Abstract
Child maltreatment is considered as a global social issue and results as combined effect of parental background, socioeconomic environment, family structure, and child characteristics. The aim of this study was to determine factors associated with child maltreatment among children aged 11 to 17 years in Karachi, Pakistan. A cross-sectional survey of 800 pairs (children ranging from 11 to 17 years old and their parents) was randomly selected from 32 clusters of Karachi, using multistage cluster sampling. A structured questionnaire was adopted from the International Society for the Prevention of Child Abuse and Neglect (International Child Abuse Screening Tool for Parent [ICAST-P] and for Child [ICAST-C]). Multiple linear regression technique was used to assess the association of factors with child maltreatment score, by using STATA software. Our study found that children who always get bullied and mistreated by their siblings are at increased risk of getting maltreatment by parents (adjusted β: 10.78, 95% CI = [8.5, 13.05]).The mean estimated ICAST-C score increases by 9.86 (95% CI = [6.17, 13.55]) for children with exposure of verbal abuse and quarrel within family members. The mean estimated ICAST-C score increases by 5.09 among male children as compared with female children (95% CI = [3.65, 6.52]). Among children whose family always fight with each other and whose parents have exposure to childhood maltreatment, the mean estimated ICAST-C score increases by 22.25 (95% CI = [16.53, 27.98]). This study reflects the potential factors of child maltreatment in Karachi. Our findings provide evidence to raise awareness about child maltreatment.
Introduction
The dynamics of child maltreatment have been recognized as a pandemic social issue highly associated with child humiliation (Goldman, Salus, Wolcott, & Kennedy, 2003a). It has become a universal health priority due to its perilous impacts on child development, child’s brain structure, social functioning, health risk behavior, and psychological functioning. Child maltreatment is defined as
any malevolent, destructive, offensive contact on a child’s body which humiliates, embarrasses or frightens a child through occurrence of any non-accidental behavior which is brutally perpetrated upon child in a form of intentional or unintentional act. This is usually by the person with a custodial role, i.e. parents, caregivers or the one who is very close to that child. This often results in the omission (neglect) or commission (abuse). (Giardino, Christian, & Giardino, 1997; Leeb, Paulozzi, Melanson, Simon, & Arias, 2008; World Health Organization [WHO], 1999)
The definition of child maltreatment varies from region to region and from one culture to another culture (Afridi et al., 1998). According to Pakistani context, child maltreatment is described as
intentional use of physical force, intended to cause a high degree of pain or discomfort for disciplining, controlling, or changing behaviors of a child in the belief of educating them, which every so often has a high likelihood of resulting in physical harm, mal-development or deprivation and psychological harm. (Govt., 2010)
Research evidences suggested that child maltreatment is a combination of multiple forces working at the same time. A cohort study conducted in Bristol, the United Kingdom, highlighted that individual characteristics, family system, community, and culture can be the push factors of child maltreatment (Sidebotham & Heron, 2006). A Belsky model of ecological interactions underlined that child maltreatment occurs due to interaction of parental background (ontogenic), socioeconomic environment (exosystem), family structure or family relationship (microsystem), and child characteristics. As child maltreatment is conceptualized as a social-psychological phenomenon, this model determines factors associated with child maltreatment in the context of the family, community, and society rather than highlighting only individual factors (Goldman, Salus, Wolcott, & Kennedy, 2003b; Sidebotham & Heron, 2006). Literature also suggested that 78.8% of children have been maltreated by parents; approximately three fifth were maltreated by mothers and 42% of the mothers were aged less than 30 years (Goldman et al., 2003a; Linares et al., 2001). In contrast, a study conducted in Karachi found that mothers aged 40 years and above with low educational background are one of the predictors of child maltreatment (Ali, Ali, Khuwaja, & Nanji, 2014). In addition, teenage parenthood, high stress level of parents (Buchholz & Korn-Bursztyn, 1993; Goldman et al., 2003b), higher expectations from a child (Bardi & Borgognini-Tarli, 2001; WHO, 2002), alcohol abusing parents (Goldman et al., 2003a), and those with paternal history of child maltreatment are the common determinants of child maltreatment (Ali et al., 2014). Another significant predictor of child maltreatment is socioeconomic context: Lower socioeconomic status (SES), poverty, and unemployment of father are found to be strongly associated with child maltreatment (Buchholz & Korn-Bursztyn, 1993; Goldman et al., 2003a; Sidebotham & Heron, 2006). Apart from socioeconomic background, family system plays an important role toward child nurturing. Some other common predictors such as lack of family support, large family size, marital conflicts, single parenthood, domestic violence, and stressful home environment, and so on, can lead to child maltreatment (Buchholz & Korn-Bursztyn, 1993; Goldman et al., 2003b). Literature also suggested that parental punishments are also used as a preparation of being strong for future roles and responsibilities in some cultures by families (WHO, 2002). The impact of witnessing domestic violence in childhood induces aggressive behavior into adulthood, thus giving rise to a constant cycle of violence and aggression leading to intergenerational abuse/maltreatment (Higgins & McCabe, 2000). In addition, some child characteristics also make a child prone for child maltreatment, such as gender or age of a child. According to WHO, children less than 3 years of age have highest rate of maltreatment among whom female children are at risk for all types of maltreatment, whereas male children are prone for more harsh physical maltreatment (Goldman et al., 2003b). In Pakistan, harsh parental disciplinary practices are common societal norm and typically assumed as acceptable disciplinary strategies (Sahil, 2012; Society for the Protection of the Rights of the Child [SPARC], 2012; Sahil, 2013). Hence, it was crucial to identify factors associated with child maltreatment in our context to raise awareness about these practices used by parents. Therefore, the aim of this study was to determine the factors associated with child maltreatment among adolescents aged 11 to 17 years in the communities of Karachi, Pakistan.
Method
An analytical cross-sectional design was employed from December 2014 to March 2015 for this study. The Federal Bureau of Statistics has divided Karachi urban area into about 7,750 clusters of 125 to 350 households forming 18 towns in total (Anonymous, 2007). The sampling frame was based on the recent data covering 15 random towns comprising of 80 random clusters, and each cluster has a minimum of 125 households. Out of 80 clusters, we randomly selected 32 clusters which served as the primary sampling unit through systematic random sampling technique. We targeted one third of all households (25) per cluster. These households were considered as the secondary sampling unit. Selection of households was based on the presence of at least one child with age between 11 and 17 years in that household. Participants within the secondary sampling unit were considered as the tertiary sampling unit. A total of 800 children and 800 parents, that is, 800 child–parent pairs, were selected who were able to understand Urdu language and fulfilling eligibility criteria and were present at the time of data collection. Only one child from one household was included in the study. All children and parents with known severe physical and mental impairment were excluded. Study was approved by institutional Ethical Review Committee of Aga Khan University, Karachi. Informed consent and assent were taken from parents and their children, respectively. Face to face interviews were conducted, using two separate questionnaires: International Child Abuse Screening Tool for Parent (ICAST-P; Runyan et al., 2009) and for child (ICAST-C; Zolotor et al., 2009) were adopted from International Society for the Prevention of Child Abuse and Neglect (ISPCAN). In the modified ICAST-P, there were 34 questions with 4-point scale (1 = never, 2 = yes but not in past 3 months, 3 = sometimes, and 4 = many times). Five items in this scale were scores in descending order, whereas rest were in ascending order. In the modified ICAST-C, there were 30 questions with 6-point scale (1 = never, 2 = yes but not in past 3 months, 3 = once or twice, 4 = 3 to 5 times, 5 = 6 to 10 times, and 6 = ≥10 times). Three items in this scale had scores in descending order, whereas rest were in ascending order. The potential risk factors were categorized into four major categories following Belsky model, that is, parental ontogenic background (parental characteristics), exosystem (socioeconomic determinants), microsystem (family and relationship determinants), and child characteristics. The outcome was child maltreatment score based on the modified form of ICAST-C. The total child maltreatment score on IACST-C was taken as sum of scores of all 30 items. Internal consistency of this tool is moderate to high (Cronbach’s α coefficients between .720 and .855). The content validity of this tool was established by expert psychologists, and face validity was established based on pretesting of tool in three different clusters of Karachi on approximately 5% of overall sample size. The tool was modified based on the understanding of participants and according to cultural context. The internal consistency within the responses was measured by Cronbach’s alpha. All normally distributed continuous variables were summarized with their mean and standard deviation. For categorical variables, frequency counts and percentage were reported. Multiple linear regression was used for analysis where regression coefficients were adjusted for clusters, to determine the association of various risk factors with child maltreatment score, by using STATA software (StataCorp, 2011)
Results
Descriptive statistics of study population are shown in Table 1, The M ± SD age (years) of the mothers was 38.5 ± 6, whereas the M ± SD age (years) of the fathers was 43.5 ± 7. Most of the parents (92.6%) were married. The majority of fathers (95%) were employed, whereas majority of mothers (87%) were housewives. Parental history of intergenerational abuse was reported by parents (51.1%). In addition, 25.6% of parents had self-reported suffering from psychiatric illness. Almost 13.1% of participants belonged to lower SES, 72% belonged to middle SES, and 15% belonged to higher SES. Above variables constitute the exosytem that is the socioeconomic domain of our conceptual framework. Approximately 57% of the children belonged to nuclear family system. The average total number of siblings within a family was 3.6 ± 2. Approximately 33% of parents reported their home environment as stressful. Verbal abuse and quarreling reported by parents were 56%. Almost 15% of children reported physical fighting among family members. Nearly, 50% of children reported that they were bullied or mistreated by their siblings and other children at home. Above-mentioned variables constitute microsystem family characteristics of Belsky ecological model. The child characteristics of Belsky ecological model showing M ± SD age (years) of the children was 13.1 ± 1.8. Out of 800 children, 375 (47%) were females, whereas 425 (53%) were males. Approximately 267 (33.3%) children were first child, 361 (45.12%) were middle child, and 172 (22%) children were last child of the family.
Descriptive Characteristics of Children and Their Parents in Karachi City, Pakistan, From December 2014 to March 2015 Following Belsky Framework of Ecology (N = 800 Dyads).
Note. SES = socioeconomic status.
Total mothers were 798 as two mothers were deceased.
Total fathers were 744 as 56 were deceased.
The average score of overall ICAST scale was 51.71 ± 11.98. The reliability of the scale was measured to be 87.80%, indicating excellent internal consistency within the responses by the participants.
Multiple linear regressions (adjusted for clusters) were run to determine predictors contributing to mean ICAST-C score. A stepwise approach to building the model was undertaken, assuming p value <.05 to be statistically significant for primary outcome (ICAST-C score). The final model indicates that 46% of the variability in the mean ICAST-C score is strongly explained by following variables: bullying by elder sibling, verbal abuse, quarreling in family, physical fighting using hard object in family, child educational status, child’s gender, age of child, parental history of childhood maltreatment, parental educational status, socioeconomic wealth index, age of mother, birth order of child, interaction between physical fighting using hard object in family and parental history of childhood maltreatment, and interaction between parental education and age of mother as shown in Table 2. No multicollinearity was seen between any independent variable.
Multiple Linear Regression Analysis of Factors Associated With ICAST-C Score Among Children Age 11 to 17 Years in Karachi City, Pakistan, From December 2014 to March 2015 (N = 800 Dyads).
Note. Adjusted R2 = .461, β0 = 51.40, F = 92.40. ICAST-C = International Child Abuse Screening Tool for Child; CI = confidence interval; SES = socioeconomic status.
Interaction term added to the model. The beta coefficients and their confidence intervals were calculated at 10% level of significance.
Significant p value.
The final model indicates that with every 1-year increase in age of child, the mean estimated ICAST-C score decreases by 0.67 (95% CI = [−1.08, −0.26]). Children who were always bullied and mistreated by their siblings are at increased risk of getting maltreatment by parents (adjusted β: 10.78, 95% CI = [8.5, 13.05]) as compared with children who are never bullied and mistreated by their siblings. Among children, where there are always verbal abuse and quarrel within family members, the mean estimated ICAST-C score increases by 9.86 score as compared with children, where there are no verbal abuse and quarrel within family members (95% CI = [6.17, 13.55]). Moreover, among children who had no formal education, the estimated mean ICAST-C score is 5.55 higher than children who had formal education (95% CI = [1.40, 9.69]). The mean estimated ICAST-C score increases by 5.09 score among male child as compared female child (95% CI = [3.65, 6.52]) with a declining severity with increment in age exceptionally sharp increment was seen at the ages of 14 and 15 years in both male and female children. In their late adolescent years, female children experienced slightly higher maltreatment. The mean estimated ICAST-C score increases by 2.48 among children who belonged to low socioeconomic wealth index as compared with children who belonged to high socioeconomic wealth index (95% CI = [–0.08, 5.04]). Among middle-ordered child, the estimated mean ICAST-C score is 1.93 higher than first-ordered or only child of family (95% CI = [0.08, 3.79]).
There is an interaction between parental exposures to childhood maltreatment and physical fighting with hard object among family members. Among children whose family always fight with each other and whose parents had exposure to childhood maltreatment, the mean estimated ICAST-C score increases by 22.25 (95% CI = [16.53, 27.98]) as compared with children whose family never fight with each other and parents had no exposure to childhood maltreatment. There is another interaction between age of mother and parental education. The estimated mean ICAST-C score increases 1.99 unit for every 1-year decrease in age of mother and if both parents had no formal education, when the mother’s age held constant at 40 years (95% CI = [0.18, 3.80]).
Discussion
This is the first community-based study in Pakistan to identify the associated factors of child maltreatment among children aged 11 to 17 years in Karachi, Pakistan. This study examined the factors associated with the ICAST-C maltreatment score and major background variables comprised of parental background, family relations and characteristics, socioeconomic or cultural background, and child characteristics following Belsky ecological model. All variables were examined at three levels of ecological model such as individual, family, and community levels (Goldman et al., 2003b; Sidebotham & Heron, 2006). The factors that were significant with child maltreatment score were individual factors (gender of child, age of child, birth order of child, education status of child, age of mother, and parental educational background), family relationship factors (mistreatment and bullying by siblings, verbal abuse and quarreling among family, parental history of childhood maltreatment, physical fighting, and violence among family), community factors (SES), and so on.
Our study also found that age of mother is an important predictor in child maltreatment. Children having younger mother are at higher risk of maltreatment, which might be due to lack of experience in fostering a child and can promote harsh disciplinary techniques used for upbringing and nurturing a child (Buchholz & Korn-Bursztyn, 1993; Connelly & Straus, 1992; Sidebotham & Heron, 2006). Parental education also plays an important role in upbringing and nurturing of child. Children with low or uneducated parents are more on risk of getting maltreated by their parents (Kotch, Browne, Dufort, Winsor, & Catellier, 1999; Sidebotham & Heron, 2006). In addition, our study highlighted interaction between age of mother and parental education; that is, those children who belonged to younger mothers and those with no formal education found to be at greater risk of maltreatment with twofold increase in risk. The reason could be the low level of knowledge of nurturing and upbringing which increases with age. This finding is consistent with other studies done in developed countries (Kotch et al., 1999; Sidebotham & Heron, 2006). Similarly, also if a parent is exposed to maltreatment or neglect in his or her childhood, it can continue a vicious cycle of intergenerational abuse and it was aligned with past researchers (Pears & Capaldi, 2001; Sidebotham & Heron, 2006).
Further findings show that children who belonged to lower socioeconomic strata are at higher risk of child maltreatment than high socioeconomic strata. This finding was consistent with other studies (Black, Heyman, & Slep, 2001; Black, Slep, & Heyman, 2001; Sebre et al., 2004). The probable reasons could be unable to fulfill child basic needs and child demand due to constrain resources. The frustration caused by limited resources may lead to displacement of such frustration onto child.
The structure and dynamics of the home environment and family are important factor helps in nurturing and development of child. Our study shows that verbal abuse among family and poor communication between parents significantly increase the risk of child maltreatment ninefold, and it is consistent with the numerous studies conducted in developed countries (Black, Heyman, & Slep, 2001; McGuigan & Pratt, 2001; Rumm, Cummings, Krauss, Bell, & Rivara, 2000; Schumacher, Slep, & Heyman, 2001). Verbal and physical abuse among parents and other family members increased the risk of violence and abuse toward the children, and as the children exposed to such acts in home, they develop the acceptance of such violent behavior which may result in a vicious cycle of domestic violence and intergenerational abuse (Sidebotham & Heron, 2006; Tajima, 2000). Furthermore, family violence significantly affects the family harmony and can lead to disruption in supportive relations among the family members, eventually interrupting the transmission of positive cultural values and traditions which enhance the vicious cycle of intergenerational abuse in society. Moreover, among families where the family quarrel is highly prevalent, it is unlikely that children of these families will be able to learn positive traits of their custom values and traditions such as caring family roles, respect, nurturing of children, or good communication that may play an central role in cushioning families against individual, family, and community factors that lead to child maltreatment (Elliott & Urquiza, 2006).
Sibling relationship is also found to be one of the vital predictors of child maltreatment. Our study found a significant association between siblings abuse and child maltreatment. The findings are in line with past studies (Black, Heyman, & Slep, 2001; Kotch et al., 1999).
Our study revealed a significant association of child gender with child maltreatment. Male child is more prone for child maltreatment as compared with female child with fivefold of maltreatment. The findings are consistent with other studies (Black, Heyman, & Slep, 2001; Tajima, 2000; Wolfner & Gelles, 1993). Our study finding discovered one important niche; that is, at the age of 17 years, female child was found to be more maltreated as compared with the male child. Up to our knowledge, there could be two possible reasons in our setting. One could be that due to hormonal changes during the pubertal epoch of development, the male children have more apparent changes, including heavy body, increased muscle mass, and appearance of beard and mustaches. Hence, it pictures a well-grown man, so parents are reluctant to hit or abuse male children. Another reason could be that at the age of 17 years and on, female children are more to be involved in home-based activities in our culture, including putting responsibilities of home and other family members to prepare her for marital life ahead, so parents are stricter and apply stringent disciplinary techniques for girl children as compared with male children. Our study found that with an increment of child’s age, the risk of maltreatment is low except at the age of 13 to 15 where there was a sharp escalation in child maltreatment. Most of the studies show the consistent result that increment in age is playing a protective factor in child maltreatment, but to the best of our knowledge, there were no such studies supporting the sharp rising of maltreatment in 13 to 15 years especially in boys. This could be hypothesized that 13th year of age is the starting of teenage, that is, to start with a new turn in life where children go through many developmental changes, including social development (peer involvement, increase in social activities), psychological changes (anger, development of self-esteem, impulsiveness, ego, pride), and bodily changes (hair growth, puberty, hormonal changes). These changes can bring a very instantaneous and new personality in the child, which is the part of normal development but not every parent can understand it. Hence, in most of the cases, parents find detachment in usual bonding with the child. In response to that feeling of detachment, parents try to control child with stringent and firm boundaries of harsh disciplinary acts to restore their relation.
Birth order also showed significant association with child maltreatment. Our study findings revealed that middle child are more prone to be maltreated as compared with the first and last children. The reason could be that the first child is considered as a valuable asset of family, and as the time goes, he or she becomes the role model for other siblings, whereas the last child is usually too young and treated with less discipline and rule due to pampering by the family.
Education and knowledge of child also play an important role in the development of the child. Our study revealed that those children who were aware and were educated were at lower risk of maltreatment. The reason could be that the educated child is more matured and learned discipline, good behaviors, and develop good habits in the school environment. However, this factor by itself may not cause the child abuse itself; rather, it might reveal the poor parenting style and poor parental value to education and neglect of parents which may have a significant relation with maltreatment (Buchholz & Korn-Bursztyn, 1993; Connelly & Straus, 1992; Sidebotham & Heron, 2006).
This study has several strengths: To the best of our knowledge, this is the first community-based study on child maltreatment in Pakistan. It reveals different factors, such as individual, family, and community levels. It was based on a large number of sample populations. We used ICAST tools for our study, which is the amalgamation of all available global tools and was made specifically for developing countries. This has also been revised by several psychologists according to local context and was piloted in three different clusters.
This is a cross–sectional study, so as the limitation of the study design, we cannot predict the temporality between factors and child maltreatment. There is also a chance that parents may not reveal all the disciplinary techniques with the same severity, leading a possibility of wish bias which could result in underestimation of the results due to hitches in recall and disclosure of some events (Fergusson & Lynskey, 1997).
Conclusion
The current study determined that child maltreatment is a multifaceted phenomenon where multiple factors are associated with child maltreatment such as bullying by elder sibling, verbal abuse, quarreling in family, physical fighting using hard object in family, child’s educational status, child’s gender, age of child, parental history of childhood maltreatment, parental educational status, socioeconomic wealth index, age of mother, birth order of child, and interaction between physical fighting using hard object in family and parental history of childhood maltreatment. Early screening and prevention of modifiable factors are more likely to break the vicious cycle of maltreatment. There is a dire need to identify norms and beliefs of community people in the context of different disciplinary techniques using qualitative research. Furthermore, a longitudinal approach of this kind may be useful to determine the consequences of child maltreatment on their mental well-being.
Footnotes
Authors’ Note
The content is solely the responsibility of the authors, and the funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is exclusively the accountability of the author and does not signify the authorized views of the Johns Hopkins University–Pakistan Fogarty International Collaborative Trauma and Injury Research Training Program, and it does not represent the views of Fogarty or National Institutes of Health (NIH).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Johns Hopkins University–Pakistan Fogarty International Collaborative Trauma and Injury Research Training Program Grant 5D43-TW007292-10 from the Fogarty International Center of the U.S. National Institutes of Health.