Scholarly article on topic 'Prevalence of different forms of child maltreatment among Taiwanese adolescents: A population-based study'

Prevalence of different forms of child maltreatment among Taiwanese adolescents: A population-based study Academic research paper on "Health sciences"

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{"Child maltreatment" / "Childhood victimization" / Violence / Prevalence / Taiwan}

Abstract of research paper on Health sciences, author of scientific article — Jui-Ying Feng, Yi-Ting Chang, Hsin-Yi Chang, Susan Fetzer, Jung-Der Wang

Abstract Reported cases of child maltreatment are increasing in Taiwan. Yet, comprehensive epidemiological characteristics of adolescents’ exposure over the wide spectrum of violence are still lacking. The purpose of this study was to estimate the prevalence and magnitude of child maltreatment among Taiwanese adolescents. A population-based study was conducted with 5,276 adolescents aged 12–18 from 35 schools in 17 cities and townships to determine the prevalence of five forms of child maltreatment in Taiwan. A total of 5,236 adolescents completed anonymous, self-report, structured questionnaires. Most adolescents (91%, n =4,788) experienced at least one form of maltreatment with 83% (n =4,347) exposed during the previous year. Violence exposure was the most common type of child maltreatment experienced, followed by psychological abuse, physical abuse, neglect, and sexual abuse. Adolescents reported an average of 7.4 (SD=5.87) victimizations over their lifetime and 4.8 (SD=4.82) victimizations during the past year. Females reported a higher rate of neglect, while males reported a higher rate of sexual abuse. Most of the sexual abuse perpetrators were known by their victims. Adolescents’ victimization and polyvictimization from child maltreatment in Taiwan deserves a review and modification of national control and prevention policies.

Academic research paper on topic "Prevalence of different forms of child maltreatment among Taiwanese adolescents: A population-based study"

ELSEVIER

Prevalence of different forms of child maltreatment among Taiwanese adolescents: A population-based study*

Jui-Ying Fenga, Yi-Ting Changb, Hsin-Yi Changc, Susan Fetzerd, Jung-Der Wange*

a Department of Nursing, College of Medicine, National Cheng Kung University and Hospital, Tainan, Taiwan b Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan c National Cheng Kung University Hospital, Tainan, Taiwan d Department of Nursing, University of New Hampshire, NH, USA

e Department of Public Health, College of Medicine, National Cheng Kung University and Hospital, Tainan, Taiwan

ARTICLE INFO ABSTRACT

Reported cases of child maltreatment are increasing in Taiwan. Yet, comprehensive epidemiological characteristics of adolescents' exposure over the wide spectrum of violence are still lacking. The purpose of this study was to estimate the prevalence and magnitude of child maltreatment among Taiwanese adolescents. A population-based study was conducted with 5,276 adolescents aged 12-18 from 35 schools in 17 cities and townships to determine the prevalence of five forms of child maltreatment in Taiwan. A total of 5,236 adolescents completed anonymous, self-report, structured questionnaires. Most adolescents (91%, n = 4,788) experienced at least one form of maltreatment with 83% (n = 4,347) exposed during the previous year. Violence exposure was the most common type of child maltreatment experienced, followed by psychological abuse, physical abuse, neglect, and sexual abuse. Adolescents reported an average of 7.4 (SD = 5.87) victimizations over their lifetime and 4.8 (SD = 4.82) victimizations during the past year. Females reported a higher rate of neglect, while males reported a higher rate of sexual abuse. Most of the sexual abuse perpetrators were known by their victims. Adolescents' victimization and polyvictimiza-tion from child maltreatment in Taiwan deserves a review and modification of national control and prevention policies.

© 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

Introduction

Child maltreatment is a global public health problem with the potential for a lifelong impact on victims without proper treatment. Child maltreatment is broadly defined as any act(s) committed or failure to provide supervision by caregiver(s) that results in actual or potential harm to a child's health, development or dignity including physical abuse, psychological abuse, sexual abuse, neglect and exposure to violent environments (Centers for Disease Control and Prevention [CDC], 2014; World Health Organization, 2014). Advances in developmental neuroscience provide insights and perspectives about how trauma or stress early in life, such as child maltreatment, interplays with genes and environmental factors

* This study was supported by the Ministry of Science and Technology of Taiwan (NSC101-2314-B-006-062-MY3) and partially by the Ministry of Education, Taiwan, The Aim for the Top University Project to National Cheng Kung University.

* Corresponding author address: National Cheng Kung University and Hospital, Room 08091,8F, No. 35,Xiaodong Road, East District, Tainan 701, Taiwan.

Contents lists available at ScienceDirect

Child Abuse & Neglect

CrossMark

Article history:

Received 1 July 2014

Received in revised form

14 November 2014

Accepted 18 November 2014

Available online 1 December 2014

Keywords:

Child maltreatment

Childhood victimization

Violence

Prevalence

Taiwan

http://dx.doi.org/10.1016/j.chiabu.2014.11.010

0145-2134/© 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/3.0/).

to influence the developing brain and neuronal network (Hart & Rubia, 2012). The Adverse Childhood Experiences study (CDC, 2010) indicated a graded effect of child maltreatment and family dysfunction on somatic concerns, chronic illness, poor quality of life and mortality for adolescents and adults (Bellis et al., in press; Flaherty et al., 2013). The risk of psy-chopathology for victims and their children increases due to epigenetic changes in gene expressions and impairment of brain structure and function (Bair-Merritt, Zuckerman, Augustyn, & Cronholm, 2013; Hart & Rubia, 2012; McGowan et al., 2009).

In Taiwan the revised Child Welfare Law of 1993 mandated that professionals report suspected cases of child maltreatment (e.g., desertion, physical/emotional/sexual abuse, neglect, educational deprivation and exploitation). The mandatory reporters of child maltreatment were expanded in 2011 to administrators and directors of villages, communities and residential security guards. Reports of child maltreatment have increased substantially since 1993. However, the official statistic of 0.6% in 2012 (Department of Statistics, Ministry of the Interior, 2013) likely underestimates the extent of child maltreatment in Taiwan when compared to the rates of 22-34% for physical abuse and 2.5% for sexual abuse from survey research (Chou, Su, Wu, & Chen, 2011; Yen et al., 2008).

The prevalence estimation of child maltreatment varies significantly depending on study definitions, measurements, sample characteristics and methodologies. Survey prevalence rates range from 5 to 83% for each form of child maltreatment across studies (Pereda, Guilera, & Abad, 2014; Tsuboi et al., in press). A series of meta-analyses provided overall estimations of 17.7%, 26.7%, 11.8% and 16.3% for physical abuse, psychological abuse, sexual abuse, and neglect, respectively (Stoltenborgh, Bakermans-Kranenburg, Alink, & van Ijzendoorn, 2012; Stoltenborgh, Bakermans-Kranenburg, & van Ijzendoorn, 2013; Stoltenborgh, Bakermans-Kranenburg, van Ijzendoorn, & Alink, 2013; Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011).

Significant variations exist in the reported rates of child maltreatment across official data and research reports (Theodore et al., 2005). Few population-based studies are available to examine the full range of different forms of child maltreatment, particularly in Asia. Accurate epidemiological data are needed to describe the extent of child maltreatment, the characteristics of the victims and perpetrators and the forms and characteristics of victimization. Once identified, policies can be directed to reduce the burden and serious consequences of child maltreatment (Gilbert et al., 2009). Epidemiological data are important for the appropriate allocation of governmental resources and to develop intervention strategies targeted for children at high risk.

Multiple factors influence the impact of child maltreatment on victims and gender is an important consideration. Evidence on the impact of gender on the type of child maltreatment, victims' health consequences and their interactions is evolving, though findings are mixed (Arnow, Blasey, Hunkeler, Lee, & Hayward, 2011). Generally, males report more physical abuse than females (5-54% vs 4-42%; Chou et al., 2011; Dong, Cao, Cheng, Cui, & Li, 2013; MacMillan, Tanaka, Duku, Vaillancourt, & Boyle, 2013) and females report more sexual abuse than males (16-22% vs4-11%; CDC, 2010; Chen, Dunne, & Han, 2004; MacMillan et al., 2013; Pereda et al., 2014). However, in meta-analytic reviews gender differences were established only for the prevalence of sexual abuse (F: 18% vs M: 8%) and not for other forms of child maltreatment (Stoltenborgh et al., 2012; Stoltenborgh, Bakermans-Kranenburg, & van Ijzendoorn, 2013; Stoltenborgh, Bakermans-Kranenburg, van Ijzendoorn, & Alink, 2013; Stoltenborgh et al., 2011). Gender difference in sexual abuse is significantly greater in high-income countries than for low-income countries where males' experiences of sexual abuse are increased (Choo, Dunne, Marret, Fleming, & Wong, 2011; Dong et al., 2013; Stoltenborgh et al., 2011).

Although child maltreatment causes significant long-term health problems for all victims, the degree and types of impairment vary by gender. Women are more likely to suffer from chronic physical and mental health problems, such as cardiovascular disease (Scott-Storey, 2013), post-traumatic stress disorder and suicidal behaviors (Thompson, Kingree, & Desai, 2004). The interaction of gender and the types and consequences of child maltreatment has received less attention, but deserves greater study to determine proactive prevention strategies.

The dose-response effect of trauma is a major consideration in child maltreatment. Cumulative exposure to maltreatment causes long-term negative outcomes and comorbidities while posing a serious threat to public health (Anda, Tietjen, Schulman, Felitti, & Croft, 2010; Felitti, 2009). Finkelhor, Ormrod, Turner, and Hamby (2005) used the 34-item Juvenile Victimization Questionnaire to assess polyvictimization, the exposure to multiple types of maltreatment, among children and youth with categories of as low (4-6 victimizations) and high (7 or more victimizations). The lifetime prevalence of polyvictimization across studies using the Juvenile Victimization Questionnaire was 14-37% (CDC, 2010; Chan, 2013).

Empirical studies on the prevalence of child maltreatment in Taiwan including the gender and cumulative effects on victims are limited. Two regional studies in Taiwan have examined physical abuse or sexual abuse. (Chou et al., 2011; Yen et al., 2008). While 32% of the students in the Taipei area (northern Taiwan) reported experiencing physical abuse, 22% of students from rural areas in southern Taiwan reported experiences physical abuse and 3% experiencing sexual abuse (Chou et al., 2011; Yen et al., 2008). Indigenous adolescent males were found to have a higher risk of being the victims of sexual abuse than non-indigenous males (Yen et al., 2008).

The effect of cultural and geographic factors on the prevalence of child maltreatment is difficult to determine due to differences in defining child maltreatment and the availability of surveillance systems across cultures and countries (Al-Eissa et al., in press; International Society for the Prevention of Child Abuse and Neglect, 2012). In general, Africa has the highest prevalence rate for all forms of child maltreatment, except for neglect as a lack of available data, while Asia has the lowest rate of sexual abuse (Stoltenborgh et al., 2012; Stoltenborgh, Bakermans-Kranenburg, & van Ijzendoorn, 2013; Stoltenborgh et al., 2011). The ICAST-CH-C (ISPCAN Child Abuse Screening Tool Children's Home Version, Chinese) provides

an opportunity to tackle the cultural and geographical challenges and to compare child maltreatment prevalence rates internationally (Chang, Lin, Chang, Tsai, & Feng, 2013; Zolotor et al., 2009).

Given the tremendous cost of child maltreatment to the individual, family and society, an in-depth investigation on the prevalence of different forms of childhood victimization and polyvictimization is vital. It remains unclear if gender is a predictor of different forms of maltreatment or polyvictimization and the health consequences. As a comprehensive epidemiological profile of children's exposure over the wide spectrum of violence is lacking in Taiwan, a population-based study using the ICAST-CH-C to estimate the magnitude of childhood victimization due to maltreatment was conducted.

Method

The study commenced after approval by the University Institution Review Board (No. BR-99-058-C). A national representative sample of adolescents aged 12-18 were surveyed to determine the prevalence of different forms of child abuse in Taiwan. The ICAST-CH is recommended for adolescents aged 12-18 due to the cognitive and emotional maturity of the survey content (Zolotor et al., 2009). Data were collected anonymously using the self-report, structured ICAST-CH-C questionnaire. Parental consent was waived to prevent the child from worrying about the potential to be identified or abusive parents' reluctance to be exposed (Spriggs, 2010; U.S. Department of Health and Human Services [DHHS], 2009).

Participants and Setting

For the purpose of this study, Taiwan was divided into 5 geographical regions. In Taiwan, 98% of all children attend school. In 2011, the total number of students in grades 7-12 in Taiwan was 1,682,958 with 754,275 (44.8%) in the northern, 342,312 (20.3%) in the central, 498,311 (29.6%) in the southern, 77,199 (4.6%) in the eastern regions and 10,861 (0.7%) in the offshore islands (Department of Statistics, Ministry of education in Taiwan, 2011). As the population of the eastern region and offshore islands has a higher rate of child abuse (Department of Statistics, Ministry of the Interior, 2013), oversampling was appropriate. Therefore, disproportionate stratified random sampling was used to identify students aged 12-18 and in grades 7-12 from the northern, central, southern, and eastern and offshore islands regions in Taiwan; 1,420 (25%), 1,136 (20%), 1,420 (25%), 852 (15%) and 852 (15%), respectively, were the desired number of participants across the 5 regions.

Following the sample size estimation method proposed by Runyan, Dunne, & Zolotor, 2009, the epidemiological estimation of the number of participants needed for this study would be 438 from offshore islands and 456 from each of four regions based on an anticipated 5% prevalence, 95% confidence level, and 2% precision. The current sample size met the above criteria. Schools were randomly selected in each region and replaced in the case of refusal until the sample size from the region was obtained. Students aged 12-18 years old from the identified schools were invited to participate.

Measurement

The ICAST-CH-C was used to collect the forms, characteristics, frequency and perpetrators of child maltreatment experienced during the previous year and over the child's lifetime. Developed by 40 experts from 31 countries, the original ICAST-CH is a population-based survey tool with a comprehensive coverage of the forms of childhood victimization in the home of adolescents aged 11-18 across cultures. The ICAST-CH consists of 51 items with 9 demographic items (e.g., gender, age, living arrangement, religion and ethnicity), 36 child maltreatment experience items, and 6 open-ended questions. Child maltreatment is categorized into 5 forms: violence exposure (7 items), psychological abuse (8 items), physical abuse (9 items), sexual abuse (6 items), and neglect (6 items) (see Table 2 for details). Adolescents are questioned about their experiences of (1) seeing adults' behaviors in the home or nearby that frightened them (violence exposure), (2) people saying or doing things to make the adolescent feel embarrassed, ashamed or bad (psychological abuse), (3) being physically hurt by adults at home (physical abuse), (4) adults doing or showing them sexual things without their consent (sexual abuse), and (5) not getting what they need to grow up healthy (neglect). Adolescents are asked to report each victimization based on their experience in the past year as many times, sometimes, never, or not in the past year but this has happened.

The ICAST-CH has been tested for construct validity with Cronbach's a coefficients ranging from .69 to .83 in four countries (Zolotor et al., 2009). The ICAST-CH-C is the Chinese version of the ICAST-CH with good construct validity and internal consistencies of .90 for the total scale and .61-.78 for the subscales (Chang et al., 2013).

Procedure

Principals of the stratified, randomly selected 44 schools were contacted by phone. Principals who agreed to participate were asked to provide the number of potential student participants. Seven principals declined participation because students were too busy with heavy course loads or had already filled out questionnaires from other studies; one expressed that the topic was too sensitive. Two principals later withdrew resulting in a sample of 5,236 students from 35 schools.

The ICAST-CH-C questionnaires, with returned postage, were mailed to the 35 principals who agreed to participate. Class teachers or school counselors were asked to assist in explaining information described in the cover letter about the study purpose, participant anonymity and the right to withdraw at any time. Questionnaires were distributed to the students who were willing to participate. Students filled out questionnaires during one school period (40 min). Class teachers or school

counselors were asked to be present to provide support to students as needed, but directed not to intervene as students' completed the ICAST-CH-C. A list of social resources related to child protection and counseling institutions was provided to students. Due to the extreme sensitivity of childhood victimization, students' names or any type of identification were not required on questionnaires.

Data Analysis

Following the scoring schema provided by ICAST-CH developers and others (Imola, Roth, David-Kacso, & Mezei, 2013; Sofuoglu et al., 2014; Zolotor et al., 2009), maltreatment occurring the previous year (PY) was counted as 1 if many times or sometimes was checked. The lifetime (LT) exposure of maltreatment was counted as 1 if many times, sometimes or not in the past year but this has happened were checked. Lifetime prevalence is determined as the proportion of adolescents who have experienced maltreatment during their childhood. The total numbers of victimizations for PY and LT are weighted back according to the original proportions of adolescent population in different regions and summed up to estimate the overall prevalence. The Mantel-Haenszel summary statistics and overall odds ratios (with confidence limits) are calculated to test and estimate whether gender was a significant factor for different types of maltreatment (Breslow & Day, 1980). Reports of many times, sometimes or not in the past year but this has happened are scored as 1, with never assigned as 0. Any item scored as 1 is considered positive for the specific form of maltreatment, with a total score ranging from 0 to 5 for each subject; a score over one indicates that the child has experienced more than one form of abuse.

The total number of victimizations experienced by every student was summed to determine polyvictimization. Participants were categorized into four groups based on the number of victimizations (0,1-3, 4-6 and 7 or more; Finkelhor et al., 2005; Pereda et al., 2014). Direct victimization describes a child who has directly experienced a violent act or neglect rather than witnessing the violence. In this study, direct victimization includes any form of psychological abuse, physical abuse, sexual abuse or neglect. Questionnaires with more than 20% of missing data were excluded listwise.

Results

Demographic

Data were analyzed from 5,236 completed questionnaires with a response rate of 99.4%. The mean age of adolescents was 14.5 years (SD = 1.32) with nearly equal representation of males and females. Almost all resided with parents or family members (99.4%). Table 1 describes adolescents' demographic characteristics by the five geographic regions of Taiwan.

Prevalence

Ninety-one percent (n = 4,788) of adolescents experienced at least one type of maltreatment with 83% (n = 4,347) being exposed to maltreatment during the previous year (Table 2). Violence exposure was the most common type of child maltreatment that children experienced in their lifetime (82.2%), followed by psychological abuse (69.2%), physical abuse (61.4%), neglect (54.6%), and sexual abuse (19.8%). Eighty-two percent (n = 4,310) experienced at least one form of direct victimization with 71.9% (n = 3,765) reporting an occurrence within the previous year. Adolescents reported experiencing an average of 2.9 (SD =1.48) different forms of maltreatment. One out of eight adolescents (n = 665,12.7%) reported to have been exposed to five different forms of maltreatment over their lifetime.

Adolescents experienced a mean of 7.4 (SD = 5.87) victimizations over their lifetime and 4.8 (SD = 4.82) victimizations during the past year (Table 3). Two-thirds of adolescents experienced polyvictimization (>4 victimizations) over their lifetime and almost half of them reported an occurrence during the previous year. No age or gender difference was found in the prevalence of polyvictimization.

The home was the most common place adolescents reported being exposed to maltreatment. Twenty-six percent (n = 1,384) of adolescents witnessed adults physically hurting each other with 10.6% witnessing adults using weapons. Psychological abuse was the most common type of adolescents' direct victimization. One hundred twenty-six (2.4%) reported being threatened with a knife or a gun. One out of five (n = 1,036) reported experiencing various degrees of sexual victimization. About 7.6% (n = 400) were forced to expose or touch the genital areas of the perpetrators or themselves; 1.8% (n = 95) reported that someone had tried to have sex with them. The vast majority (73.5-89.7%) of the sexual abuse perpetrators were known by their victims (Table 4).

Gender Differences

Females reported a higher rate of neglect (odds ratio [OR]: 1.43, 95% confidence interval [CI]: 1.28-1.61), while males reported a higher rate of sexual abuse (OR: 1.46, 95% CI: 1.25-1.70) (Table 2). Females reported more types of psychological abuse than males. Females were more likely to report that someone had wished they were dead (LT = 24.1%, OR: 1.28, 95% CI: 1.12-1.45) or had been bullied by another child at home. Both genders reported significant neglect victimization. Females felt less cared for, less important, and less supported than males. While females reported emotional neglect, males were more likely to be neglected physically, such as going hungry or having inadequate clothing. Males were more likely to experience

Table 1

Participant demographics stratified by geographic region of Taiwan (n = 5,236) (%).

North (n = 1286)

Central (n = 1086)

South (n =1365)

East (n = 763)

Offshore Island (n = 736)

Total (n = 5236)

Female Religion Aboriginal Living with family Both parents Single parent Grandparent(s) Age, mean (SD)

Weight for reconstruction (population proportion/sample proportion)

77.4 18.4

15.0(1.46) 1.824 (44.8%/24.6%)

49.4 68.9 13

75.0 21 2.5 14.4(1.37) 0.979 (20.3%/20.7%)

45.6 61.6 3.1

77.4 17.2

2.4 14.6(1.30) 1.135 (29.6%/26.1%)

48.8 80.1 19.7

72.6 20.6 3.4

13.72 (.83) 0.316 (4.6%/14.6%)

50.8 66.8 6.5

77.6 16.3

14.2 (.92) 0.050 (0.7%/14.1%)

67 9.6

76.2 18.7 2.4 14.5(1.32)

Table 2

Prevalence of child abuse among a national sample of Taiwanese adolescent (males, n = 2,708; females, n = 2,513). Victimization Overall prevalence (%) Gender differences (%)

Past year Lifetime Past year Lifetime

M F p M F p

Violence exposure 62.9 82.2 63.1 62.7 .862 81.6 82.9 .163

Frightened by adults' using drugs 15.4 26.4 14.9 16.0 .227 25.2 27.7 .040

Adults shouted in frightening way 44.0 68.3 42.8 45.5 .041 66.7 70.0 .011

Witnessed adults in home hit, kick, slap 9.1 23.0 8.8 9.6 .303 22.0 24.0 .072

Witnessed adults in home using weapons 4.4 10.6 5.5 3.2 <.001 11.2 10.0 .170

Someone close got killed near home 10.5 12.3 10.6 10.1 .632 12.2 12.1 1.00

Saw people being shot or rioting 11.0 14.9 12.3 9.5 .001 16.7 13.0 <.001

Something stolen from home 23.3 38.5 24.2 22.5 .169 38.7 38.4 .920

Psychological abuse 56.7 69.2 57.0 56.6 .823 69.3 69.3 1.00

Screaming 30.9 42.0 31.0 30.8 1.00 43.2 40.9 .110

Insulted 32.4 42.5 33.8 31.0 .045 43.5 41.6 .213

Made you feel embarrassed 27.6 38.1 28.2 27.1 .462 37.3 39.1 .165

Wished you were dead 15.6 23.7 14.5 16.8 .016 21.7 26.0 <.001

Threatened to abandon 7.6 14.0 7.7 7.5 .862 13.5 14.5 .299

Locked out of home 3.5 10.4 4.8 2.0 <.001 11.3 9.4 .021

Threatened to hurt or kill you 3.5 6.2 3.7 3.2 .424 6.5 5.9 .354

Bullied by another child at home 23.2 33.5 21.7 24.9 .006 31.2 36.0 <.001

Neglect 48.9 54.6 44.7 53.6 <.001 50.2 59.4 <.001

Went hungry or thirsty 10.0 13.4 11.4 8.6 .001 15.1 11.6 <.001

Inadequate clothing 4.2 5.6 5.3 3.0 <.001 6.6 4.5 .001

Unmet medical need 5.5 7.0 5.7 5.2 .549 6.9 7.2 .655

Felt not cared for 33.0 38.3 26.8 39.9 <.001 31.3 46.0 <.001

Felt unimportant 35.7 40.5 30.1 41.8 <.001 34.2 47.4 <.001

Inadequate support/help 25.6 29.9 22.2 29.2 <.001 26.8 33.4 <.001

Physical abuse 36.3 61.4 38.5 34.0 .001 61.9 61.1 .632

Pushed, grabbed, kicked 24.2 41.2 25.2 23.3 .134 41.9 40.7 .439

Hit, beat, spanked with hand 16.7 35.6 18.2 15.2 .005 36.4 34.9 .284

Hit, beat, spanked with object 9.8 30.3 11.2 8.4 .001 30.7 29.8 .538

Tried to choke, smother, or drown 1.5 3.2 1.9 1.0 .016 3.6 2.9 .169

Burned or scalded 1.7 3.0 2.3 1.0 <.001 3.9 2.0 <.001

Locked in small place 1.0 4.2 1.6 0.4 <.001 5.2 3.2 <.001

Pulled hair, pinched, twisted ear 16.5 29.5 17.0 16.1 .403 29.1 30.1 .488

Held heavy load as punishment 9.1 20.0 11.9 6.0 <.001 23.3 16.4 <.001

Threatened with knife or gun 1.1 2.4 1.6 0.6 .001 3.0 1.7 .003

Sexual abuse 15.0 19.8 17.4 12.5 <.001 21.8 17.7 <.001

Talked to you in a sexual way 11.4 14.3 11.8 11.0 .498 14.2 14.5 .689

Shown pornography 1.9 2.9 2.9 0.9 <.001 4.0 1.8 <.001

Looked at private parts 3.2 5.6 4.7 1.7 <.001 7.4 3.6 <.001

Touched private parts 5.0 7.6 7.7 2.1 <.001 10.7 4.4 <.001

Made a sex video of you 0.6 0.8 0.9 0.2 .001 1.1 0.3 .001

Forced sex behaviors 1.2 1.8 1.6 0.7 .005 2.2 1.4 .031

physical abuse in nearly every form including beatings, choking, spanking and were more likely to report sexual abuse of all forms.

Aborigine

Nearly 9 percent of the sample was aboriginal, descendants of the indigenous population of Taiwan (n = 454). Compared to non-aboriginal, aboriginal adolescents reported significantly less physical abuse (OR: 0.92, 95% CI: 0.91-0.93). Among all

Table 3

Students' experiences of polyvictimization in Taiwan (%).

Number ofvictimizations Past year Lifetime

Total Number of forms Total Number of forms

1 2 3 4 5 1 2 3 4 5

None 17.0 - - - - - 8.6 - - - - -

1-3 33.6 59.2 35.0 5.8 - - 22.5 53.5 37.7 8.7 - -

4-6 20.3 1.4 32.3 52.2 13.7 0.5 20.2 2.9 30.7 53.0 13.1 0.3

7+ 29.2 - 2.5 27.4 47.3 22.8 48.8 - 1.8 19.8 52.5 25.9

Table 4

Victims' familiarity with perpetrators of sexual abuse during childhood stratified by gender [n, (%)].

Not at all familiar Not very familiar Very familiar

M F M F M F

Talked to you in a sexual way 38(5.3) 36(5.0) 180(25.0) 201 (27.9) 150(20.9) 115(16.0)

(n = 720)

Showed pornography (n = 129) 15(11.6) 8 (6.2) 36(27.9) 16(12.4) 40(31.0) 14(10.9)

Made you look at their private 18(6.6) 13(4.8) 66(24.4) 42(15.5) 103(38.0) 29(10.7)

parts or wanted to look at yours

(n=271)

Touched private parts (n=354) 24(6.8) 16(4.5) 84(23.7) 49(13.8) 141(39.8) 40(11.3)

Made a sex video of you (n = 34) 7(20.6) 2(5.9) 5(14.7) 2(5.9) 13(38.2) 5(14.7)

Forced sexual behaviors (n = 82) 7(8.5) 4(4.9) 20(24.4) 13(15.9) 27(32.9) 11(13.4)

Table 5

Forms of violence victimization by perpetrators' age.

Adult (%) Teen(%) X2 P

Psychological abuse

Screaming 69.6 30.4 309.5 <.001

Insulted 41.3 58.7 62.35 <.001

Made you feel embarrassed 51.4 48.6 1.41 .235

Wished you were dead 66.8 33.2 112.13 <.001

Threatened to abandon 86.0 14.0 323.38 <.001

Locked out of home 92.6 7.4 310.01 <.001

Threatened to hurt or kill you 49.8 50.2 <0.01 1.00

Physical abuse

Pushed, grabbed, kicked 29.7 70.3 307.87 <.001

Hit, beat, spanked with hand 70.6 29.4 268.13 <.001

Hit, beat, spanked with object 92.5 7.5 966.27 <.001

Tried to choke, smother, or drown 45.8 54.2 0.91 .340

Burned or scalded 48.5 51.5 0.09 .764

Locked in small place 77.5 22.5 53.90 <.001

Pulled hair, pinched, twisted ear 66.0 34.0 128.41 <.001

Held heavy load as punishment 96.7 3.3 704.19 <.001

Threatened with knife or gun 70.0 30.0 16.23 <.001

Sexual abuse

Talked to you in a sexual way 30.0 70.0 114.17 <.001

Showed pornography 34.5 65.5 12.83 <.001

Looked at private parts 28.1 71.9 52.66 <.001

Touched private parts 24.5 75.5 95.41 <.001

Made a sex video of you 57.3 42.7 0.77 .380

Forced sexual behaviors 38.6 61.4 4.17 .041

the aboriginal adolescents, females reported a statistically significant higher rate of neglect (OR: 1.55, 95% CI: 1.49-1.61) and higher polyvictimization (>7 victimizations; OR: 1.21, 95% CI: 1.19-1.24) than males.

Perpetrators' Age

Adolescents reported adults as the primary perpetrator inflicting psychological and physical abuse. However, other teens were more often the perpetrators of sexual abuse (Table 5).

Discussion

The findings of this study indicate an extensive rate of violence exposure among high school students in Taiwan. Adolescents' experiences of exposure to maltreatment within the past 12 months approached 80%. Severe and potential lethal forms of abuse were reported. Five hundred eighty adolescents (11%) reported serious incidents on the items of being threatened with a knife or a gun, burned or scalded, verbally threatened with injury or death, or experiencing someone trying to choke, smother or drown them. The resulting health problems, given the magnitude of child maltreatment in Taiwan, cannot be overlooked.

Compared to the 0.6% prevalence official report of abuse in Taiwan in 2012 (Department of Statistics, Ministry of the Interior, 2013) the findings of this study corroborate the previous suggestion of severe under-reporting (Feng & Levine, 2005) and validate estimation of the prevalence of child maltreatment by population-based surveys which were much higher than those of official reports (Theodore et al., 2005). As many child victims are still hidden in the community and living in an unsafe environment, it is recommend that discrepancy between self-reported data in this study and official

reports be further investigated. Health care professionals and community leaders must engage and take action to resolve this grave public health issue and address victims' safety without delay.

Two-third of adolescents in this nationwide sample reported experiencing lifetime polyvictimization. High prevalence of victimization and polyvictimization has been reported in other studies using the ICAST-CH questionnaire and with other instruments measuring abuse among children and adolescents (Al-Eissa et al., in press; Flaherty et al., 2013; Imola et al., 2013). Using the ICAST-CH, Al-Eissa et al. (in press) found that the incidence of psychological abuse, physical abuse, exposure to violence, neglect, and sexual abuse were 75%, 58%, 51%, 50%, and 14%, respectively among adolescents in Saudi Arabia. Likewise, 78.6% of Turkish adolescents reported experiencing multiple negative childhood experiences (Sofuoglu et al., 2014). Consistent with studies in the US (Finkelhor, Turner, Hamby, & Ormrod, 2011), the current findings revealed no gender difference in the prevalence of polyvictimization. However, studies from China (Dong et al., 2013) and Sweden (Nilsson, Gustafsson, & Svedin, 2012) found that adolescent males reported experiencing more polyvictimization than females. The underlying vulnerabilities, consequences and gender influence on children with polyvictimization require further investigation.

Youth's exposure to domestic violence, especially the direct witnessing of physical violence, significantly links to delinquency, crime, and poor educational and health outcomes, such as asthma and other chronic diseases (Bair-Merritt et al., 2013). Nearly 1/4 of adolescents in this study reported witnessing adults engaging in physical altercations including using weapons, actions that places the child in danger of physical harm. Youth's presence during domestic violence receives little attention due to the overwhelming caseload of the child protection system or the perception that the child or youth is not in imminent danger. However, according to the U.S. DHHS (2012) domestic violence is the biggest risk factor for child fatality (U.S. DHHS, 2012). Routine screening and brief counseling by health care providers for interpersonal and domestic violence has been recommended by the Institute of Medicine (de Boinville, 2013). A comparable policy is not yet available in Taiwan, but should be advocated to protect both women and their children from additional harm or aggravating negative impact. The negative health consequences of witnessing domestic violence and children's needs must be addressed during violence screening or consultation in adult medical settings and well-child visits (Bair-Merritt et al., 2013). Both women and children should be considered when develops safety plans, care interventions and referrals. Collaboration between professionals in schools and institutions in the community is important to promote health care for violence victims (Bair-Merritt et al., 2013).

In general, the proportion of participants who had experienced a violence event was similar between adolescent males and females. However, adolescent males had a greater prevalence of physical abuses while females reported more psychological abuse. In the study by Thompson and colleagues (2004), men were also found to experience more physical abuse in childhood than female (Thompson et al., 2004). Females' experiences with less physical but greater psychological abuse maybe related to the lower value placed on females in Taiwan culture (Kan & Feinberg, 2010). Reasons for adolescent females' experiences of more bullying by another child or adolescent at home may be the transmission of female insignificance by parents to siblings. Societal values can lead to treating females gently and more likely expose them to psychological abuse, a more subtle form of abuse. Psychological abuse has long-lasting, devastating impacts on children's self-esteem, socialization, development and behavior (Hibbard, Barlow, MacMillan, & the Committee on Child Abuse and Neglect and American Academy of Child and Adolescent Psychiatry, Child Maltreatment and Violence Committee, 2012).

Almost a half of all the adolescents, regardless of gender, reported experiencing various degrees of neglect, a finding not previously documented by official sources or empirical studies in Taiwan. Neglect encompasses the greatest number of forms of child maltreatment, but has been ignored by society and overlooked by reporting systems. Reports from the U.S. DHHS (2012) indicated that the fatality rate from child abuse was decreasing slightly, while neglect remained as the most prevalent form of maltreatment (U.S. DHHS, 2012). Unlike other forms of abuse, parents in neglect cases are often troubled by their own inability to care for the child due to economic hardship or psychological problems. Interventions targeted to identify children and families at risk are critical. By assessing parents' needs for social, ecological or mental health services, the child's needs for health, development, education and safety can be improved (Dubowitz & Poole, 2012).

Compared to the sexual abuse prevalence reported by Latino (54%) and European American (27%) adolescents (Newcomb, Munoz, & Carmona, 2009), the current study revealed that adolescents in Taiwan experience a lower rate (20%) of sexual abuse with only 1.8% reporting forced sexual behaviors over their lifetime, a prevalence similar to that in China and Malaysia (Chen et al., 2004; Choo et al., 2011). In Barth, Bermetz, Heim, Trelle, and Tonia (2013) meta-analysis of 55 empirical studies, females were 2-3 times more likely to experience child sexual abuse than males with 9% of females and 3% of males exposed to forced intercourse. Compared to inconsistent results from studies in other Asia countries (Chen et al., 2004; Choo et al., 2011), the results of the current study indicated that males were also vulnerable to sexual abuse. Culturally related factors in the context of sexual abuse and willingness of disclosure need further investigation. Adolescent females may have been more reluctant or frightened to disclose sexual abuse in this study even in an anonymous survey. Moreover, most perpetrators of adolescent males were teens while most perpetrators of female victims were adults in this study. The phenomenon of peer-to-peer sex violence or bullying requires further study. It is important to note that the sexual perpetrator is likely to be known by the victim. Familiarity with the perpetrator and the problem of parental or relative abuse within the home makes child abuse identification and reporting problematic but mandatory, and should be considered in a prevention plan.

The sensitivity of the ICAST-CH instrument needs further testing due to the high prevalence of adolescent experiences of child maltreatment and polyvictimization reported by the study sample. More rigorous evaluation and validation of individual items is needed for the meaning of child maltreatment in the sociocultural and legal context across different cultures or countries. Two previous studies of child maltreatment in Taiwan (Chou et al., 2011; Yen et al., 2008) adopted a strict definition for physical abuse, counting only events that caused chronic and severe physical injuries. Such a narrow definition of

child abuse compromises comparisons with other findings where the intention of perpetrators was the determining factor of child maltreatment. Items in the ICAST-CH originated from many well-known childhood victimization instruments including the Juvenile Victimization Questionnaire with a purpose to generate a cross-cultural, universal instrument for children (Zolotor et al., 2009). Nevertheless, the ICAST-CH-C is a relatively new instrument and the construct validity of the subscales needs more corroboration. The concept of polyvictimization measured by the ICAST-CH-C may not be directly comparable to findings from the Juvenile Victimization Questionnaire. Further examination of the comparability and equivalence between the instruments is indicated.

Conclusion

This is the first population-based national study in Taiwan using adolescents' self-report of their maltreatment experiences in the home. The findings are dramatically different from official reports of child abuse and neglect in Taiwan. It is a challenge for healthcare providers and policy makers to prevent the large number of adolescents who report experiencing maltreatment from becoming a much smaller number in official reports of cases with significant or serious injuries. Effective and practical strategies are needed to identify children and youth at risk and help victims recover from trauma. Given such high prevalence rates of adolescent-reported maltreatment and polyvictimization we recommend that child maltreatment in Taiwan be designated a national priority that mandates a careful and comprehensive review and modification of the current policies for control and prevention.

Conflicts of interest

All authors report no biomedical financial interests or potential conflicts of interest.

Acknowledgments

The authors acknowledge the help of the students who participated in this study and the teachers who delivered and collected questionnaires. The authors also acknowledge the contribution of Chiao-Li Lin, BS, the Sandplay World Expressive & Therapeutic Training Center, Taiwan, for her assistance in data collection.

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