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Child abuse and neglect in a rapidly developing country: Parents’ perspectives

Purpose: To identify parental awareness and knowledge regarding child abuse and neglect in the State of Qatar. Methods: A cross‐sectional study using a questionnaire was conducted at Hamad Medical Corporation, the only tertiary pediatric hospital in the State of Qatar at the time of the study. Parents of children of all ages were offered a questionnaire that included demographic details, parental knowledge, and awareness of child abuse and neglect. Results: 300 questionnaires were completed (response rate = 95%). More than 70% of parents were older than 30 years of age, 60% of them were females, and 66% were college graduates. The majority of the participants stated their familiarity about child abuse, and 6% witnessed morbidity or mortality due to child abuse in the society. Despite the identified laws, only 50% of the parents were aware of laws restricting child abuse. In regards to children with special needs, only 16% of the participants agreed that disabled children are at a higher risk of abuse compared to healthy children, while 33% were neutral and 52% disagreed. In addition, one‐fifth of the respondents stated that hitting is discipline, while 63% disagreed. Almost one‐third of the respondents agreed that hitting hands and buttock or hitting with soft objects is acceptable form of discipline. Unexpectedly, one‐quarter of participants stated that it is okay to hit a child as long as no damage incurs. As for verbal abuse, around one‐third of parents stated that yelling is not a form of child abuse, and that yelling does not affect growth and development. Comparing both corporal and verbal abuse, approximately 70% of parents stated that yelling is less harmful than hitting. In terms of child neglect, around half of the respondents agreed with the statement “Leaving a child (<5 years) unattended at home is a form of neglect,” while 42% were neutral. Finally, approximately 50% of the participants believed that it is okay to depend on nannies in assisting their children in eating and using the bathroom. Conclusion: Parents residing in the State of Qatar believe that they have a good knowledge regarding child abuse and neglect. However, this study shows many deficiencies in parental knowledge of child abuse and neglect. Parents’ attitudes and perceptions are considered indispensable targets for community health intervention.


Introduction
The Child Abuse Prevention and Treatment Act (CAPTA) has defined child abuse and neglect as "any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm." [1] Abuse of a child's right to protection is a common issue and one of the paramount barriers to interfere in such a problem is the parental lack of knowledge on the use of positive attitudes as a way to discipline children. [2] The concept of child abuse and neglect (CAN) is a well-known issue globally. However,

Child abuse and neglect in a rapidly developing country:
Parents' perspectives its implications are unidentified in many countries. [3] CAN might lead to repercussions related to mental and physical state and can lead to behavioral issues. [4] Harsh abuse is linked to poor outcomes in adulthood. For instance, childhood sexual abuse has been linked, in adulthood, to body complaints such as chronic pain that are more likely associated with depression. Moreover, people with a history of childhood abuse, especially sexual abuse, are at higher risk compared to individuals with no history of abuse to become frequent users of medical care and emergency services. [5] In support, childhood maltreatment, particularly emotional abuse and neglect, has been highly detected in adults with migraine, [6] and all types of CAN are highly linked to depression and anxiety, and the link is stronger with a recurrent maltreatment. [6] In a recently published meta-analysis, Gardner et al. [7] studied the influence of childhood physical abuse, sexual abuse, emotional abuse, neglect, and exposure to intimate partner violence (IPV) on depression and anxiety disorder. The study showed that all methods of child maltreatment were linked to depressive disorders. Children and adolescents with a history of sexual abuse are at higher risk of having diagnoses of genitourinary infections, as well as more respiratory and ear infection. [8] In spite of the proof of the far-reaching effects, CAN research remains rare. [4] Children in the Arab Peninsula are exposed to all methods of CAN. [9] In spite of this, the literature has shown that CAN research remains scant with few scattered studies in Saudi Arabia, [10,-13] Turkey, [3] Egypt, [14] and Jordan. [15,16] Other studies in the region have evaluated the perception of possible CAN among a variety of populations such as medical students, [17] pediatric physicians, [18] and preschool teachers (rather than parents). [19] The World health organization has reported that 25% of adults had experienced physical abuse as children, 36% had experienced emotional abuse, 26% had experienced sexual abuse, and 16% had experienced neglect. [20] In his report series, Kattan [21] concluded that abuse in the Arabian Peninsula might be ignored, tolerated, or even accepted as a form of discipline. A report from Yemen exposed the extensive use of physical castigation and brutality to children in schools, homes, and juvenile centers, reaching up to 80%. [9] The State of Qatar has been tackling child abuse and neglect for a while and currently a very well-structured program has been established, the Sidra Medicine Child Advocacy Program (S-CAP). This program is leading child protection efforts in Qatar with the ultimate goal of supporting the health, wellbeing, and development of a child who has been the victim of abuse or neglect. [22] Risk factors for child abuse and neglect can be numerous and include, but are not limited to, parental history of being abused themselves as children, low socioeconomic status, single parent, domestic violence, parental inadequate coping skills, parental stress and low education level, and child's medical condition. [23] In Turkey, a study conducted by Sofuoğlu et al. [3] has shown that child maltreatment is common and a substantial healthcare issue, but parents are lacking the knowledge of its magnitude. One of the concerning factors of the study was that parents tend to under-report child maltreatment. Such a finding underlines that parental perceptions and awareness of CAN are crucial. Knowledge and attitudes of accountable parents are important in the prevention of child abuse; [23] hence, it is crucial to establish if parents in the community lacked basic knowledge of CAN.
This study was conducted because, in spite of many reports of child abuse globally, parental perceptions of CAN have not been delineated properly. The specific objectives were to assess parental views and concerns on: general aspects of child abuse; specific aspects of child abuse and neglect; verbal abuse; sexual abuse; and, neglect. To the best of our knowledge, this is the first study in Qatar and one of the very few in the Middle East to investigate parental perceptions of CAN. The findings of this study will be incorporated into future interventions that aim to identify risk factors for CAN by monitoring parents' attitudes. The study will also be used to develop prevention schemes such as testing and counseling for parents of children at risk for CAN.

Materials and Methods
Study design, ethics, and setting

Research tool
The content of the questionnaire was adopted from published studies [24,25] and was validated by a group of experts at our institution. Translation and back translation of the questionnaire from English to Arabic and vice versa was carried out by the translation services at the research center in Hamad Medical Corporation. Parents were presented questionnaires in both Arabic and English languages. The self-administered questionnaire comprised 38 items that included the following: 1. Parent and children demographics (7 questions

Procedure and participants
Despite the fact that there are many manuscripts published related to CAN, there were no similar studies investigating the specific topics of our questionnaire within the context of parental perception and, thus, we could not extrapolate or calculate the needed sample size. We then chose a convenient sample of 300 participants. The inclusion criteria comprised parents of children of all ages visiting the outpatient pediatric clinic and the inpatient department; the exclusion criteria comprised parents of children with conditions such genetic disorders, developmental delay, diabetes, cerebral palsy, and metabolic disorders. We have excluded the above to minimize as possible any confounders.
Parents were contacted during their visits to our pediatric outpatient department and inpatient ward, checked for eligibility and if eligible were invited to participate in the study.
After describing the aims and objectives of the study, verbal consent was acquired and parents were informed of why the data was being collected and how it would be used in future for interventions to prevent child abuse and neglect. Parents were told that their participation was voluntary and that their answers were confidential and anonymous. There was no monetary or non-monetary compensation for participating.

Statistical analysis
Statistical analyses were conducted using statistical package SPSS, version 21.0 (IBM corporation, Armonk, NY); a two-sided P value < 0.05 was statistically significant. Qualitative and quantitative data values were displayed as percentages.
Descriptive statistics explained the demographics and other features of parents and children. Associations between two or more categorical variables were assessed using Chi-square test. For small cell frequencies, Chi-square test with continuity correction factor or Fisher's exact test was used. Univariate and multivariate logistic regression analyses were applied to assess the associations of various potential predictors and covariates.
Missing data were not accounted in the analysis.

Results
Around 50% of respondents were between 30 and 39 years of age, and 61% were females. About two-thirds had at least bachelor's degree, 60% were in full-time employment, and 30% were not employed. 30% of the respondents had one child, 30% had two children, 20% had three children, and around 22% had more than 4 children. The majority of the sample (88%) lived in the capital city, Doha [ Table 1].
While the majority of the parents had heard about child abuse, about half had actually witnessed child abuse. 90% of the respondents have never witnessed any morbidities or mortalities due to child abuse or neglect. Roughly half the sample was aware of laws restricting child abuse, a quarter agreed that boys were generally more abused than girls, and about half reported that disabled children were generally more abused than healthy children. While less than a quarter of the parents agreed that abuse is a common problem in Qatar, the majority felt that it is a serious problem that requires strict laws [ Table 2].
Around 20% of the respondents agree and strongly agree that hitting is discipline, while 63% disagree and strongly disagree. In addition, 90% of the respondents never witnessed disabilities due to child abuse. Table 3 shows answers related to physical abuse.
In terms of verbal abuse, around 44% strongly agree and 19% agree that "Yelling is a form of child abuse," while 22% disagree and strongly disagree. Around 44% strongly agree and 27% agree that "Yelling affects child growth and development." More answers related to verbal use are displayed in Table 4.
The majority of respondents strongly agree and agree with the statement "Teach our children about child sexual abuse." Furthermore, 51% strongly agree and 37% agree that "Child's exposure to pornography on social media is a form of abuse." In terms of child neglect, around half of the respondents agreed with the statement "Leaving a child (<5 years) unattended at home is a form of neglect," while 42% were neutral. The majority of respondents strongly agree with the statements: "It's parents' duty to make sure that children are safe," "Parents should have at least 6 hours of direct interaction with children," and "I often approach my children to talk about their daily problems." Finally, one-half of the participants believed that it is okay to depend on nannies in assisting their children in eating and using the bathroom.

Discussion
Discipline is a measure by which children are notified of both the morals of acceptable behavior and the consequences of not abiding by such measures. Children relate this information during their constant pursuit for independence. [26] Childhood maltreatment can significantly affect long-term wellbeing, [27,28] and children suffering abusive parenting are at a high risk of becoming abusive parents themselves. [29] Hence, attempts to avert CAN are growing worldwide. [17] The current study is the first to examine parental perceptions of CAN in Qatar. It assessed parental views and concerns on the general and specific aspects of child abuse and neglect, including verbal and sexual abuse.
The majority of our participants have heard about child abuse, consistent with the study in Saudi Arabia where the majority of Saudi parents had adequate knowledge and perception of child abuse, [11] and also with published studies in Jordan. [15,16] About half of our parents had actually witnessed child abuse in their society. This is considered less than other studies where the majority of the respondents agreed that child sexual abuse is common in their community. [11,30,31]   A quarter of our sample agreed that boys were generally more abused than girls. This is in contrast with other authors who observed that females were more likely than males to have experienced physical abuse during childhood. [3,32] Perhaps in countries of the Muslim tradition, females are generally more protective than in other countries and, hence, this might be why parents might have a different threshold in their views about females being the subject of CAN. Another reason could be the likelihood of under-reporting, where for instance, sexually abused girls were up to 2.2 times more likely to seek medical attention than sexually abused boys. [8] Less than a quarter of the parents agreed that abuse is a common problem in Qatar. This low figure and percentage could be due to the fact that it is under-reported or perceived as child maltreatment. Efficacious adoption of a system of interference comprising child protection centers in the medical facilities, in combination with obligatory reporting and data collection plans, can increase the reporting rate. In a study conducted by Al-Eissa and Almuneef showed that the total number of referred cases to suspected child abuse and neglect team increased 10-fold from 6.4 cases per year in the first period to 61.5 cases per year using the above strategy. [10] Other barriers that hinder reporting of child abuse and neglect are unfamiliarity about how to report, in addition to having previous unpleasant backlash after reporting. [33] Risk factors for parental insufficient knowledge and weak perception linked to child sexual abuse (CSA) are low socio-economic status and low education. Protective factors comprise parental older age and size of the family. Poverty is not an issue in wealthy Qatar. However, all population can benefit from counseling. Education should be considered for parents and the community to augment the knowledge and perception of CSA. [11] One of the surprising results of our study showed that more than two-thirds of participating parents believed that yelling is less harmful than hitting.
Parental tough verbal discipline can have a striking effect on the emotional and behavioral development of adolescents. Tough verbal discipline infers to the use of psychological force with the goal of instigating a child to experience emotional pain or distress with the intention of rectification or control of misbehavior. [34] Parenting practices might increase a youth's involvement in problem behavior, [35] which is outlined by the lack of affection and by the existence of many psychologically and physically detrimental behaviors and affects. [36] Our participants believe that parents should have at least 6 hours of direct interaction with children. This is a substantial number of hours. For working family, that number of hours could be unreasonable. In the State of Qatar, a large proportion of children are engaged in school extra-curricular activities with some arriving home around 4 pm. In addition, many parents work split shifts, one in the morning with 4 hours break and then resume work at late evening.
It is anticipated that higher educational levels are associated with a higher chance of employment opportunities and good living standards. [37] In our sample, higher educational status was correlated with laws that would restrict people from abusing their children (P = 0.002), and that child abuse is a serious problem, and there should be strict implementable laws (P = 0.002). Moreover, the higher educational status was inversely correlated with the fact that it is ok to hit the child as long as it does not cause permeant pain, bruises, or fractures (P = 0.007) and that using soft object to discipline a child is ok (P = 0.01). In terms of sexual abuse, higher educated parents agree that children should be taught about child abuse (P = 0.001).
Child abuse and neglect could be dealt with by a comprehensive range of services such as parental education and community perception. Prenatal education programs could be designed for expectant parents, and awareness campaigns must be organized to avert child abuse. Primary care clinicians can be the frontrunners in preventing child abuse and neglect by screening for risk factors and liaise referral services to provide available resources. The State of Qatar is a very well resourceful country and these programs are very feasible to be applied.
This study has limitations. There might be a likelihood that other characteristics pertaining to parental perceptions in this topic were not assessed in this study. In addition, parental perception of CAN may not mirror reality as different parents have different parenting styles. This current study also has considerable strengths. The findings will be used to benchmark parental perception of CAN, especially that the study included several domains within the context of physical, sexual, and emotional abuse. Moreover, the present study will contribute to creating a better framework of child abuse and neglect prevention programs in Qatar, particularly contributing to the well-funded suspected child abuse program. Further investigation with larger multicenter studies is required for a more definite conclusion.

Conclusion
Parents residing in the State of Qatar believe that they have a good knowledge regarding child abuse and neglect. However, this study shows many deficiencies in parental knowledge of child abuse and neglect. Parents' attitudes and perceptions are considered indispensable targets for community health intervention.

Financial support and sponsorship
The publication of this article was funded by the Qatar National Library.