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

ContentslistsavailableatScienceDirect

Child

Abuse

&

Neglect

Prevalence

of

different

forms

of

child

maltreatment

among

Taiwanese

adolescents:

A

population-based

study

夽

Jui-Ying

Feng

_,

_Yi-Ting

_Chang

_,

_Hsin-Yi

_Chang

_,

_Susan

_Fetzer

_,

Jung-Der

Wang

a_{DepartmentofNursing,CollegeofMedicine,NationalChengKungUniversityandHospital,Tainan,Taiwan} b_{DepartmentofNursing,CollegeofMedicine,NationalChengKungUniversity,Tainan,Taiwan}

c_{NationalChengKungUniversityHospital,Tainan,Taiwan} d_{DepartmentofNursing,UniversityofNewHampshire,NH,USA}

e_{DepartmentofPublicHealth,CollegeofMedicine,NationalChengKungUniversityandHospital,Tainan,Taiwan}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received1July2014 Receivedinrevisedform 14November2014 Accepted18November2014 Availableonline1December2014 Keywords: Childmaltreatment Childhoodvictimization Violence Prevalence Taiwan

a

b

s

t

r

a

c

t

ReportedcasesofchildmaltreatmentareincreasinginTaiwan.Yet,comprehensive epi-demiologicalcharacteristicsofadolescents’exposureoverthewidespectrumofviolence arestilllacking.Thepurposeofthisstudywastoestimatetheprevalenceandmagnitude ofchildmaltreatmentamongTaiwaneseadolescents.Apopulation-basedstudywas con-ductedwith5,276adolescentsaged12–18from35schoolsin17citiesandtownshipsto determinetheprevalenceoffiveformsofchildmaltreatmentinTaiwan.Atotalof5,236 adolescentscompletedanonymous,self-report,structuredquestionnaires.Most adoles-cents(91%,n=4,788)experiencedatleastoneformofmaltreatmentwith83%(n=4,347) exposedduringthepreviousyear.Violenceexposurewasthemostcommontypeofchild maltreatmentexperienced,followedbypsychologicalabuse,physicalabuse,neglect,and sexualabuse.Adolescentsreportedanaverageof7.4(SD=5.87)victimizationsovertheir lifetimeand4.8(SD=4.82)victimizationsduringthepastyear.Femalesreportedahigher rateofneglect,whilemalesreportedahigherrateofsexualabuse.Mostofthesexualabuse perpetratorswereknownbytheirvictims.Adolescents’victimizationand polyvictimiza-tionfromchildmaltreatmentinTaiwandeservesareviewandmodificationofnational controlandpreventionpolicies.

©2014TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/3.0/).

Introduction

Childmaltreatmentisaglobalpublichealthproblemwiththepotentialforalifelongimpactonvictimswithoutproper treatment.Childmaltreatmentisbroadlydefinedasanyact(s)committedorfailuretoprovidesupervisionbycaregiver(s) thatresultsin actualor potentialharmtoa child’shealth, developmentordignityincludingphysical abuse, psycho-logicalabuse,sexualabuse,neglectand exposuretoviolentenvironments(CentersforDiseaseControland Prevention [CDC],2014;WorldHealthOrganization,2014).Advancesindevelopmentalneuroscienceprovideinsightsand perspec-tivesabouthowtraumaorstressearlyinlife,suchaschildmaltreatment,interplayswithgenesandenvironmentalfactors

夽 ThisstudywassupportedbytheMinistryofScienceandTechnologyofTaiwan(NSC101-2314-B-006-062-MY3)andpartiallybytheMinistryof Education,Taiwan,TheAimfortheTopUniversityProjecttoNationalChengKungUniversity.

∗ Correspondingauthoraddress:NationalChengKungUniversityandHospital,Room08091,8F,No.35,XiaodongRoad,EastDistrict,Tainan701,Taiwan. http://dx.doi.org/10.1016/j.chiabu.2014.11.010

0145-2134/©2014TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/3.0/).

J.-Y.Fengetal./ChildAbuse&Neglect42(2015)10–19 11 toinfluencethedevelopingbrainandneuronalnetwork(Hart&Rubia,2012).TheAdverseChildhoodExperiencesstudy (CDC,2010)indicatedagradedeffectofchildmaltreatmentandfamilydysfunctiononsomaticconcerns,chronicillness, poorqualityoflifeandmortalityforadolescentsandadults(Bellisetal.,inpress;Flahertyetal.,2013).Theriskof psy-chopathologyforvictimsandtheirchildrenincreasesduetoepigeneticchangesingeneexpressionsandimpairmentof brainstructureandfunction(Bair-Merritt,Zuckerman,Augustyn,&Cronholm,2013;Hart&Rubia,2012;McGowanetal., 2009).

InTaiwantherevisedChildWelfareLawof1993mandatedthatprofessionalsreportsuspectedcasesofchild maltreat-ment(e.g.,desertion,physical/emotional/sexualabuse,neglect,educationaldeprivationandexploitation).Themandatory reportersofchildmaltreatmentwereexpandedin2011toadministratorsanddirectorsofvillages,communitiesand resi-dentialsecurityguards.Reportsofchildmaltreatmenthaveincreasedsubstantiallysince1993.However,theofficialstatistic of0.6%in2012(DepartmentofStatistics,MinistryoftheInterior,2013)likelyunderestimatestheextentofchild maltreat-mentinTaiwanwhencomparedtotheratesof22–34%forphysicalabuseand2.5%forsexualabusefromsurveyresearch (Chou,Su,Wu,&Chen,2011;Yenetal.,2008).

Theprevalenceestimationofchildmaltreatmentvariessignificantlydependingonstudydefinitions,measurements, samplecharacteristicsandmethodologies.Surveyprevalenceratesrangefrom5to83%foreachformofchild maltreat-mentacrossstudies(Pereda,Guilera,&Abad,2014;Tsuboietal.,inpress).Aseriesofmeta-analysesprovidedoverall estimationsof17.7%,26.7%,11.8%and16.3%forphysicalabuse,psychologicalabuse,sexualabuse,andneglect, respec-tively(Stoltenborgh,Bakermans-Kranenburg,Alink,&vanIjzendoorn,2012;Stoltenborgh,Bakermans-Kranenburg,&van Ijzendoorn,2013;Stoltenborgh,Bakermans-Kranenburg,vanIjzendoorn,&Alink,2013;Stoltenborgh,vanIjzendoorn,Euser, &Bakermans-Kranenburg,2011).

Significantvariationsexistinthereportedratesofchildmaltreatmentacrossofficialdataandresearchreports(Theodore etal.,2005).Fewpopulation-basedstudiesareavailabletoexaminethefullrangeofdifferentformsofchildmaltreatment, particularlyinAsia.Accurateepidemiologicaldataareneededtodescribetheextentofchildmaltreatment,thecharacteristics ofthevictimsandperpetratorsandtheformsandcharacteristicsofvictimization.Onceidentified,policiescanbedirectedto reducetheburdenandseriousconsequencesofchildmaltreatment(Gilbertetal.,2009).Epidemiologicaldataareimportant fortheappropriateallocationofgovernmentalresourcesandtodevelopinterventionstrategiestargetedforchildrenathigh risk.

Multiplefactorsinfluencetheimpactofchildmaltreatmentonvictimsandgenderisanimportantconsideration.Evidence ontheimpactofgenderonthetypeofchildmaltreatment,victims’healthconsequencesandtheirinteractionsisevolving, thoughfindingsaremixed(Arnow,Blasey,Hunkeler,Lee,&Hayward,2011).Generally,malesreportmorephysicalabuse thanfemales(5–54%vs4–42%;Chouetal.,2011;Dong,Cao,Cheng,Cui,&Li,2013;MacMillan,Tanaka,Duku,Vaillancourt, &Boyle,2013)andfemalesreportmoresexualabusethanmales(16–22%vs4–11%;CDC,2010;Chen,Dunne,&Han,2004; MacMillanetal.,2013;Peredaetal.,2014).However,inmeta-analyticreviewsgenderdifferenceswereestablishedonlyfor theprevalenceofsexualabuse(F:18%vsM:8%)andnotforotherformsofchildmaltreatment(Stoltenborghetal.,2012; Stoltenborgh,Bakermans-Kranenburg,&vanIjzendoorn,2013;Stoltenborgh,Bakermans-Kranenburg,vanIjzendoorn,& Alink,2013;Stoltenborghetal.,2011).Genderdifferenceinsexualabuseissignificantlygreaterinhigh-incomecountries thanforlow-incomecountrieswheremales’experiencesofsexualabuseareincreased(Choo,Dunne,Marret,Fleming,& Wong,2011;Dongetal.,2013;Stoltenborghetal.,2011).

Althoughchild maltreatmentcausessignificantlong-termhealth problemsfor allvictims,thedegreeand typesof impairmentvarybygender.Womenaremorelikelytosufferfromchronicphysicalandmentalhealthproblems,such ascardiovasculardisease(Scott-Storey,2013),post-traumaticstressdisorderandsuicidalbehaviors(Thompson,Kingree,& Desai,2004).Theinteractionofgenderandthetypesandconsequencesofchildmaltreatmenthasreceivedlessattention, butdeservesgreaterstudytodetermineproactivepreventionstrategies.

Thedose–responseeffectoftraumaisamajorconsiderationinchildmaltreatment.Cumulativeexposureto maltreat-mentcauseslong-termnegativeoutcomesandcomorbiditieswhileposingaseriousthreattopublichealth(Anda,Tietjen, Schulman,Felitti,&Croft,2010;Felitti,2009).Finkelhor,Ormrod,Turner,andHamby(2005)usedthe34-itemJuvenile VictimizationQuestionnairetoassesspolyvictimization,theexposuretomultipletypesofmaltreatment,amongchildren andyouthwithcategoriesofaslow(4–6victimizations)andhigh(7ormorevictimizations).Thelifetimeprevalenceof polyvictimizationacrossstudiesusingtheJuvenileVictimizationQuestionnairewas14–37%(CDC,2010;Chan,2013).

EmpiricalstudiesontheprevalenceofchildmaltreatmentinTaiwanincludingthegenderandcumulativeeffectson victimsarelimited.TworegionalstudiesinTaiwanhaveexaminedphysicalabuseorsexualabuse.(Chouetal.,2011;Yen etal.,2008).While32%ofthestudentsintheTaipeiarea(northernTaiwan)reportedexperiencingphysicalabuse,22%of studentsfromruralareasinsouthernTaiwanreportedexperiencesphysicalabuseand3%experiencingsexualabuse(Chou etal.,2011;Yenetal.,2008).Indigenousadolescentmaleswerefoundtohaveahigherriskofbeingthevictimsofsexual abusethannon-indigenousmales(Yenetal.,2008).

Theeffectofculturalandgeographicfactorsontheprevalenceofchildmaltreatmentisdifficulttodeterminedueto differencesindefiningchildmaltreatmentandtheavailabilityofsurveillancesystemsacrossculturesandcountries (Al-Eissaetal.,inpress;InternationalSocietyforthePreventionofChildAbuseandNeglect,2012).Ingeneral,Africahasthe highestprevalencerateforallformsofchildmaltreatment,exceptforneglectasalackofavailabledata,whileAsiahas thelowestrateofsexualabuse(Stoltenborghetal.,2012;Stoltenborgh,Bakermans-Kranenburg,&vanIjzendoorn,2013; Stoltenborghetal.,2011).TheICAST-CH-C(ISPCANChildAbuseScreeningToolChildren’sHomeVersion,Chinese)provides

anopportunitytotackletheculturalandgeographicalchallengesandtocomparechildmaltreatmentprevalencerates internationally(Chang,Lin,Chang,Tsai,&Feng,2013;Zolotoretal.,2009).

Giventhetremendouscostofchildmaltreatmenttotheindividual,familyandsociety,anin-depthinvestigationon theprevalenceofdifferentformsofchildhoodvictimizationandpolyvictimizationisvital.Itremainsunclearifgender isapredictorofdifferentformsofmaltreatmentorpolyvictimizationandthehealthconsequences.Asacomprehensive epidemiologicalprofileofchildren’sexposureoverthewidespectrumofviolenceislackinginTaiwan,apopulation-based studyusingtheICAST-CH-Ctoestimatethemagnitudeofchildhoodvictimizationduetomaltreatmentwasconducted.

Method

ThestudycommencedafterapprovalbytheUniversityInstitutionReviewBoard(No.BR-99-058-C).Anational repre-sentativesampleofadolescentsaged12–18weresurveyedtodeterminetheprevalenceofdifferentformsofchildabuse inTaiwan.TheICAST-CHisrecommendedforadolescentsaged12–18duetothecognitiveandemotionalmaturityofthe surveycontent(Zolotoretal.,2009).Datawerecollectedanonymouslyusingtheself-report,structuredICAST-CH-C ques-tionnaire.Parentalconsentwaswaivedtopreventthechildfromworryingaboutthepotentialtobeidentifiedorabusive parents’reluctancetobeexposed(Spriggs,2010;U.S.DepartmentofHealthandHumanServices[DHHS],2009).

ParticipantsandSetting

Forthepurposeofthisstudy,Taiwanwasdividedinto5geographicalregions.InTaiwan,98%ofallchildrenattend school.In2011,thetotalnumberofstudentsingrades7–12inTaiwanwas1,682,958with754,275(44.8%)inthenorthern, 342,312(20.3%)inthecentral,498,311(29.6%)inthesouthern,77,199(4.6%)intheeasternregionsand10,861(0.7%)inthe offshoreislands(DepartmentofStatistics,MinistryofeducationinTaiwan,2011).Asthepopulationoftheeasternregion andoffshoreislandshasahigherrateofchildabuse(DepartmentofStatistics,MinistryoftheInterior,2013),oversampling wasappropriate.Therefore,disproportionatestratifiedrandomsamplingwasusedtoidentifystudentsaged12–18andin grades7–12fromthenorthern,central,southern,andeasternandoffshoreislandsregionsinTaiwan;1,420(25%),1,136 (20%),1,420(25%),852(15%)and852(15%),respectively,werethedesirednumberofparticipantsacrossthe5regions.

FollowingthesamplesizeestimationmethodproposedbyRunyan,Dunne,&Zolotor,2009,theepidemiological esti-mationofthenumberofparticipantsneededforthisstudywouldbe438fromoffshoreislandsand456fromeachoffour regionsbasedonananticipated5%prevalence,95%confidencelevel,and2%precision.Thecurrentsamplesizemetthe abovecriteria.Schoolswererandomlyselectedineachregionandreplacedinthecaseofrefusaluntilthesamplesizefrom theregionwasobtained.Studentsaged12–18yearsoldfromtheidentifiedschoolswereinvitedtoparticipate.

Measurement

TheICAST-CH-Cwasusedtocollecttheforms,characteristics,frequencyandperpetratorsofchildmaltreatment expe-riencedduringthepreviousyearandoverthechild’slifetime.Developedby40expertsfrom31countries,theoriginal ICAST-CHisapopulation-basedsurveytoolwithacomprehensivecoverageoftheformsofchildhoodvictimizationinthe homeofadolescentsaged11–18acrosscultures.TheICAST-CHconsistsof51itemswith9demographicitems(e.g.,gender, age,livingarrangement,religionandethnicity),36childmaltreatmentexperienceitems,and6open-endedquestions.Child maltreatmentiscategorizedinto5forms:violenceexposure(7items),psychologicalabuse(8items),physicalabuse(9 items),sexualabuse(6items),andneglect(6items)(seeTable2fordetails).Adolescentsarequestionedabouttheir expe-riencesof(1)seeingadults’behaviorsinthehomeornearbythatfrightenedthem(violenceexposure),(2)peoplesayingor doingthingstomaketheadolescentfeelembarrassed,ashamedorbad(psychologicalabuse),(3)beingphysicallyhurtby adultsathome(physicalabuse),(4)adultsdoingorshowingthemsexualthingswithouttheirconsent(sexualabuse),and (5)notgettingwhattheyneedtogrowuphealthy(neglect).Adolescentsareaskedtoreporteachvictimizationbasedon theirexperienceinthepastyearasmanytimes,sometimes,never,ornotinthepastyearbutthishashappened.

TheICAST-CHhasbeentestedforconstructvaliditywithCronbach’s˛coefficientsrangingfrom.69to.83infourcountries (Zolotoretal.,2009).TheICAST-CH-CistheChineseversionoftheICAST-CHwithgoodconstructvalidityandinternal consistenciesof.90forthetotalscaleand.61–.78forthesubscales(Changetal.,2013).

Procedure

Principalsofthestratified,randomlyselected44schoolswerecontactedbyphone.Principalswhoagreedtoparticipate wereaskedtoprovidethenumberofpotentialstudentparticipants.Sevenprincipalsdeclinedparticipationbecausestudents weretoobusywithheavycourseloadsorhadalreadyfilledoutquestionnairesfromotherstudies;oneexpressedthatthe topicwastoosensitive.Twoprincipalslaterwithdrewresultinginasampleof5,236studentsfrom35schools.

TheICAST-CH-Cquestionnaires,withreturnedpostage,weremailedtothe35principalswhoagreedtoparticipate.Class teachersorschoolcounselorswereaskedtoassistinexplaininginformationdescribedinthecoverletteraboutthestudy purpose,participantanonymityandtherighttowithdrawatanytime.Questionnairesweredistributedtothestudentswho werewillingtoparticipate.Studentsfilledoutquestionnairesduringoneschoolperiod(40min).Classteachersorschool

J.-Y.Fengetal./ChildAbuse&Neglect42(2015)10–19 13 counselorswereaskedtobepresenttoprovidesupporttostudentsasneeded,butdirectednottointerveneasstudents’ completedtheICAST-CH-C.Alistofsocialresourcesrelatedtochildprotectionandcounselinginstitutionswasprovidedto students.Duetotheextremesensitivityofchildhoodvictimization,students’namesoranytypeofidentificationwerenot requiredonquestionnaires.

DataAnalysis

FollowingthescoringschemaprovidedbyICAST-CHdevelopersandothers(Imola,Roth,Dávid-Kacsó,&Mezei,2013; Sofuo˘gluetal.,2014;Zolotoretal.,2009),maltreatmentoccurringthepreviousyear(PY)wascountedas1ifmanytimes orsometimeswaschecked.Thelifetime(LT)exposureofmaltreatmentwascountedas1ifmanytimes,sometimesornotin thepastyearbutthishashappenedwerechecked.Lifetimeprevalenceisdeterminedastheproportionofadolescentswho haveexperiencedmaltreatmentduringtheirchildhood.ThetotalnumbersofvictimizationsforPYandLTareweightedback accordingtotheoriginalproportionsofadolescentpopulationindifferentregionsandsummeduptoestimatetheoverall prevalence.TheMantel–Haenszelsummarystatisticsandoveralloddsratios(withconfidencelimits)arecalculatedtotest andestimatewhethergenderwasasignificantfactorfordifferenttypesofmaltreatment(Breslow&Day,1980).Reportsof manytimes,sometimesornotinthepastyearbutthishashappenedarescoredas1,withneverassignedas0.Anyitemscored as1isconsideredpositiveforthespecificformofmaltreatment,withatotalscorerangingfrom0to5foreachsubject;a scoreoveroneindicatesthatthechildhasexperiencedmorethanoneformofabuse.

Thetotalnumberofvictimizationsexperiencedbyeverystudentwassummedtodeterminepolyvictimization. Partici-pantswerecategorizedintofourgroupsbasedonthenumberofvictimizations(0,1–3,4–6and7ormore;Finkelhoretal., 2005;Peredaetal.,2014).Directvictimizationdescribesachildwhohasdirectlyexperiencedaviolentactorneglectrather thanwitnessingtheviolence.Inthisstudy,directvictimizationincludesanyformofpsychologicalabuse,physicalabuse, sexualabuseorneglect.Questionnaireswithmorethan20%ofmissingdatawereexcludedlistwise.

Results

Demographic

Datawereanalyzedfrom5,236completedquestionnaireswitharesponserateof99.4%.Themeanageofadolescents was14.5years(SD=1.32)withnearlyequalrepresentationofmalesandfemales.Almostallresidedwithparentsorfamily members(99.4%).Table1describesadolescents’demographiccharacteristicsbythefivegeographicregionsofTaiwan. Prevalence

Ninety-onepercent(n=4,788)ofadolescentsexperiencedatleastonetypeofmaltreatmentwith83%(n=4,347)being exposedtomaltreatmentduringthepreviousyear(Table2).Violenceexposurewasthemostcommontypeofchild maltreat-mentthatchildrenexperiencedintheirlifetime(82.2%),followedbypsychologicalabuse(69.2%),physicalabuse(61.4%), neglect(54.6%),andsexualabuse(19.8%).Eighty-twopercent(n=4,310)experiencedatleastoneformofdirectvictimization with71.9%(n=3,765)reportinganoccurrencewithinthepreviousyear.Adolescentsreportedexperiencinganaverageof 2.9(SD=1.48)differentformsofmaltreatment.Oneoutofeightadolescents(n=665,12.7%)reportedtohavebeenexposed tofivedifferentformsofmaltreatmentovertheirlifetime.

Adolescentsexperiencedameanof7.4(SD=5.87)victimizationsovertheirlifetimeand4.8(SD=4.82)victimizations duringthepastyear(Table3).Two-thirdsofadolescentsexperiencedpolyvictimization(≥4victimizations)overtheir life-timeandalmosthalfofthemreportedanoccurrenceduringthepreviousyear.Noageorgenderdifferencewasfoundinthe prevalenceofpolyvictimization.

The homewasthe mostcommonplace adolescents reportedbeing exposed tomaltreatment. Twenty-six percent (n=1,384)ofadolescentswitnessedadultsphysicallyhurtingeachotherwith10.6%witnessingadultsusingweapons. Psy-chologicalabusewasthemostcommontypeofadolescents’directvictimization.Onehundredtwenty-six(2.4%)reported beingthreatenedwithaknifeoragun.Oneoutoffive(n=1,036)reportedexperiencingvariousdegreesofsexual victimiza-tion.About7.6%(n=400)wereforcedtoexposeortouchthegenitalareasoftheperpetratorsorthemselves;1.8%(n=95) reportedthatsomeonehadtriedtohavesexwiththem.Thevastmajority(73.5–89.7%)ofthesexualabuseperpetrators wereknownbytheirvictims(Table4).

GenderDifferences

Femalesreportedahigherrateofneglect(oddsratio[OR]:1.43,95%confidenceinterval[CI]:1.28–1.61),whilemales reportedahigherrateofsexualabuse(OR:1.46,95%CI:1.25–1.70)(Table2).Femalesreportedmoretypesofpsychological abusethanmales.Femalesweremorelikelytoreportthatsomeonehadwishedtheyweredead(LT=24.1%,OR:1.28,95%CI: 1.12–1.45)orhadbeenbulliedbyanotherchildathome.Bothgendersreportedsignificantneglectvictimization.Femalesfelt lesscaredfor,lessimportant,andlesssupportedthanmales.Whilefemalesreportedemotionalneglect,malesweremore likelytobeneglectedphysically,suchasgoinghungryorhavinginadequateclothing.Malesweremorelikelytoexperience

J.-Y. Feng et al. / Child Abuse & Neglect 42 (2015) 10–19 Table1

ParticipantdemographicsstratifiedbygeographicregionofTaiwan(n=5,236)(%).

North(n=1286) Central(n=1086) South(n=1365) East(n=763) OffshoreIsland(n=736) Total(n=5236)

Female 49.1 49.4 45.6 48.8 50.8 48.5

Religion 63.6 68.9 61.6 80.1 66.8 67

Aboriginal 9.3 13 3.1 19.7 6.5 9.6

Livingwithfamily

Bothparents 77.4 75.0 77.4 72.6 77.6 76.2

Singleparent 18.4 21 17.2 20.6 16.3 18.7

Grandparent(s) 1.4 2.5 2.4 3.4 3.0 2.4

Age,mean(SD) 15.0(1.46) 14.4(1.37) 14.6(1.30) 13.72(.83) 14.2(.92) 14.5(1.32)

Weightforreconstruction(population proportion/sampleproportion)

J.-Y.Fengetal./ChildAbuse&Neglect42(2015)10–19 15

Table2

PrevalenceofchildabuseamonganationalsampleofTaiwaneseadolescent(males,n=2,708;females,n=2,513).

Victimization Overallprevalence(%) Genderdifferences(%)

Pastyear Lifetime Pastyear Lifetime

M F p M F p

Violenceexposure 62.9 82.2 63.1 62.7 .862 81.6 82.9 .163

Frightenedbyadults’usingdrugs 15.4 26.4 14.9 16.0 .227 25.2 27.7 .040

Adultsshoutedinfrighteningway 44.0 68.3 42.8 45.5 .041 66.7 70.0 .011

Witnessedadultsinhomehit,kick,slap 9.1 23.0 8.8 9.6 .303 22.0 24.0 .072

Witnessedadultsinhomeusingweapons 4.4 10.6 5.5 3.2 <.001 11.2 10.0 .170

Someoneclosegotkillednearhome 10.5 12.3 10.6 10.1 .632 12.2 12.1 1.00

Sawpeoplebeingshotorrioting 11.0 14.9 12.3 9.5 .001 16.7 13.0 <.001

Somethingstolenfromhome 23.3 38.5 24.2 22.5 .169 38.7 38.4 .920

Psychologicalabuse 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

Madeyoufeelembarrassed 27.6 38.1 28.2 27.1 .462 37.3 39.1 .165

Wishedyouweredead 15.6 23.7 14.5 16.8 .016 21.7 26.0 <.001

Threatenedtoabandon 7.6 14.0 7.7 7.5 .862 13.5 14.5 .299

Lockedoutofhome 3.5 10.4 4.8 2.0 <.001 11.3 9.4 .021

Threatenedtohurtorkillyou 3.5 6.2 3.7 3.2 .424 6.5 5.9 .354

Bulliedbyanotherchildathome 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

Wenthungryorthirsty 10.0 13.4 11.4 8.6 .001 15.1 11.6 <.001

Inadequateclothing 4.2 5.6 5.3 3.0 <.001 6.6 4.5 .001

Unmetmedicalneed 5.5 7.0 5.7 5.2 .549 6.9 7.2 .655

Feltnotcaredfor 33.0 38.3 26.8 39.9 <.001 31.3 46.0 <.001

Feltunimportant 35.7 40.5 30.1 41.8 <.001 34.2 47.4 <.001

Inadequatesupport/help 25.6 29.9 22.2 29.2 <.001 26.8 33.4 <.001

Physicalabuse 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,spankedwithhand 16.7 35.6 18.2 15.2 .005 36.4 34.9 .284

Hit,beat,spankedwithobject 9.8 30.3 11.2 8.4 .001 30.7 29.8 .538

Triedtochoke,smother,ordrown 1.5 3.2 1.9 1.0 .016 3.6 2.9 .169

Burnedorscalded 1.7 3.0 2.3 1.0 <.001 3.9 2.0 <.001

Lockedinsmallplace 1.0 4.2 1.6 0.4 <.001 5.2 3.2 <.001

Pulledhair,pinched,twistedear 16.5 29.5 17.0 16.1 .403 29.1 30.1 .488

Heldheavyloadaspunishment 9.1 20.0 11.9 6.0 <.001 23.3 16.4 <.001

Threatenedwithknifeorgun 1.1 2.4 1.6 0.6 .001 3.0 1.7 .003

Sexualabuse 15.0 19.8 17.4 12.5 <.001 21.8 17.7 <.001

Talkedtoyouinasexualway 11.4 14.3 11.8 11.0 .498 14.2 14.5 .689

Shownpornography 1.9 2.9 2.9 0.9 <.001 4.0 1.8 <.001

Lookedatprivateparts 3.2 5.6 4.7 1.7 <.001 7.4 3.6 <.001

Touchedprivateparts 5.0 7.6 7.7 2.1 <.001 10.7 4.4 <.001

Madeasexvideoofyou 0.6 0.8 0.9 0.2 .001 1.1 0.3 .001

Forcedsexbehaviors 1.2 1.8 1.6 0.7 .005 2.2 1.4 .031

physicalabuseinnearlyeveryformincludingbeatings,choking,spankingandweremorelikelytoreportsexualabuseofall

forms. Aborigine

Nearly9percentofthesamplewasaboriginal,descendantsoftheindigenouspopulationofTaiwan(n=454).Compared

tonon-aboriginal,aboriginaladolescentsreportedsignificantlylessphysicalabuse(OR:0.92,95%CI:0.91–0.93).Amongall

Table3

Students’experiencesofpolyvictimizationinTaiwan(%).

Numberofvictimizations Pastyear Lifetime

Total Numberofforms Total Numberofforms

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

Table4

Victims’familiaritywithperpetratorsofsexualabuseduringchildhoodstratifiedbygender[n,(%)].

Notatallfamiliar Notveryfamiliar Veryfamiliar

M F M F M F

Talkedtoyouinasexualway (n=720)

38(5.3) 36(5.0) 180(25.0) 201(27.9) 150(20.9) 115(16.0)

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

Madeyoulookattheirprivate partsorwantedtolookatyours (n=271)

18(6.6) 13(4.8) 66(24.4) 42(15.5) 103(38.0) 29(10.7)

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

Madeasexvideoofyou(n=34) 7(20.6) 2(5.9) 5(14.7) 2(5.9) 13(38.2) 5(14.7)

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

Table5

Formsofviolencevictimizationbyperpetrators’age.

Adult(%) Teen(%) 2 _p

Psychologicalabuse

Screaming 69.6 30.4 309.5 <.001

Insulted 41.3 58.7 62.35 <.001

Madeyoufeelembarrassed 51.4 48.6 1.41 .235

Wishedyouweredead 66.8 33.2 112.13 <.001

Threatenedtoabandon 86.0 14.0 323.38 <.001

Lockedoutofhome 92.6 7.4 310.01 <.001

Threatenedtohurtorkillyou 49.8 50.2 <0.01 1.00

Physicalabuse

Pushed,grabbed,kicked 29.7 70.3 307.87 <.001

Hit,beat,spankedwithhand 70.6 29.4 268.13 <.001

Hit,beat,spankedwithobject 92.5 7.5 966.27 <.001

Triedtochoke,smother,ordrown 45.8 54.2 0.91 .340

Burnedorscalded 48.5 51.5 0.09 .764

Lockedinsmallplace 77.5 22.5 53.90 <.001

Pulledhair,pinched,twistedear 66.0 34.0 128.41 <.001

Heldheavyloadaspunishment 96.7 3.3 704.19 <.001

Threatenedwithknifeorgun 70.0 30.0 16.23 <.001

Sexualabuse

Talkedtoyouinasexualway 30.0 70.0 114.17 <.001

Showedpornography 34.5 65.5 12.83 <.001

Lookedatprivateparts 28.1 71.9 52.66 <.001

Touchedprivateparts 24.5 75.5 95.41 <.001

Madeasexvideoofyou 57.3 42.7 0.77 .380

Forcedsexualbehaviors 38.6 61.4 4.17 .041

theaboriginaladolescents,femalesreportedastatisticallysignificanthigherrateofneglect(OR:1.55,95%CI:1.49–1.61)

andhigherpolyvictimization(≥7victimizations;OR:1.21,95%CI:1.19–1.24)thanmales.

Perpetrators’Age

Adolescentsreportedadultsastheprimaryperpetratorinflictingpsychologicalandphysicalabuse.However,otherteens

weremoreoftentheperpetratorsofsexualabuse(Table5).

Discussion

ThefindingsofthisstudyindicateanextensiverateofviolenceexposureamonghighschoolstudentsinTaiwan. Adoles-cents’experiencesofexposuretomaltreatmentwithinthepast12monthsapproached80%.Severeandpotentiallethalforms ofabusewerereported.Fivehundredeightyadolescents(11%)reportedseriousincidentsontheitemsofbeingthreatened withaknifeoragun,burnedorscalded,verballythreatenedwithinjuryordeath,orexperiencingsomeonetryingtochoke, smotherordrownthem.Theresultinghealthproblems,giventhemagnitudeofchildmaltreatmentinTaiwan,cannotbe overlooked.

Comparedtothe0.6%prevalenceofficialreportofabuseinTaiwanin2012(DepartmentofStatistics,Ministryofthe Interior,2013)thefindingsofthisstudycorroboratetheprevioussuggestionofsevereunder-reporting(Feng&Levine, 2005)andvalidateestimationoftheprevalenceofchildmaltreatmentbypopulation-basedsurveyswhichweremuch higherthanthoseofofficialreports(Theodoreetal.,2005).Asmanychildvictimsarestillhiddeninthecommunityand livinginanunsafeenvironment,itisrecommendthatdiscrepancybetweenself-reporteddatainthisstudyandofficial

J.-Y.Fengetal./ChildAbuse&Neglect42(2015)10–19 17 reportsbefurtherinvestigated.Healthcareprofessionalsandcommunityleadersmustengageandtakeactiontoresolve thisgravepublichealthissueandaddressvictims’safetywithoutdelay.

Two-thirdofadolescentsinthisnationwidesamplereportedexperiencinglifetimepolyvictimization.Highprevalence ofvictimizationandpolyvictimizationhasbeenreportedinotherstudiesusingtheICAST-CHquestionnaireandwithother instrumentsmeasuringabuseamongchildrenandadolescents(Al-Eissaetal.,inpress;Flahertyetal.,2013;Imolaetal.,2013). UsingtheICAST-CH,Al-Eissaetal.(inpress)foundthattheincidenceofpsychologicalabuse,physicalabuse,exposureto vio-lence,neglect,andsexualabusewere75%,58%,51%,50%,and14%,respectivelyamongadolescentsinSaudiArabia.Likewise, 78.6%ofTurkishadolescentsreportedexperiencingmultiplenegativechildhoodexperiences(Sofuo˘gluetal.,2014). Consis-tentwithstudiesintheUS(Finkelhor,Turner,Hamby,&Ormrod,2011),thecurrentfindingsrevealednogenderdifference intheprevalenceofpolyvictimization.However,studiesfromChina(Dongetal.,2013)andSweden(Nilsson,Gustafsson, &Svedin,2012)foundthatadolescentmalesreportedexperiencingmorepolyvictimizationthanfemales.Theunderlying vulnerabilities,consequencesandgenderinfluenceonchildrenwithpolyvictimizationrequirefurtherinvestigation.

Youth’sexposuretodomesticviolence,especiallythedirectwitnessingofphysicalviolence,significantlylinksto delin-quency,crime,andpooreducationalandhealthoutcomes,suchasasthmaandotherchronicdiseases(Bair-Merrittetal., 2013).Nearly1/4ofadolescentsinthisstudyreportedwitnessingadultsengaginginphysicalaltercationsincludingusing weapons,actionsthatplacesthechildindangerofphysicalharm.Youth’spresenceduringdomesticviolencereceiveslittle attentionduetotheoverwhelmingcaseloadofthechildprotectionsystemortheperceptionthatthechildoryouthisnotin imminentdanger.However,accordingtotheU.S.DHHS(2012)domesticviolenceisthebiggestriskfactorforchildfatality (U.S.DHHS,2012).Routinescreeningandbriefcounselingbyhealthcareprovidersforinterpersonalanddomesticviolence hasbeenrecommendedbytheInstituteofMedicine(deBoinville,2013).AcomparablepolicyisnotyetavailableinTaiwan, butshouldbeadvocatedtoprotectbothwomenandtheirchildrenfromadditionalharmoraggravatingnegativeimpact. Thenegativehealthconsequencesofwitnessingdomesticviolenceandchildren’sneedsmustbeaddressedduringviolence screeningorconsultationinadultmedicalsettingsandwell-childvisits(Bair-Merrittetal.,2013).Bothwomenandchildren shouldbeconsideredwhendevelopssafetyplans,careinterventionsandreferrals.Collaborationbetweenprofessionalsin schoolsandinstitutionsinthecommunityisimportanttopromotehealthcareforviolencevictims(Bair-Merrittetal.,2013). Ingeneral,theproportionofparticipantswhohadexperiencedaviolenceeventwassimilarbetweenadolescentmalesand females.However,adolescentmaleshadagreaterprevalenceofphysicalabuseswhilefemalesreportedmorepsychological abuse.InthestudybyThompsonandcolleagues(2004),menwerealsofoundtoexperiencemorephysicalabuseinchildhood thanfemale(Thompsonetal.,2004).Females’experienceswithlessphysicalbutgreaterpsychologicalabusemayberelated tothelowervalueplacedonfemalesinTaiwanculture(Kan&Feinberg,2010).Reasonsforadolescentfemales’experiencesof morebullyingbyanotherchildoradolescentathomemaybethetransmissionoffemaleinsignificancebyparentstosiblings. Societalvaluescanleadtotreatingfemalesgentlyandmorelikelyexposethemtopsychologicalabuse,amoresubtleform ofabuse.Psychologicalabusehaslong-lasting,devastatingimpactsonchildren’sself-esteem,socialization,development andbehavior(Hibbard,Barlow,MacMillan,&theCommitteeonChildAbuseandNeglectandAmericanAcademyofChild andAdolescentPsychiatry,ChildMaltreatmentandViolenceCommittee,2012).

Almostahalfofalltheadolescents,regardlessofgender,reportedexperiencingvariousdegreesofneglect,afinding notpreviouslydocumentedbyofficialsourcesorempiricalstudiesinTaiwan.Neglectencompassesthegreatestnumberof formsofchildmaltreatment,buthasbeenignoredbysocietyandoverlookedbyreportingsystems.ReportsfromtheU.S. DHHS(2012)indicatedthatthefatalityratefromchildabusewasdecreasingslightly,whileneglectremainedasthemost prevalentformofmaltreatment(U.S.DHHS,2012).Unlikeotherformsofabuse,parentsinneglectcasesareoftentroubled bytheirowninabilitytocareforthechildduetoeconomichardshiporpsychologicalproblems.Interventionstargetedto identifychildrenandfamiliesatriskarecritical.Byassessingparents’needsforsocial,ecologicalormentalhealthservices, thechild’sneedsforhealth,development,educationandsafetycanbeimproved(Dubowitz&Poole,2012).

ComparedtothesexualabuseprevalencereportedbyLatino(54%)andEuropeanAmerican(27%)adolescents(Newcomb, Munoz,&Carmona,2009),thecurrentstudyrevealedthatadolescentsinTaiwanexperiencealowerrate(20%)ofsexual abusewithonly1.8%reportingforcedsexualbehaviorsovertheirlifetime,aprevalencesimilartothatinChinaandMalaysia (Chenetal.,2004;Chooetal.,2011).InBarth,Bermetz,Heim,Trelle,andTonia(2013)meta-analysisof55empiricalstudies, femaleswere2–3timesmorelikelytoexperiencechildsexualabusethanmaleswith9%offemalesand3%ofmalesexposed toforcedintercourse.ComparedtoinconsistentresultsfromstudiesinotherAsiacountries(Chenetal.,2004;Chooetal., 2011),theresultsofthecurrentstudyindicatedthatmaleswerealsovulnerabletosexualabuse.Culturallyrelatedfactorsin thecontextofsexualabuseandwillingnessofdisclosureneedfurtherinvestigation.Adolescentfemalesmayhavebeenmore reluctantorfrightenedtodisclosesexualabuseinthisstudyeveninananonymoussurvey.Moreover,mostperpetrators ofadolescentmaleswereteenswhilemostperpetratorsoffemalevictimswereadultsinthisstudy.Thephenomenonof peer-to-peersexviolenceorbullyingrequiresfurtherstudy.Itisimportanttonotethatthesexualperpetratorislikelytobe knownbythevictim.Familiaritywiththeperpetratorandtheproblemofparentalorrelativeabusewithinthehomemakes childabuseidentificationandreportingproblematicbutmandatory,andshouldbeconsideredinapreventionplan.

ThesensitivityoftheICAST-CHinstrumentneedsfurthertestingduetothehighprevalenceofadolescentexperiences ofchildmaltreatmentandpolyvictimizationreportedbythestudysample.Morerigorousevaluationandvalidationof indi-vidualitemsisneededforthemeaningofchildmaltreatmentinthesocioculturalandlegalcontextacrossdifferentcultures orcountries.TwopreviousstudiesofchildmaltreatmentinTaiwan(Chouetal.,2011;Yenetal.,2008)adoptedastrict defi-nitionforphysicalabuse,countingonlyeventsthatcausedchronicandseverephysicalinjuries.Suchanarrowdefinitionof

childabusecompromisescomparisonswithotherfindingswheretheintentionofperpetratorswasthedeterminingfactorof childmaltreatment.ItemsintheICAST-CHoriginatedfrommanywell-knownchildhoodvictimizationinstruments includ-ingtheJuvenileVictimizationQuestionnairewithapurposetogenerateacross-cultural,universalinstrumentforchildren (Zolotoretal.,2009).Nevertheless,theICAST-CH-Cisarelativelynewinstrumentandtheconstructvalidityofthesubscales needsmorecorroboration.TheconceptofpolyvictimizationmeasuredbytheICAST-CH-Cmaynotbedirectlycomparableto findingsfromtheJuvenileVictimizationQuestionnaire.Furtherexaminationofthecomparabilityandequivalencebetween theinstrumentsisindicated.

Conclusion

Thisisthefirstpopulation-basednationalstudyinTaiwanusingadolescents’self-reportoftheirmaltreatment experi-encesinthehome.ThefindingsaredramaticallydifferentfromofficialreportsofchildabuseandneglectinTaiwan.Itisa challengeforhealthcareprovidersandpolicymakerstopreventthelargenumberofadolescentswhoreportexperiencing maltreatmentfrombecomingamuchsmallernumberinofficialreportsofcaseswithsignificantorseriousinjuries.Effective andpracticalstrategiesareneededtoidentifychildrenandyouthatriskandhelpvictimsrecoverfromtrauma.Givensuch highprevalenceratesofadolescent-reportedmaltreatmentandpolyvictimizationwerecommendthatchildmaltreatment inTaiwanbedesignatedanationalprioritythatmandatesacarefulandcomprehensivereviewandmodificationofthe currentpoliciesforcontrolandprevention.

Conflictsofinterest

Allauthorsreportnobiomedicalfinancialinterestsorpotentialconflictsofinterest.

Acknowledgments

Theauthorsacknowledgethehelpofthestudentswhoparticipatedinthisstudyandtheteacherswhodeliveredand collectedquestionnaires.TheauthorsalsoacknowledgethecontributionofChiao-LiLin,BS,theSandplayWorldExpressive &TherapeuticTrainingCenter,Taiwan,forherassistanceindatacollection.

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