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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 266-271

Child abuse in a sample of children and adolescents with externalizing disorders


1 Department of Psychiatry, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Pediatric, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt

Date of Submission04-Mar-2020
Date of Decision15-Apr-2020
Date of Acceptance02-Jun-2020
Date of Web Publication30-Oct-2020

Correspondence Address:
Rania A Hamed
Department of Psychiatry, Faculty of Medicine for Girls, Al-Azhar University, Cairo 11787
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_39_20

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  Abstract 


Objectives Many children in Egypt are being subjected to different forms of abuse. Numerous studies have documented that children exposed to child abuse are more likely to experience a set of adverse psychosocial and behavioral outcomes including low self-esteem and externalizing disorders.
Patients and methods A total of 100 children and adolescents were included in the study; 50 of them were the case group with externalizing behavior [attention-deficit hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder] recruited from the outpatient clinic of psychiatry department, Al Zahraa University Hospital, whereas the other 50 were the control group from the outpatient clinic of Pediatric Department, Al Zahraa University Hospital. They were subjected to clinical assessment, the Wechsler Intelligence Scale, Child Trauma Questionnaire, and Coopersmith Self-Esteem Inventory.
Results The most prevalent diagnoses of the externalizing disorder group were ADHD (46%), CD (26%), oppositional defiant disorder (16%), and ADHD with CD (12%). Comparison between the case group (externalizing disorders) and the control group regarding different types of abuse showed that there was statistically significant difference regarding emotional abuse, severe physical abuse, sexual abuse, and physical neglect. Comparison between different types of abuse in different diagnoses showed that both ADHD and CD are significantly associated with severe physical abuse and sexual abuse. The relation between self-esteem and different types of abuse showed that all types of abuse are significantly associated with low self-esteem.
Conclusion The results highlight the need for strategies aiming at reducing child abuse and improving parenting style.

Keywords: child abuse, children and adolescents, externalizing disorders


How to cite this article:
Hamed RA, Hammouda SM, El Sehmawy AA. Child abuse in a sample of children and adolescents with externalizing disorders. Al-Azhar Assiut Med J 2020;18:266-71

How to cite this URL:
Hamed RA, Hammouda SM, El Sehmawy AA. Child abuse in a sample of children and adolescents with externalizing disorders. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Nov 25];18:266-71. Available from: http://www.azmj.eg.net/text.asp?2020/18/3/266/299569




  Introduction Top


Child abuse is a widespread issue in various countries. According to the WHO, exposure to abuse leads to significant negative adverse effects that affect the brain development of the child [1].

Many children in Egypt are being subjected to different forms of abuse. A research study conducted in Alexandria, Assiut, and Cairo revealed the high prevalence of violence against children in its different forms whether physical (61–67%), emotional (72–86%), or sexual (2–6%) [2].

The adverse effects of child abuse have been well known. Numerous studies have documented that children exposed to child abuse are more likely to experience a set of adverse psychosocial and behavioral outcomes [3]. These behavioral outcomes include low self-esteem, social withdrawal [4], externalizing behavior problems, such as delinquency and violence perpetration [5].

Externalizing disorders are disruptive, overt, and attention getting [6]. They are characterized by problematic behavior such as rule breaking, aggression, impulsivity, and inattention. They include conduct disorder (CD), oppositional defiant disorder (ODD), and attention-deficit hyperactivity disorder (ADHD) [7].

In Egypt, a study held in Cairo revealed that the most distressing symptom among children attending the child psychiatry outpatient clinic was behavioral problems (63%) [8].

These facts rise the need to explore the association between child abuse experiences and externalizing disorders so as to direct mental health policymakers to select this problem in their awareness programs and to help parents to improve their parenting style and to use more positive discipline methods.


  Patients and methods Top


This is a case–control study that was held during the period from 1/1/2018 to 31/12/2018. A total of 100 children and adolescents were included in the study; 50 of them were the case group with externalizing behavior (ADHD, CD, ODD) based on DSM-5 criteria recruited from the outpatient clinic of Psychiatry Department, Al Zahraa University Hospital, whereas the other 50 were the control group from the outpatient clinic of pediatric department, Al Zahraa University Hospital. Written informed consents were obtained from the parents and they approved applying personal data for research purposes. The study was done consistent with good clinical practice and Declaration of Helsinki and WHO guidelines.

Inclusion criteria for the patient groups:
  1. Age range between 6 and 18 years.
  2. Both sexes were included.
  3. Intelligent quotient (IQ) scores of more than 80.


Exclusion criteria

  1. IQ scores less than 80.
  2. Severe neurological disabilities.
  3. Illiterate or refusing to join the study.


Inclusion criteria of the control group:
  1. Acute illness that did not affect the psychological state.
  2. No history of psychiatric or neurological disorders.
  3. Age range between 6 and 18 years.
  4. Both sexes were included.


Measurements

All patients were subjected to the following:
  1. Clinical assessment with a semistructured psychiatric interview based on a psychiatric sheet for children and adolescents.
  2. Wechsler Intelligence Scale for Children [9], Arabic version [10]: to assess IQ.
  3. Assessment of childhood maltreatment using Child Trauma Questionnaire [11], Arabic version [12]: the Child Trauma Questionnaire provides screening for histories of abuse and neglect. It is a 28-item questionnaire. It includes five subscales, three assessing abuse (physical, emotional, and sexual), and two assessing neglect (emotional and physical).
  4. The Coopersmith self-esteem inventory (Arabic version) [13]: it consist of 58 items measuring attitudes toward oneself; the inventory was developed by Coopersmith S, (1967) [14].


Statistical analysis

The Statistical Package for the Social Sciences (SPSS, version 21.0) was used for data entry and analysis. Descriptive statistics were computed in the form of frequency and percentage for categorical data and in the form of measures of central tendency (arithmetic mean) and measures of dispersion (SD) for continuous variables. c2 test was used to test for the association and/or difference between categorical variables. Student’s t test was used for comparing two means and analysis of variance for comparing more than two means. Multiple comparison among sample means were checked by post-hoc LSD. Pearson’s correlation coefficient (r) or Spearmen’s rank order correlation coefficient was used for testing the association between two variables. Differences were considered as statistically significant when the P value was less than 0.05.


  Results Top


The sociodemographic data showed that cases were matching with the controls. No statistically significant difference between patient and control groups was observed regarding age, sex, education, child position, and health status ([Table 1]).
Table 1 Sociodemographic characteristics of the studied groups

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Also, sociodemographic characteristics of the studied families were matching; no statistically significant difference between patient and control groups was observed regarding family size, mother’s education, father’s education, mother’s work, and father’s work ([Table 2]).
Table 2 Sociodemographic characteristics of the studied families

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The most prevalent diagnoses of the externalizing disorder group were ADHD (46%), CD (26%), ODD (16%), and ADHD with CD (12%) ([Table 3]).
Table 3 Distribution of externalizing disorders among the case group

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Comparison between case group (externalizing disorders) and control group regarding different types of abuse showed that there was statistically significant difference regarding emotional abuse, severe physical abuse, sexual abuse, and physical neglect whereas mild/moderate physical abuse and emotional neglect were statistically nonsignificant ([Table 4]).
Table 4 Comparison between case group (externalizing disorders) and control group regarding different types of abuse

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Comparison between different types of abuse in different diagnoses showed that ADHD is significantly associated with severe physical abuse and sexual abuse; also, CD is significantly associated with severe physical abuse and sexual abuse. However, ODD and combined ADHD and CD are not significantly associated with any type of child abuse ([Table 5]).
Table 5 Comparison between case group (externalizing disorders) regarding different types of abuse

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The relation between self-esteem and different types of abuse showed that all types of abuse are significantly associated with low self-esteem ([Table 6]).
Table 6 The relation between self-esteem and different types of abuse

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  Discussion Top


In this study, our aim was to explore the association between externalizing disorders in a sample of children and adolescents and their exposure to child abuse, including emotional, physical, sexual abuse, and neglect (emotional and physical neglect).

In this study, there was no significant difference between age, sex, education, child position, and health status of the externalizing disorder group and the control group. Sociodemographic characteristics of the studied families were matched among the two groups.

Children’s mental health affects their risk for exposure to abuse, peer, and sexual victimization [15].

In this study, five types of child abuse were measured. There was statistically significant difference regarding emotional abuse, severe physical abuse, sexual abuse, and physical neglect between externalizing disorders group and control group.

Our findings are in agreement with previous studies showing that externalized behaviors, including ADHD and CD lead to increased risk of exposure to various forms of abuse and neglect as their aggression and impulsivity make them more prone to various forms of victimization [16].

Also, another study done by Stern et al. [17] showed that children with ADHD and ADHD and comorbid CD are exposed to moderate and severe abuse/neglect.

Another study done by Hadianfard [18] showed that nearly 60% of ADHD participants experienced neglect and 35% psychological abuse.

In this study, mild/moderate physical abuse and emotional neglect were statistically nonsignificant between externalizing disorders group and control group. This can be explained by the fact that parental use of physical discipline is considered as a parenting style in many areas of the world. The tradition of using physical discipline is being transmitted across generations. Parents may imitate the way of their rearing themselves and corporal punishment is considered as a method of child discipline.

The current study revealed that ADHD is significantly associated with severe physical abuse and sexual abuse; also, CD is significantly associated with severe physical abuse and sexual abuse. However, ODD and combined ADHD and CD are not significantly associated with any type of child abuse.

Many evidences suggests that child abuse is strongly associated with high risk of ADHD [19].

The relation between ADHD and child abuse is complicated as child abuse increases ADHD symptoms; moreover, ADHD increases risk for abuse due to dysfunctional relationships as a result of impulsivity and other behavioral troubles [20].

A study that recruited 2491 Latino male and female children (aged 5–13 years) revealed that physical abuse was significantly associated with ADHD [21].

Another study done by Stern et al. [17] revealed that children exposed to severe abuse/neglect had higher odds of 2.78 for having ADHD; also, the study by Ohlsson Gotby et al. [22] revealed that hyperactive and impulsive behaviors predicted sexual abuse in both sexes.

The association between child abuse and delinquent behaviors is evident in many studies. A study done by Lyttle and Brodie [23] revealed that 65% of those who experienced physical abuse were found to have CD followed by those sexually abused (62%).The explanation of this is that these abused children on facing any conflict will become verbally or physically aggressive to resolve their problem and will demonstrate high levels of hostility and violation of rules.

Another study done by Maniglio [24] revealed that rates of CD were significant among participants with a history of both sexual and physical abuse.

In this study, all types of abuse are significantly associated with low self-esteem.

Parents who provide a supportive atmosphere play a major role in shaping self-esteem in their children [25]. Conversely, negative parental attitude is detrimental to the development of self-esteem.

Similar to our result, a study by Xiang et al. [26] revealed that those who have suffered from child abuse have less social support leading to lower self-esteem.


  Conclusion Top


This study addressed the associations between child abuse and externalizing disorders. The results highlight the need for strategies aiming at reducing child abuse and improving parenting style and the need for risk reduction, educational advertising, and prevention programs to reduce the prevalence rates and serious long-term consequences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krug EG. World report on violence and health, World Health Organization. Available at: http://www. who. int/violence_injury_prevention/violence/world_report/en/. 2002.  Back to cited text no. 1
    
2.
National Council for Childhood and Motherhood (NCCM) and UNICEF. Violence against children in Egypt. A quantitative survey and qualitative study in Cairo, Alexandria and Assiut, NCCM and UNICEF Egypt, Cairo. 2015.  Back to cited text no. 2
    
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Herrenkohl TI, Sousa C, Tajima EA, Herrenkohl RC, Moylan CA. Intersection of child abuse and children’s exposure to domestic violence. Trauma Violence Abuse 2008; 9:84–99.  Back to cited text no. 3
    
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El Beheiry A, Abou Deif E. Childhood Trauma Questionnaire in Mahmoud A. The extent of the effectiveness of assertive training in enhancing low self-esteem among abused children [MA thesis for the requirements of M.A. degree in education]. Assiut, Egypt: The Department of Mental Health, Assiut University, 2003.  Back to cited text no. 12
    
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Musa F, Dassouki M. A test of self-esteem for children. Cairo: Al-Nahda Publishers 1981.  Back to cited text no. 13
    
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Coopersmith S. The antecedents of self-esteem. New York: W. Freeman 1967.  Back to cited text no. 14
    
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Turner HA, Finkelhor D, Ormrod R. Child mental health problems as risk factors for victimization. Child Maltreat 2010; 15:132–143.  Back to cited text no. 15
    
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Gokten ES, Duman NS, Soylu N, Uzun ME. Effects of attention-deficit/hyperactivity disorder on child abuse and neglect. Child Abuse Negl 2016; 62:1–9.  Back to cited text no. 16
    
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Stern A, Agnew-Blais J, Danese A, Fisher HL, Jaffee SR, Matthews T et al. Associations between abuse/neglect and ADHD from childhood to young adulthood: a prospective nationally-representative twin study. Child Abuse Negl 2018; 81:274–285.  Back to cited text no. 17
    
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Hadianfard H. Child abuse in group of children with attention deficit-hyperactivity disorder in comparison with normal children. Int J Community Based Nurs Midwifery 2014; 2:77.  Back to cited text no. 18
    
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Fuller-Thomson E, Lewis DA. The relationship between early adversities and attention-deficit/hyperactivity disorder. Child Abuse Negl 2015; 47:94–101.  Back to cited text no. 19
    
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Aebi M, Linhart S, Thun-Hohenstein L, Bessler C, Steinhausen HC, Plattner B. Detained male adolescent offender’s emotional, physical and sexual maltreatment profiles and their associations to psychiatric disorders and criminal behaviors. J Abnorm Child Psychol 2015;43:999–1009.  Back to cited text no. 20
    
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González RA, Vélez-Pastrana MC, McCrory E, Kallis C, Aguila J, Canino G et al. Evidence of concurrent and prospective associations between early maltreatment and ADHD through childhood and adolescence. Soc Psychiatry Psychiatr Epidemiol 2019; 54:671–682.  Back to cited text no. 21
    
22.
Ohlsson Gotby V, Lichtenstein P, Långström N, Pettersson E. Childhood neurodevelopmental disorders and risk of coercive sexual victimization in childhood and adolescence − a population‐based prospective twin study. J Child Psychol Psychiatry 2018; 59:957–965.  Back to cited text no. 22
    
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Lyttle S, Brodie S. Child abuse and its relationship to conduct disorder. Lastet ned. 2007; 5:2011.  Back to cited text no. 23
    
24.
Maniglio R. Prevalence of sexual abuse among children with conduct disorder: a systematic review. Clin Child Fam Psychol Rev 2014; 17:268–282.  Back to cited text no. 24
    
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Shaffer DR, Kipp K. Developmental psychology: childhood and adolescence, 8th edn. Belmont, CA: Wadsworth, Cengage Learning 2010.  Back to cited text no. 25
    
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Xiang Y, Wang W, Guan F. The relationship between child maltreatment and dispositional envy and the mediating effect of self-esteem and social support in young adults. Front Psychol 2018; 9:1054.  Back to cited text no. 26
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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