Child Abuse in the Gulf Cooperation Council Countries

Subject: Psychology
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Abstract

The main objective of the present systematic review was to analyze peer-reviewed articles in English on the theme of child abuse in the countries of GCC. The problem of child maltreatment in the countries of the Gulf Cooperation Council was explored as an unresolved issue on the international level. The systematic review examined peer-reviewed studies in English language. Quantitative study design was a common feature of all examined works. The results of the systematic review showed that peculiarities of the cultures along with the lack of the legal support allowed parents to use beating as one of the main methods of child disciplining. Different patterns of child abuse were explored, including physical and psychological maltreatment. The majority of research papers included in this systematic review analyzed the awareness of people in the GCC region about the child maltreatment and their opinions about this problem. Custom questionnaires were employed to gain information from parents, children, dentists, and school specialists. According to the accumulated results, parents supported beating as an effective method of children disciplining. Medical workers and teachers showed low awareness of the child maltreatment in their regions. The systematic review confirmed that the problem of child maltreatment in the countries of GCC region is far from being resolved.

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Introduction

Child abuse broadly refers to the maltreatment of children in the hands of their parents, guardians and caregivers. Butchart, Harvey, Mian, and Furniss define child maltreatment as “all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power” (Butchart et al., 2006, p. 9). Also, in literature, legislation and policy, terminology such as ‘child maltreatment’ and “child abuse and neglect” are often used interchangeably (AIFS, 2015). Historically, it was possible to deny that child abuse and neglect occurred because people found it outrageous to support the view that children needed protection from their parents (Bentovim & Gray, 2014). Nonetheless this view changed after people realized that children often suffered different emotional and psychological damage in the hands of their caregivers. Child abuse is a common problem for many countries. In fact, societies that are divided along religious, cultural, and political dynamics report cases of child abuse (Committee on Child Maltreatment Research, 2014). Kaufman (2014) says that a quarter of all adults have reported experiencing abuse as children. Furthermore, he says that one in five women and one in 13 men have reported experiencing some form of sexual abuse in their childhood (Kaufman, 2014). A study by Deanda and Becerra (2014) to investigate the incidence of child abuse in several European countries, including Lithuania, Macedonia, Moldova, and Latvia found that there were incidences of child abuse in all the countries sampled. The incidences were 33%, 18%, 43%, and 42%, respectively (Deanda & Becerra, 2014). The incidences are higher in countries that have an authoritarian parenting style.

Child abuse could happen in different forms and types, including psychological, sexual, and physical abuse (Committee on Child Maltreatment Research, 2014). Child sexual abuse, incitation in mendicancy, incitation in prostitution, and psychological abuse are also other types of abuse prevalent in many parts of the world (Missing Kids, 2016). The vice is often a product of acts of omission, or commission, by those mandated to protect a child. It may happen in different settings, including a child’s home, school, church or any other institution and setting where a child is. Nonetheless, neglect is the most common type of abuse (Bentovim & Gray, 2014). Physical abuse is a close second (Kaufman, 2016). These types of abuses are often associated with visible physical injuries on their victims, but evidence also points out that victims may suffer several developmental problems in their lives (Committee on Child Maltreatment Research, 2014). For example, ill-health, high-risk health behaviors and decreased life expectancies are common problems associated with this form of abuse (Kaufman, 2014). The common reasoning is that child abuse victims would often grow up to be maltreating adults. This type of outcome often suffices because of social, emotional and cognitive problems, which victims of child abuse develop because of adverse childhood experiences (Committee on Child Maltreatment Research, 2014). They, in turn, lead to the adoption of health-risk behaviors, which could lead to the development of diseases, disability and social problems. The worst cases of child abuse often lead to death. In fact, estimates show that as of 2014, there were more than 41,000 cases of homicide stemming from child abuse (Schwartz & Isser, 2016). The World Health Organization estimates that this number may be higher because most deaths attributed to child abuse (such as drowning or fire burns) are often reported as accidental deaths (Missing Kids, 2016). Nonetheless, the degree, or percentage, of each type of abuse varies according to the region under investigation.

Substance abuse and poverty are global concerns that researchers have affirmed to have a direct correlation with the vice (Gitterman, 2014). There is a strong correlation between child abuse cases and unemployment status among parents, size of family, and substance abuse (Deanda & Becerra, 2014). Similarly, there is a strong correlation between child abuse cases and father absenteeism. These problems are often global and although they significantly contribute to child abuse incidences, cultural factors across different parts of the world also dictate the types and levels of child abuse we see today. Nonetheless, the causative factors influencing the incidence of child abuse cases among different societies vary because of cultural differences (Deanda & Becerra, 2014). These differences could be investigated from different perspectives, depending on what factors researchers want to investigate. Here, it is important to understand these differences because parental styles often vary across different cultures. More importantly, it is crucial to recognize that different cultures have unique parenting issues they would deem acceptable and intolerable. Indeed, as Bentovim and Gray (2014) say, some cultures may deem some behaviors as normal, while others may deem them unacceptable.

In line with this argument, Gitterman (2014) explored some of these differences across different societies and found out that Asian cultures hold different belief systems about parenting compared to their European and American counterparts. Many countries, especially in the Arab world, also highlight the importance of establishing parental authority and child obedience by employing different disciplinary techniques (mostly harsh ones). Indeed, striking a balance between disciplinary and parental responsibilities is a key concern for many parents in Asian cultures. Deanda and Becerra (2014) affirm this fact by saying the same is true for many Asian countries, including Japan, China, and Korea.

Regardless of the cultural differences underlying child abuse cases, generally, most forms of abuse are perpetrated by people who are close to the victims. In fact, parents are the most common perpetrators (Kaufman, 2016). Mothers often perpetrate this vice more than fathers do because many societies accord them the responsibility of raising children. Different jurisdictions have different definitions of child abuse, based on the context of their laws and their application of justice when removing children from an abusive environment. Although these jurisdictions report different incidences of child abuse, broadly, many researchers believe it is a global problem (Mathews & Bross, 2015). This paper is a systematic review paper, which will be based on relevant studies and a specific appraisal of others to come up with research data that would provide a holistic understanding of child abuse in the Arab world specifically in GCC countries.

GCC stands for the Gulf Cooperation Council (GCC) and its a group of six countries: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates (UAE). (Benbouziane & Benmar, 2010). Those countries also share couple characteristics beside their close geographical location on map. They all share the same religion (Islam), common social structures and economical development. GCC countries also have similar governmental systems and collective cultures. (Christie, 1987).

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All of the GCC countries have ratified United Nation Convention of the Right of the Child (CRC) and should be bound to its articles which clearly stated on protecting children from all forms of physical and sexual abuse (Article 19 and 34) and from inhuman and degrading treatment or punishment (Article 37) and calls the countries to take all appropriate legislative, administrative, social and educational measurement to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation. In addition, Article 39 of the CRC requires the countries to take all appropriate measures to promote physical and psychological recovery and social reintegration of abused children. Although GCC countries have signed the convention, yet none of them has an active law that follows it (Al-Mahroos, 2007)

Rationale

Norms and traditions are highly respected in the GCC and the Arab world. Therefore, issues of child abuse and neglect are rarely discussed by elders, or in public forums. Relative to this fact, Al-Moosa, Shaiji, Al-Fadhli, Al-Bayed, and Adib (2003) claim, “Reporting or publicly acknowledging this issue would mean a grave intrusion into the family sanctity and a threat to the family’s honor and reputation, the overwhelmingly essential elements of Arab culture” (p. 1162). Although there has been a slight paradigm shift when it comes to reporting cases of child abuse, Bentovim and Gray (2014) say that some forms of child abuse exist in many Arab nations. However, in the Arab world there is a lack of researches conducted about child maltreatment even though Child abuse and neglect is there it is underreported and unaddressed (Al-Mahroos & Al-Amer, 2011).

The first reported case of child abuse happened in Kuwait. In 1987, this case sparked the first ever debate about child abuse in the Gulf Cooperation Council (GCC) at social and professional levels (Al-Ateeqi, Shabani, & Abdulmalik, 2002). Nonetheless, several reports about child abuse in the Arab world have been reported since the late 1980s. For example, there have been several cases of child abuse cases reported in Saudi Arabia, which has similar cultural and social dynamics as Kuwait (Al-Ateeqi et al., 2002). Notwithstanding the cultural reluctance to report incidences of child abuse, many experts often thought that child abuse cases were only limited to some cases in Kuwait and other countries in the Arab region that shared the same social and cultural dynamics (Al-Ateeqi et al., 2002).

It was difficult to solve issues of child abuse in the GCC countries (during the early days) because of the absence of regulation and law. In fact, the existing legislations (about the issue) were mostly prevalent in the western world, it reflects their social, political, and economic dynamics. Therefore, these laws could not be applied in the GCC countries because they did not conform to the culture of the religion and its religious dynamics. Even though there are several documented cases of child abuse in many GCC and Arab countries, many of them do not take these cases seriously, or use them to prevent further cases of child abuse (Al-Moosa et al., 2003). Furthermore, some Arab countries do not require people to report cases of child abuse or neglect. For example, Kuwait does not impose such legal obligation to its citizens (Al-Moosa et al., 2003). Although physicians may report cases of child abuse to social services, families in Kuwait are also under no legal obligation to accept their services. These types of injustices are prevalent in the Arab world (Al-Ateeqi et al., 2002).

At the center of these discussions is an ongoing debate regarding the use of corporal punishment to discipline children in Arab nations because some of its advocates say it could be acceptable, when children are smacked on the buttocks (Maker, Priti, & Agha, 2005). Nonetheless, its critics say it is unacceptable because physical punishment could easily escalate to increased cases of abuse. According to Al-Ateeqi et al. (2002), all forms of open abuse are unacceptable under Islamic law. However, limited physical abuse is acceptable under certain conditions. Islam dictates that such punishment should not exceed minimal force, especially to the head and face. Furthermore, they dictate that such punishment should not include bruising (Al-Ateeqi et al., 2002).

Objectives

The main objective of the present systematic review was to analyze peer-reviewed articles in English about child abuse in the countries of GCC. The articles included in the systematic review represented the rates of child maltreatment in the GCC countries, parental attitudes to the child abuse, the awareness of paediatricians, dentists, and school specialists about child maltreatment. The articles made use of the quantitative study design to address the abovementioned questions. The researchers obtained the necessary information from self-administered questionnaires, medical literature reviews, and multiple data analysis methods. Parents, children, paediatricians, dentists, and school specialists in the GCC countries took part in the studies. The analyzed studies detected greater rates of child abuse in single-parent families or in step-parent households, girls were abused significantly more often that boys, and participant reported about co-occurring forms of abuse (Al-Eissa et al., 2016). Potential abusers often refused to take part in the studies and prohibited their children from filling out questionnaires. The researchers presented statistics and described reasons for low rates of awareness about child maltreatment among all specialists working with children and adolescents. One third of school professionals were not aware of child abuse among their pupils (AlBuhairan, Inam, AlEissa, Noor, & Almuneef, 2011). Paediatricians reported more frequently about child neglect than of child maltreatment, and the majority did not know where to report about child maltreatment (Al-Moosa et al., 2003). In many cases, dentists did not recognize the signs of child maltreatment (Mogaddam, Kamal, Merdad, & Alamoudi, 2016). The lack of proper education about child abuse, and the absence of legal support were named as the main reasons for low awareness and underreporting about the cases of child maltreatment. The majority of participating specialists in all studies were willing to attend specific training.

Population of Concern

Our population of concern for this study would be children who live in the GCC Countries. Here, children refer to people who are under 18 years, which is the legal age of transition from childhood to adulthood in many Arab states (Al-Mahroos, 2007; Fukkink, Bruns, & Ligtvoet, 2016). The population under study would also include both boys and girls who are ordinarily raised in a two-parent home, single-parent home, or by guardians. As opposed to some western societies, child abuse in the Arab world is rarely discussed, or examined (Maker et al., 2005). In fact, history shows us that many Arab countries accepted female infanticide for purposes of family planning (Al-Moosa et al., 2003). Thus, many nomadic societies in the region practiced it. However, with the coming of Islam in the Middle East, this practice was abolished because the religion forbade its members from disrespecting the sanctity of human life (Fukkink et al., 2016). Nonetheless, men reserved the power to discipline women and children. Their techniques did not exclude physical confrontations. Even when it led to abuse, the maltreatment would be safeguarded in the context of the family structure (Maker et al., 2005).

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In many Middle Eastern countries, the trend towards gender equality has a significant impact on how families bring up their children. For example, in many nations, there has been a consistent battle of the sexes where families have often struggled with the notion of giving women the same rights as men (as opposed to demanding that women assume the traditional role of a housewife) (Al-Mahroos, 2007). Often, families that require women to assume the traditional role of a housewife adopt the authoritarian parenting style where they “dominate” their children and create a big emotional distance with them (Al-Mahroos, 2007). Such kinds of households are also often oppressive and overprotective over their children. Conversely, such types of conditioning have often created a negative environment for children to grow, thereby leading to increased cases of child abuse in the Middle East.

Although there has been a departure from this kind of parenting style in some Middle East households, in many Arab countries, child abuse remains a critical concern. Indeed, as Deanda and Becerra (2014) observe, although people have increasingly started to recognize cases of child abuse in the Middle East, the vice is still uncontrolled in many parts of the region. While traditional roles of parents greatly influenced parenting styles in the past, recently, cases of financial difficulty and unemployment have increased the incidence of child abuse in the region. Al-Mahroos (2007) affirms this fact by saying that these issues are largely to blame for incidences of child abuse in some of these countries. Generally, the unique social and political dynamics of the Middle East necessitates a culture-specific understanding of child abuse in the region.

Method

Criteria for Study Inclusion

This systematic review included studies that were English, peer reviewed, full- text journal articles published between years 1990 and 2017. The aim was to find articles done by social work discipline, however, studies from other professions than social work were included due to the lack of studies covering the topic from social work. Other professions were: pediatricians, dentists and schoolteachers because they consider as frontline in suspecting child abuse since those professions works with children closely. In addition, exclusion criteria for this systematic review was as follow: any document other than an article, articles about child abuse from mental health perspective, and articles about other countries than the GCC countries. Also reports, case studies, and studies about one type of child abuse were excluded because they show limited experience and cannot be generalized on the topic.

Electronic Search

A comprehensive search of different databases including: ProQuest, Web of Science, Social Work Abstracts, Social Service Abstracts, Sociological Abstracts, PsycINFO and Google scholar along with other databases such as Medline and JStor was undertaken using the key words and synonyms of “ Child”, “maltreatment/ abuse/ punishment” and one of each GCC countries (Kuwait, Saudi Arabia, United Arab Emirates, Qatar, Bahrain, Oman). In addition, manual search of references and through Google scholar was used to find related articles. Furthermore, author contacted couple other authors for articles that were not available online and there was no response for three months period.

Risk of Bias Across Studies

The researcher of this systematic review put an effort to reduce the risk of any type of bias. However, a number of limitations was faced. This systematic review aimed to cover all of the GCC countries. However, two main countries (Kuwait and Saudi Arabia) contributed a lot to the overall systematic review results because databases search found more information on these two countries. However, all other GCC countries had at least one related article. It was assumed that the results were about the GCC because the majority of countries shared similar results on child maltreatment, abuse and neglect. In addition, there was a lack of articles on the topic in English. The GCC countries’ primary language is Arabic, future search should pay attention to include articles in this language too.

Results

Study Sample

Below is a figure of Preferred Reporting Items for Systematic Review and Meta- Analysis (PRISMA) flowchart that shows the search of articles, screening and inclusion/exclusion process (Moher, Liberati, Tetzlaff, Altman, & Prisma Group, 2009).

PRISMA flow chart
Figure 1. PRISMA flow chart

A total of 83 articles were found, 82 from databases search and one was found through manual search of articles references. Out of the 83 articles, 39 were excluded because they were repeated in different databases; 22 articles were removed at the abstract level due to its irrelevance to the topic, and 10 were removed at the full-text reading for not meeting the inclusion criteria. A total of 12 articles were qualified as the study sample for meeting all of the inclusion requirements of this systematic review.

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Each of the 12 articles that were selected for the review was summarized in a table that shows; Location, study design, intervention used, strength and weakness, reliability and validity of article, and the main results and outcomes. The summarized tables are tabulated in the appendix of this paper (see appendix A)

Study Design

The analyzed studies used a range of designs to evaluate the frequency of child abuse and awareness about different child maltreatment types in the GCC countries. All works used quantitative design while they relied heavily on the results of questionnaires and statistics. Ten studies were of the quantitative cross-sectional design on either the target population (abused children) or caregivers and professionals working with children and adolescents. Two studies used the retrospective design to explore family profiles of child maltreatment (Al-Ateeqi et al., 2002) and child disciplining in Qatar and Palestine (Eldeeb et al., 2016). In addition, one study was a descriptive exploratory that used the correlational design to find connections between child maltreatment and other specified variables (Elarousy & Al-Jadaani, 2013).

Intervention

Interventions used to assess the knowledge, awareness and detection of child maltreatment varied between using self-administered questionnaires conducted by researchers to capture the needed aspects of the issue, or using the ISPCAN Child Abuse Screening Tool that was developed by the experts of the Switzerland International Society for the Prevention of Child Abuse and Neglect (2017). It’s a well structured and widely used child abuse screening tool that has different versions; two versions were used: ICAST-CH child version that was used with children, and ICAST-R the retrospective version that was offered to young adults. Some of the researchers conducted in-depth examination of medical literature, case-reports, and hospital data (Al-Mahroos, 2007). Multiple data analysis methods were used in the study of information from Child Protection Centre in King Abdulaziz Medical City (Almuneef, Alghamdi, & Saleheen, 2016). The reliability of questionnaires was measured by Cronbach’s alpha.

Study Location

All of the studies were located in one of GCC countries. Five of the articles were done in Saudi Arabia (Al-Eissa, et al, 2016; Almuneef et al., 2016; Elarousy & Al-Jadaani, 2013; Al Buhairan, Inam, Al Eissa, Noor, & Almuneef, 2011; Mogaddam et al., 2016), four were done in Kuwait (Al-Ateeqi et al., 2002; Al-Moosa et al., 2003; Qasem, Mustafa, Kazem, & Shah 1998; Al-Fayez, Ohaeri, & Gado, 2012), one was conducted in Qatar (Eldeeb el al, 2016), one from United Arab Emirates ( Al-Amad, Awad, Al-Farsi, & Elkhaled, 2016), and one was about couple countries of the Arab peninsula that includes number of GCC countries (Al-Mahroos,2007).

Study Participants

From the twelve articles, four studies focused on children and young adults who had experience child maltreatment, neglect or abuse. One article focused on parents of abused kids, and three studies main concern was finding child abuse cases from medical files of certain hospitals in countries. Furthermore, four studies focused on professionals who work closely with abused children; school teachers, paediatricians, and dentists.

Studies’ interests were divided between the welling to rigorously study the affected children by monitoring them using a widely used child abuse and maltreatment tool, or to study the awareness of child maltreatment, abuse and neglect among professionals who work with children. Also, parents of abused children were within the concern of the research so they were included to complete the research.

Types of Identified Child Maltreatment by GCC Children

This systematic review results showed that all types of child maltreatment existed in the GCC, the highest rates were found on physical and psychological abuse (Al-Eissa et al, 2016; Al-Fayez et al., 2012). Most physically abused children showed bruises, burns, internal organs injuries and head injuries (Al-Mahroos, 2007). In some cases, children were abused even before birth when their pregnant mothers experienced physical violence (Al-Mahroos, 2007). The unawareness of dentists about signs of child maltreatment prevented the study of dental injuries in child abuse (Mogaddam et al., 2016). Nevertheless, a quarter of the interviewed dentists encountered signs of child abuse at least once (Al-Amad et al., 2016). Parents punished children and adolescents beating them with hand or with other objects (Qasem et al., 1998). Emotional abuse and neglect also showed significant results among children (Elarousy & Al-Jadaani,2013; Almuneef et al., 2016). Emotional maltreatment included both ignoring and terrorizing (Elarousy & Al-Jadaani, 2013). The underreporting of psychological abuse created obstacles to identifying of all child maltreatment types (Al-Moosa et al., 2003). While sexual abuse showed the lowest evidence in studies (Al-Eissa et al, 2016), results from study showed that sexual perpetrators were identified as relatives from the extended family, housemaids, or friends (Al-Fayez et al., 2012)

Family Characteristics

According to the results of studies, children were abused by their mothers, fathers or others (Almuneef et al., 2016; Al-Ateeqi et al., 2002; Al-Fayez et al., 2012). Child maltreatment existed in greater extent in single-parent families, step-parent households, and when parents perceived their parental skills as low (Al‐Eissa et al., 2016). Additionally, parents who were formally employed to low-skilled jobs were more abusive than parents who were never employed or retired (Al-Fayez et al., 2012). Physical abuse was higher in families with unemployed fathers (Almuneef et al., 2016). Moreover, parents who had attained lower educational degrees or had no education were more abusive than those of higher education (Almuneef et al., 2016). Daughters experienced maltreatment more frequently than sons (Al‐Eissa et al., 2016). First-born children were more abused by their parents compared to their siblings, while younger siblings were more likely to experience abuse by others (Al-Fayez et al., 2012).

Awareness of Child Maltreatment among Professionals

Data gathered from hospital records indicated that abused children received the needed medical care, however, usually if perpetrator was one of the parents the case was handled with secrecy, and often data was lost after the death of children (Al-Mahroos, 2007). In addition, Roy, Al-Saleem, Al-Ibrahim, and Al-Hazmi (1999) stated that medical professionals failed to use legal means to protect children in Saudi Arabia. Dentists had difficulties in recognising the signs of child maltreatment (Mogaddam et al., 2016). Nevertheless, about a quarter of dentists from private and public clinics encountered signs of child abuse (Al-Amad et al., 2016). Paediatricians did not know where to report about child maltreatment and feared the reaction from their relatives (Al-Moosa et al., 2003).

Discussion

Summary of Evidence

According to the examined studies, children in the GCC countries are exposed to all possible kinds of child maltreatment. They are at risk of abuse even before birth (Al-Mahroos, 2007). Child maltreatment is significantly greater in single-parent families, step-parent households and in homes with unemployed fathers (Al‐Eissa et al., 2016). Girls are abused more often than boys, and participants of questionnaires report about recurring forms of abuse (Al‐Eissa et al., 2016).

All patterns of child abuse are registered in the GCC countries, while people accept, tolerate, and ignore child maltreatment (Al-Mahroos, 2007). The most frequent form of abuse is physical violence (Almuneef et al., 2016). Nevertheless, the majority of children participating in self-administered questionnaires suffer regularly from emotional abuse, including ignoring and terrorizing (Elarousy & Al-Jadaani, 2013).

The awareness of professionals about child abuse remains very low. One third of school professionals participating in the research does not know about the state of child maltreatment in their classes (Al-Buhairan, Inam, AlEissa, Noor, & Almuneef, 2011). Medical reports about child abuse are scarce and vague, lacking detail. From over 60 thousand medical records in hospitals of Kuwait only 16 are identified as child abuse (Abdulmalik, 2002). Paediatricians report more frequently about child neglect because they do not know how to tell about child maltreatment without being accused by the society (Al-Moosa et al., 2003).

The majority of parents in the GCC countries accept physical punishment as a mean to control child discipline (Qasem et al., 1998). Qatari children are reported to be less abused physically and emotionally compared to Palestinian (Eldeeb et al., 2016; Haj-Yahia & Abdo-Kaloti, 2003). Dentists encounter signs of child abuse in their practice, but their reports are rare (Al-Amad et al., 2016). The unawareness of dentist about the signs of child abuse can be the reason of underreporting (Mogaddam et al., 2016). School students report about at least six cases of physiological abuse in the year, similar statistics are recorded for lifetime experience (Al-Fayez et al., 2012).

The outcomes of all examined studies are largely dependent on the quantitative study design. The lack of information in the reports from professionals working with children and from victims of abuse can lead to the discrepancies of all sorts. The participants of self-administered questionnaires can give wrong answers in fear of their caregivers. The retrospective nature of some studies weakens the reliability of the results. The reports from parents, children, and professional working with children and adolescents allow concluding that the issue of child maltreatment is far from being resolved, but they do not give any solution to the problem.

Strength and limitations

Our study was limited to the databases that we chose and Google scholar. Language and article meeting inclusion criteria were also limitations. Most of the data collected for the systematic review about child maltreatment were found from hospital files and research surveys, evidence would be stronger if we found surveys collected from children themselves because bias can be high and results are underestimated when surveys were done by parents on this topic.

Data for this systematic review were gathered from four sources; abused children, parents of children, professionals working closely with children, and medical files Participants. Majority of professionals indicated that it was not mandatory to report child abuse if it was suspected or found. Nevertheless, they indicated that in case they report child abuse they did it as a routine procedure but not a result of following child protection law.

There is a significant gap found between the years of studies, while most of them were done within the last five years, it is assumed that child maltreatment issue is being well recognized and the awareness to imply and follow child protection laws is needed immediately.

The lack of literature evidence of sexual abuse does not mean that it does not exist, but because of the “Social taboo” that is related to the issue that ban people from speaking up about it (Al-Mahroos, 2007)

In addition, it is assumed that the lack of articles found in English was because the topic is about Arabic spoken countries. Further research can find more results if Arabic language was included.

Conclusion

Although the existence of child maltreatment, abuse and neglect in the GCC countries lacked evidence, a good body of literature confirmed the issue and its profound influence on children. The accumulated results outlined a significant problem in controlling child abuse in the region. Children were exposed to physical violence even before their birth. Beating and psychological maltreatment were common in many families, exceptionally in single-parent, step-parent households. Cultural peculiarities and traditions created obstacles for the development of legal support for maltreated children and adolescents. People ignored, tolerated, and accepted physical violence as an effective mean of child disciplining. Therefore, it was uncommon for citizens to report about child abuse. Parents refused to speak on this theme and prohibited their children to take part in surveys. Moreover, professionals working with children and adolescents hesitated to speak about child maltreatment in fear of the negative reaction from the society. Educational specialists showed low awareness about the means to report child abuse. School professionals did not know how to report to the cases of child abuse. Paediatricians and dentists showed unawareness about possible signs of physical maltreatment and did not pay attention to psychological disorders and developmental issues as consequences of child abuse. Still, the majority of specialists expressed will to participate in specific courses about child maltreatment. The results of the systematic review showed that the issue of child maltreatment was far from being resolved.

Implications for Research, Policy and Practice

The findings show that urgent actions by authorities are needed to enhance social welfare in the GCC countries. A reformation of regional child protection laws can address the issue. The opponents of child maltreatment should work closely with policy makers to bring the issue on a higher level to prevent the development of a worse situation. Further research is required in the field of regional cultures and traditions that can support child maltreatment. The results of the current systematic review can be used to find effective means to protect children in the GCC countries. A collaboration of medical workers and school specialists with the local representatives of the law is needed for the timely report of child abuse. A profound research is required to find possible forms of such collaboration.

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Appendix A

Summary of Articles on Child Abuse in GCC Countries

Author and Date published Study Location Study Design and sample Intervention and Instrument Strength and Weakness Main Outcomes and Results #Times the article was cited*
  1. Al‐Eissa et al (2016)
Secondary high schools in Kingdom of Saudi Arabia Quantitative, cross-sectional
adolescents age 15-19 (N=16939 )
ISPCAN Child abuse screening tool- Child version was used for self report. All adolescents selected took part in the test; 91% of participants responded to all items; missing information in responds The occurrence of abuse and neglect among adolescents was assessed. Greater rates of child abuse were detected in single-parent families or in step-parent households. Prevalence of various form of abuse were: Lowest rate sexual abuse while highest rates scored for psychological abuse; significantly greater rates of psychological abuse were detected for girls and sexual abuse was greater for boys; participant reported about co-occurring forms of abuse 4
  1. Al-Mahroos(2007)
Kuwait, Saudi Arabia, UAE, Qatar,
Oman, Bahrain, Yemen
Quantitative, cross-sectional.
Databases research to review medical reports of child abuse between 1987-2005, and reports of child abuse that were discussed in regional meetings.
Reviewing data from different resources (World Health Organization “WHO” Index for the Mediterranean region, Google search engine, and databases. Detailed review of medical literature, case reports, and studies in 7 countries; the sources presented limited information; no documented reports found in Qatar and UAE, and that most of papers are based on limited case reports and hospital based data. Also information about sexual abuse is more limited in the most of the 7 countries The information was obtained from official medical literature, case reports, hospital data, regional meetings and professional organizations
All patterns of child abuse registered in the Arab Peninsula; people ignored, tolerated and accepted child abuse. The study showed that all of the countries in the region have ratified United Nation Convention on the Rights of the Child (CRC), however, non of them have a law that bans abuse.
50
Author and Date published Study Location Study Design and sample Intervention and Instrument Strength and Weakness Main Outcomes and Results #Times the article was cited*
  1. Almuneef, Alghamdi, and Saleheen (2016)
Child Protection Centre in King Abdulaziz Medical City, Riyadh, Saudi Arabia Quantitative, retrospective involving children <18 years of age they were N=220 cases registered in the NFSR between 2009 and 2013 and completed data in the chart were included in the final analysis. Family profile of child maltreatment in Saudi Arabia was assed by looking at four main sets of variables were assessed: 1) demographic information of the child, 2) family pro le information, 3) information of the parents (age, marital status, education level, employment status, and presence of illness or disability), and 4) information of the perpetrator and form of abuse. Credible data was obtained from authorized sources, multiple data analysis methods; the study limited to the Medical City population. Information was retrieved from the most established centre in the country. The most frequent form of abuse was physical abuse;
more than half (62%) of perpetrators were parents, the threat of physical abuse was higher in families with unemployed fathers and in single-parent/step-parent households. A significant relationship was found between the types of abuse and perpetrators: Neglect was most common among victims whose parents were the perpetrators, whereas physical and sexual abuse were common when others were the perpetrators.
3
  1. Elarousy and Al-Jadaani (2013)
3 malls in Jeddah, Saudi Arabia Quantitative, descriptive, exploratory correlational A convenience sample of 60 children aged 12-18 collected from 3 malls in Jeddah Emotional child maltreatment in families was assessed using a self-administered questionnaire completed by children with the contest of their families. The questionnaires revealed detailed information about emotional maltreatment in families; potential abusers refused to give permission to their kids to participate in the study. Experts assessed the relevance and coverage of the topic; Cronbach’s alpha for questions is 0.78.
90% of participating children suffered from emotional abuse, including ignoring and terrorizing. Also, more than half of children reported at least one form of rejecting, ignoring or terrorizing emotional abuse. Females scored more in types of emotional abuse than males.
6
Author and Date published Study Location Study Design and sample Intervention and Instrument Strength and Weakness Main Outcomes and Results #Times the article was cited*
  1. AlBuhairan, Inam, AlEissa, Noor, and Almuneef (2011)
Schools in Saudi Arabia Quantitative, cross-sectional. A stratified cluster random sampling was conducted. Total of 3777 school professionals participated
94% were teachers ages 31-40
Awareness of school professionals about child maltreatment was assessed by using self- administered questionnaire Nearly four thousand school professionals across the country took part in the study; professionals who were aware of child abuse could refuse to take part One third of school professionals had low awareness of child maltreatment; the majority of participants were willing to attend specific training on child maltreatment. Awareness among Females showed a statistically significantly result than males. 17
  1. Al-Ateeqi, Shaban, and Abdulmalik (2002)
Al-Amiri and Mubarak Al-Kabeer Hospitals, Kuwait Quantitative, exploratory study, retrospective analysis of 60,640 medical records of children admitted to the hospital. 16 children showed signs of abuse The history and recent level of child maltreatment in Kuwait assessed by reviewing medical records. Over 60 thousand reports analysed. Three paediatricians checked the diagnoses; information in the records is limited and lacks detail. Data retrieved from official medical records. From over 60 thousand medical records only 16 were identified as child abuseperpetrator was a parent in 75% of the cases; child maltreatment in Kuwait is most probably underreported, and no official management procedure are affected yet. 12
Author and Date published Study Location Study Design and sample Intervention and Instrument Strength and Weakness Main Outcomes and Results #Times the article was cited*
  1. Al-Moosa, Al-Shaiji, Al-Fadhli, Al-Bayed, and Adib, (2003)
Public hospitals of Kuwait Quantitative, cross-sectional survey. (N=117) paediatrics Using a structured self-completed questionnaire assessed awareness of paediatricians about child maltreatment in Kuwait. All paediatricians in public hospitals of Kuwait took part in the study; paediatricians did not pay much attention to psychosocial and developmental issues. Department of Community Medicine approved the study. Paediatricians reported about more cases of child neglect than of child abuse; more than 80% did not know where to report about child maltreatment. The report is usually be limited to social workers. 56
  1. Qasem, Mustafa, Kazem, and Shah (1998)
Clinics in major administrative areas of Kuwait Quantitative, cross-sectional was done in 5 clinics. N=337 mothers and fathers with at least one living child were contacted. Parental attitude to the physical punishment of children was assessed using survey 95% of contacted families were successfully interviewed; the measurements of attitudes towards beating did not differentiate between punishment with hand or with other object. Age grouped in questionnaire has large range (10-17). The study could not capture the influence of attitudes on actual behaviour of parents. Only Kuwaiti nationals were interviewed to exclude migrant workers. Selected clinics featured the highest percentage of Kuwaiti people 86% of parents accept physical punishment as a mean to control child discipline. 55
Author and Date published Study Location Study Design and sample Intervention and Instrument Strength and Weakness Main Outcomes and Results #Times the article was cited*
  1. Eldeeb et al. (2016)
Households in Qatar and Palestine Quantitative, retrospective, cross-sectional random house hold surveys were conducted among Qataris N= 697 and Palestinians N=2064 for young adults (18-24) Child disciplining in Qatar and Palestine was assessed using The ISPCAN Child Abuse Screening Tool-Retrospective Version (ICAST-R) Only Qatari households for Qatar and Palestinian for Palestine were studied; the study did not show causes for acquired results An international instrument ICAST-R was used in the study. Qatari children were less abused physically and emotionally compared to Palestinian children 0
  1. Al-Amad, Awad, Al-Farsi, and Elkhaled (2016)
Private and public clinics in the United Arab Emirates UAE Quantitative, cross-sectional N= 193 dentist working in the UAE had met inclusion criteria. Awareness of dentist of child maltreatment in the UAE was assessed using a closed ended, self administered questionnaire. Also, Logistic regression was used to determine the association between perceived training needs and other covariates. The specially developed self-administered questionnaire provided detailed information; 147 participants were excluded because they did not provide their answers. This was the first survey study conducted in the UAE about the topic Dentists from private and public clinics were invited to provide diversity of answers. A quarter of the interviewed dentists encountered signs of child abuse at least once 0
Author and Date published Study Location Study Design and sample Intervention and Instrument Strength and Weakness Main Outcomes and Results #Times the article was cited*
  1. Mogaddam, Kamal, Merdad, and Alamoudi (2016)
Dental schools in Jeddah, Saudi Arabia Quantitative, cross-sectional on (N= 208) paediatric dentists and dental interns. A structured self administered questionnaire was used to assess
Awareness and attitudes of dentists towards child maltreatment in Saudi Arabia
Only dentists from academic institutes took part in the study so results might not be generalizable, ; the amount of participants who detected signs of child abuse is insufficient, also dentist’s behaviours were assessed using self administered tool which can increase personal bias. The specially developed questionnaire was used. STATA Version 13.0 provided statistical analyses Dentists showed unawareness of signs of child maltreatment; participants were positive about child abuse reporting 5
  1. Al-Fayez, Ohaeri, and Gado, (2012)
Government secondary schools of Kuwait Quantitative, cross-sectional. Stratified random sample was used (N=4467) high school students. Standard scales on psychological, physical and sexual abuse was used to assess
Maltreatment of Kuwaiti school students by family members and others
Over four thousand students participated in the study; acquired information lacks details about abuse experience; many scientists criticized retrospective nature of analyses Reliability tests showed positive results about gender and cultural sensitivity.
Nearly twenty percent of participant reported about six cases of physiological abuse in the past year; similar statistics were recorded for lifetime experience
46

* Based on Google scholar