emotional abuse).

Child neglect was considered when the caregiver, either deliberately or by extraordinary inattentiveness, permitted the child to experience avoidable suffering and/or failed to provide one or more of the ingredients generally deemed essential for developing a person's physical, intellectual and emotional capacities.

Data were analysed using SPSS (version 7.5) and Epi-Info (version 6.03). The mean, standard deviation, 95% confidence interval of the obtained prevalence and the odds ratio (OR) were computed. The chi-square, Student's t-test, the t-test for paired comparison and multivariate logistic regression analysis were used to test the significance of the results obtained at the 5% level.

The following two scales were generated after testing for internal consistency.

1. The perception scale for abusive behaviour was developed by summing the responses to the 11 questions addressing physical and emotional abuse, yielding a score ranging from 0 to 11. Cronbach alpha reliability for this scale was 0.6638.

2. The perception scale for neglectful behaviour was developed by summing the responses to the 18 questions addressing physical, gross safety, educational and medical care neglect, yielding a score ranging from 0 to 18. Cronbach alpha reliability for this scale was 0.8182.

A high level of agreement was considered when expressed by more than 80% of mothers. Higher scores on these scales indicate better perception.

Results

A total of 210 mothers with a mean age of 37.97 + 7.86 years (minimum = 20.00 years; maximum = 55.00 years) were enrolled in the study. Only 11.9% of participants were university graduates while nearly half of them had completed their basic (18.6%) or high school education (32.9%). Those who were illiterate or just able to read and write constituted 36.7% of the sample. Less than a quarter (21.0%) of the mothers worked outside the home. The majority of them (177, 84.29%) had more than one child. The mean number of children was 2.91 + 1.46 children per women (minimum = 1.00; maximum = 7.00).

Mothers' reported behaviour is presented in Tables 1 and 2. Table 1 shows that the most frequently reported behaviour that constituted physical abuse was beating using implements (45.2%), burning an enuretic child (27.4%) and slapping with subsequent marks (16.7%). In the area of emotional abuse, half of the mothers (50.0%) stated that they subjected their children to belittling and 31.9% declared their problem publicly (Table 1).

Regarding child neglect, a considerably lower proportion of mothers reported behaviour that constituted physical neglect. However, more than a third of them reported medical care neglect, including neglecting the child's medical complaints (39.0%) and reluctance (32.4%) or delay (31.0%) in seeking medical care. Moreover, a fair proportion of mothers reported behaviour which indicated lack of supervision and educational neglect (Table 2).

According to the mothers' reported behaviour, children were subjected to one or more forms of maltreatment in 89.5% of families. The most frequently reported maltreatment behaviour was that which constituted emotional (69.0%) and physical (57.1%) abuse and neglect of medical care (53.3%) (Table 3).

With regard to mothers' perceptions, over 80% of mothers perceived four out of six behavioural aspects related to physical abuse as child maltreatment (Table 1). A low level of agreement was found in behaviour involving beating with implements (70.0%) and burning an enuretic child (71.0%). Furthermore, a low level of agreement was observed in almost all behavioural aspects relating to emotional abuse.

A high level of agreement ranging from 83% up to 100% was expressed by mothers in all behavioural aspects relating to physical, gross safety and educational neglect (Table 2). However, in the area of medical care neglect, only a small proportion of mothers perceived ignoring the child's medical complaints (65.7%), late consultation of medical care (78.6%) and reluctance to monitor the child's growth periodically (78.6%) as maltreatment.

Mothers were more apt to perceive behaviour relating to child neglect as maltreatment as their mean percentage score on the neglect perception scale (90.63 + 13.73%) was significantly higher than their mean score on the abuse perception scale (81.13 + 17.71%) where t = 10.377, P = 0.0000.

Parents' characteristics and family background in relation to maltreatment behaviour are illustrated in Tables 4a and 4b. Maltreatment behaviour was not associated with the father's age at the time of birth of the first child (t = 0.747, P = 0.456). However, mothers who reported child maltreatment were significantly younger when they had their first child (t = 4.102, P = 0.000). Moreover, significantly more child maltreatment was found in families with a large number of offspring (t = 4.559, P = 0.000) and those living in households with a high crowding index (t = 6.493, P = 0.000) (Table 4a).

An inverse association was found between child maltreatment and the parents' level of education and occupation. Relative to university graduates, the risk of child maltreatment was significantly higher among parents who had completed their basic or high school education while it was highest among those who were illiterate or just able to read and write. Similarly, relative to families where the father was a professional or semiprofessional, the risk of child maltreatment was 3.90 times higher in families where the father was a skilled or semiskilled worker (P = 0.007) and 6.35 times higher in families where the father was an unskilled or manual labourer (P = 0.047). Moreover, this risk was significantly higher among non-working mothers (OR = 3.77, P = 0.003) (Table 4b).

In families experiencing financial problems or debts, a significantly higher percentage of mothers (97.8%) reported child maltreatment. Financial problems increased the risk of child maltreatment 6.6 times (P = 0.037). Child maltreatment was also reported by all mothers who recalled being maltreated during their childhood but this was not significant (Table 4b).

The mothers' behaviour was found to be significantly related to their perception of child maltreatment. The perception score of mothers who reported child maltreatment (85.66 ± 14.10%) was significantly lower than those who did not report such behaviour (98.74 ± 2.00%) where t = 11.754, P = 0.000 (Table 4a).

Considering all the potential risk factors of maltreatment behaviour, stepwise logistic regression analysis revealed that fathers who had had less than 12 years of education (OR = 11.806, P = 0.0045), young age of the mother at the time of birth of the first child (OR = 1.216, P = 0.0121) and poor perception of behaviour relating to child abuse or neglect (OR = 3.211, P = 0.0042) were predictive of child maltreatment. These variables could identify 98.4% of families with maltreatment potential as indicated by the model sensitivity.

Discussion

A wide definition of child maltreatment tends to capture large sections of the community [8]. Undoubtedly, this is the reason for finding that, in a large proportion of families, children are subjected to one or more forms of maltreatment. It is worth mentioning that children who are subjected to one type of maltreatment are more likely to experience other types as well [8]. There are, of course, parents who both abuse and neglect their children [9].

Maltreatment behaviour triggered by the child's misconduct, including locking up, cursing, belittling and beating was reported by a high proportion of mothers. Previous studies have indicated that such behaviour characterizes abusive parents [10-12]. Its origin lies in the lack of parenting skills as well as the cultural acceptance of corporal punishment within the society [2]. In a culture like ours, there are high expectations for a child's obedience and discipline, and violating these rules provides a strong justification for punishment [5]. This is probably the reason why a proportion of mothers failed to perceive such behaviour as abusive. Indeed, the positive correlation between abusive behaviour and the belief in corrective punishment explains much about child maltreatment [13]. However, subjecting a child to physical violence with the use of implements constitutes abuse rather than discipline [14]. In this connection, a clear distinction should be made between culturally condoned physical discipline and physical abuse. Moreover, preparation for parenting significantly reduces abusive behaviour [15].

It has been reported that child neglect is far more common than abuse [4]. This is not borne out by our findings as the proportion of mothers who indicated neglecting their children's needs was lower than those who reported subjecting them to abusive treatment. This might be attributed to the characteristics of families with Middle Eastern roots where mothers tend to put aside their individual interests and attend fully to their children's needs [16]. In this series, child neglect was perceived as a form of maltreatment by a high proportion of mothers. Moreover, their perception of neglectful behaviour as child maltreatment was significantly higher than their perception of abusive behaviour.

Determining the maltreatment potential of parents and caregivers is one of the most critical tasks relevant to public health interventions aiming at the prevention of child maltreatment [17]. Child maltreatment is linked to the cultural level of women, as those from socially and economically privileged backgrounds are less likely to report any form of maltreatment [8]. This study, as well as others [18,19], indicates the association between parents' level of education and child maltreatment. The resiliency encountered in families where fathers are professionals or semiprofessionals and mothers work outside the home is simply a reflection of their educational level. This is particularly true since higher educational attainment is linked to a better career opportunity.

This study, as well as others, illustrates the association between child maltreatment and young maternal age [18,20], large number of offspring [21,22] and overcrowding [18]. Young mothers are usually immature in their responses and have a poor understanding of children's development and needs. Moreover, Sumba and Bwibo observed that mothers who maltreated their children were less likely to practise contraception [18]. Certainly, in the absence of contraceptive practices, marriage at a young age prolongs the woman's fertile span and promotes a large number of offspring. Under such circum stances, a mother is unlikely to provide all her children with the basic care deemed essential for their optimum growth and development. A large number of children greatly contributes to an overcrowded household, which increases the chances of aggressive outbursts as emphasized by Kaplan and Sadock [23].

The phenomenon of child maltreatment appears to be linked to parents' adverse life experiences [24]. Earlier studies and the present one have documented the role of poverty [25] and financial pressures [2] in this connection. McLoyd emphasized that poverty and economic losses severely constrict choices, increase the risk of emotional distress and heighten vulnerability to negative life events [25]. Accordingly, poor parents are less likely to be supportive of their children while at the same time they value obedience and power-assertive discipline [25].

Parents who were subjected to harsh treatment, abuse or neglect during their childhood are at a much higher risk of treating their own children similarly [9,26]. This explains why maltreatment behaviour was reported by all mothers who recalled being abused or neglected during their childhood. The basic inability to provide good parenting seems to be what is transmitted since it is a learned type of behaviour through observation, experience and identification with caregivers. This is true for good as well as bad parenting [9].

Individuals' perceptions directly influence health-related behaviour [27]. In this study, mothers who reported child maltreatment had significantly lower perceptions of abusive and neglectful behaviour. Moreover, perception remained as an independent predictor of child maltreatment. Indeed, mothers' perceptions have an enormous impact as all sociodemographic factors and structural variables, such as knowledge and awareness, indirectly influence health-related behaviour through their effect on an individual's perceptions [27].

This study shed light on the extent and scope of child maltreatment. One potential limitation was the estimation of the prevalence of different forms of child maltreatment based on the mothers' reported behaviour per se. Also, this study did not attempt to investigate the frequency of a particular behaviour or its sequelae. However, a strength of the study is the use of a community-based sample, which minimizes selection bias and allows the findings to be generalized to the studied community. In addition, it has relevance for structuring prevention policies and programmes as it indicates potential targets for intervention. The determinants of maltreatment potentials which have been revealed might be helpful in identifying families at risk. Every attempt should be made to assist these families and to improve their management strategies.

Family planning activities appear to be an effective tool in reducing the risk of child maltreatment by timing pregnancies in relation to the mother's age. In addition, maternal and child health services should prepare every expectant mother for parenting. Apart from increasing their knowledge about child development, it is of the utmost importance to raise their awareness about behaviour that constitutes child maltreatment, and about triggers of maltreatment as well as to promote the use of non-violent approaches to child discipline. Only when mothers acquire better perceptions of what is considered child abuse and neglect, will child maltreatment be less likely to occur. Public awareness activities are an important part of an overall approach to addressing this problem.

References

1. Giovannoni JM, Baccerra RM. Defining child abuse. New York, The Free Press, 1977.

2. Child abuse and neglect. Geneva, World Health Organization, 1997 (WHO Fact Sheet, No. 150).

3. Sirotnak AP, Krugman RD. Physical abuse of children: an update. Pediatrics in review, 1994, 15(10):394-9.

4. Sedlack AJ, Broadhurst DD. Executive summary of the third national incidence study on child abuse and neglect. Washington DC, National Center on Child Abuse and Neglect, Department of Health and Human Services, 1996.

5. Haj-Yahia MM, Shor R. Child maltreatment as perceived by Arab students of social science in the West Bank. Child abuse and neglect, 1995, 19(10):1209-19.

6. Youssef RM, Attia MS, Kamel MI. Children experiencing violence 1: parental use of corporal punishment. Child abuse and neglect, 1998, 22(10):959-73.

7. Youssef RM, Atta HY. Child abuse and neglect: its perception by those who work with children. Eastern Mediterranean health journal, 1998, 4(2):276-92.

8. Mullen PE et al. The long-lasting impact of the physical, emotional and sexual abuse of children: a community study. Child abuse and neglect, 1996, 20(1):7-21.

9. Steele BF. Notes on the lasting effects of early child abuse through the life cycle. Child abuse and neglect, 1986, 10:283-91.

10. Azar ST et al. Unrealistic expectations and problem-solving ability in maltreating and comparison mothers. Journal of consulting and clinical psychology, 1984, 52:687-91.

11. Chilamkurti C, Milner JS. Perceptions and evaluations of child transgressions and disciplinary techniques in high- and low-risk mothers and their children. Child development, 1993, 64:1801-14.

12. Trickett PK, Kuczynski L. Children's misbehaviour and parental disciplinary strategies in abusive and non-abusive families. Developmental psychology, 1986, 22:115-23.

13. Corral-Verdugo V et al. Validity of a scale-measuring belief regarding the "positive" effects of punishing children: a study of Mexican mothers. Child abuse and neglect, 1995, 19(6):669-79.

14. Stein A, Lewis DO. Discovering physical abuse: insights from a follow-up study of delinquents. Child abuse and neglect, 1992, 16:523-31.

15. Dukewich TL, Bortkowski JG, Whitman TL. Adolescent mothers and child abuse potential: an evaluation of risk factors. Child abuse and neglect, 1996, 20(11):1031-47.

16. Sharifzadeh VS. Families with Middle Eastern roots. In: Lynch EW, Hanson MJ, eds. Developing cross-cultural competence. Baltimore, Maryland, Paul H. Brooks, 1988:319-51.

17. Haskett ME, Scott SS, Fann KD. Child abuse potential inventory and parenting behaviour. Relationship with high-risk correlates. Child abuse and neglect, 1995, 19(12):1483-95.

18. Sumba RO, Bwibo NO. Child battering in Nairobi, Kenya. East African medical journal, 1993, 70(11):688-92.

19. Jaudes PK, Ekwo A, Voorhis JV. Association of drug abuse and child abuse. Child abuse and neglect, 1995, 19(9):1065-75.

20. Steir DM et al. Are children born to young mothers at increased risk of maltreatment? Pediatrics, 1993, 91(3):642-8.

21. Egami Y et al. Psychiatric profile and sociodemographic characteristics of adults who report physically abusing or neglecting their children. American journal of psychiatry, 1996, 153(7):921-5.

22. Wolfner GD, Gelles RJ. A profile of violence toward children: a national study. Child abuse and neglect, 1993, 17(2):197-212.

23. Kaplan HI, Sadock BJ. Synopsis of psychiatry, 5th ed. Baltimore, Williams and Wilkins, 1988:90-4.

24. Agathonas-Georgopoulou H, Browne KD. The prediction of child maltreatment in Greek families. Child abuse and neglect, 1977, 21(8):721-35.

25. McLoyd VC. The impact of economic hardship on black families and children: psychological distress, parenting and socioemotional development. Child development, 1990, 61:311-46.

26. Committee on psychological aspects of family health. The pediatrician's role in discipline. Pediatrics, 1983, 72(3):373-4.

27. Rosentock IM, Kirscht GP. The health belief model and personal health behaviour. Health education monograph, 1974, 2:470-3.