Parent-Child Conflict Tactics Scale Research Articles

Violence against pregnant women can increase the risk of child abuse: A longitudinal study

ObjectiveTo assess the impact of intimate partner violence (IPV) against pregnant women on subsequent perpetration of child abuse and neglect (CAN) by parents; and to test the mediation effect of recent IPV on the link between IPV during pregnancy and subsequent CAN. MethodsThis study was a longitudinal follow-up of a population-based study on pregnancy IPV conducted in antenatal clinics in 7 public hospitals in Hong Kong in 2005. Of all participants in the 2005 study, we recruited 487 women (with 184 having reported pregnancy IPV in the 2005 study) with newborn babies for a follow-up telephone interview in 2008. Participants responded to the Abuse Assessment Screen (AAS), the Parent-Child Conflict Tactics Scale, and some questions assessing demographic information. ResultsThe most common form of physical violence was corporal punishment, with a prevalence rate of 75.1% in the preceding year and 75.4% over their lifetime. Physical maltreatment was less likely to be reported, accounting for 4.7% in the preceding year and 4.9% over their lifetime. The preceding-year and lifetime prevalence rates of neglect were 11.3% and 11.5%, respectively. Findings from logistic regression analyses showed that IPV experienced by participants during pregnancy was associated with greater odds of both lifetime (aOR=1.74) and preceding-year child physical maltreatment (aOR=1.78). Results of the regression analyses also provided supportive evidence for the mediation effect of recent IPV victimization on the relationship between IPV during pregnancy and recent CAN against children. ConclusionIPV against women during pregnancy predicted subsequent CAN on newborns in Chinese populations. This underscores the importance of screening pregnant women for IPV in order to prevent CAN at an early stage. Home visitations are suggested to break the cycle of violence within a nuclear family.

대학생의 가족학대경험, 사회부적응 및 자아탄력성과 일상생활만족의 관계

The purposes of this study were to find the correlation of family abuse experience, social maladaptation, ego resilience and daily life satisfaction in university students, and to explore the mediating role between ego resilience between family abuse experience, social maladaptation and daily life satisfaction. The subjects were 265 university students. The data were analyzed with frequency, Pearson's correlation and structural equation modeling by SPSS and AMOS. Instruments were Bradburn(1969)'s The Structure of Psychological Well-being, Olson and Barnes(1982)' Quality of Life, Straus(1988)'s CTSPC(Parent-Child Conflict Tactics Scales), Shin(2001)'s social maladaptation of Korean General Health, and Block and Kremen(1996)'s ego resilience. The major findings were as follows; Family abuse experience and social maladaptation were negatively correlated with ego resilience and daily life satisfaction. Ego resilience was positively correlated with daily life satisfaction. Ego resilience mediated the effects of family abuse experience, social maladaptation and daily life satisfaction. Family abuse experience and social maladaptation negatively influenced ego resilience and daily life satisfaction. Ego resilience positively influenced daily life satisfaction. Thus special education program and counseling should be provided to increase university students' daily life satisfaction through in order to built ego resilience.

Relationship of childhood physical abuse and internet addiction disorder in adolescence: the mediating role of self-esteem

To find out whether the effects of childhood physical abuse on internet addiction disorder in adolescence could be mediated by self-esteem. 3798 high school students selected from 76 classes in Grade One and Grade Two, were asked to fill in the anonymous questionnaire, which including the demographic characteristics of students, Young's Internet Addiction Scale, Parent-Child Conflict Tactics Scales and Rosenberg's Self-Esteem Scale. Childhood physical abuse could directly predict less self-esteem and internet addiction disorder (r = -0.108, P < 0.01, r = 0.057, P < 0.01) and had significant indirect effects on internet addiction disorder which could be mediated through self-esteem (a = -0.703, standardized b = -0.104, z = 5.052, P < 0.001). Self-esteem had mediated 22.5% of the childhood physical abuse cases on their internet addiction disorders during the period of adolescence. Self-esteem could partially mediate the relationship between childhood physical abuse and internet addiction disorder. The mediating roles of self-esteem suggested that salient leverage points could make a change through empowerment training, self-esteem group training on self-esteem enhancement in the stage of adolescence.

대학생의 가족학대경험, 가족스트레스와 행복의 관계 : 사회적 지지와 가족탄력성의 매개효과를 중심으로

The purposes of this study were to find correlation between family abuse experience, family stress, social support, family resiliency and happiness in university students, and to explore the mediating role of social support and family resiliency between family abuse experience, family stress and happiness. The subjects were 295 university students. The data were analyzed by means of frequency analysis, Pearson's correlation and structural equation modeling with SPSS and AMOS. Instruments were Lee's(2010) Happiness Scale for university students, Strauss'(1988) CTSP(Parent-Child Conflict Tactics Scale), McCubbin's(1981) FILE(Family Inventory of Life Events and Changes), Yu's(2004) Family resiliency of Family Health Scale and Park's(1985) Social Support Scale. The major findings were as follows; Family abuse experience was positively correlated with family stress and negatively correlated with social support, family resiliency and happiness. Family stress was negatively correlated with family resiliency. Social support and family resiliency were positively correlated with happiness. Family abuse experience positively influenced family stress and negatively influenced social support and family resiliency. Social support positively influenced family resiliency and happiness. Family stress negatively influenced family resiliency. Family resiliency positively influenced happiness. Thus education program and counseling should be provided to increase happiness and family resiliency, and social support should be provide to increase the quality of life for university students.

Um estudo sobre a validade de construto da Parent-Child Conflict Tactics Scale (CTSPC) em uma amostra populacional urbana do Nordeste brasileiro

The Parent-Child Conflict Tactics Scale (CTSPC) is one of the most widely used instruments in the world for investigating domestic violence against children, but targeted use has proven inadequate given the phenomenon's complexity. This study focused on the factor structure of CTSPC scales in an urban population in Northeast Brazil. We conducted a cross-sectional study in a cohort of 1,370 children in Salvador, Bahia State. Factor analysis with promax oblique rotation was performed, and the Kuder-Richardson coefficient was calculated. Factor analysis showed a different distribution of items in the factors as compared to the original instrument. Violence showed a gradual profile in each factor. The Kuder-Richardson coefficient was 0.63 for factor 1, 0.59 for factor 2, and 0.42 for factor 3. The items behaved differently from the original instrument, corroborating international studies. These findings support proposing a resizing of the CTSPC.

Violência familiar contra a criança e perspectivas de intervenção do Programa Saúde da Família: a experiência do PMF/Niterói (RJ, Brasil)

This study seeks to estimate the prevalence of psychological and physical violence practiced against children in the family environment among clients of the Family Medical Program in Niterói (RJ). It also discloses some potential opportunities for action in the prevention, early detection and monitoring of families experiencing violence. This population-based survey was conducted with face-to-face interviews with parents or legal sponsors of 278 children registered in 27 teams of the Family Health Program. The population studied was randomly selected among children up to ten years of age. The Brazilian version of Parent-Child Conflict Tactics Scales - CTSPC was employed to assess the occurrence of this type of violence. Psychological aggression occurred in 96.7% (CI 95%: 94.7-98.8) of the households, and corporal punishment occurred in 93.8% (CI 95%: 92.0-96.7). Minor physical violence was reported by 51.4% (CI 95%: 45.5-57.3) of the respondents, and severe physical maltreatment by 19.8% (CI 95%: 15.1-24.5) of them. Although the mother was the foremost perpetrator of all kinds of maltreatment, most of the children were abused by both parents. In view of these results, domestic violence against children should be seen as a main concern for the Family Health Program.

Risk and protective factors for child neglect during early childhood: A cross-study comparison

The present analysis relies upon data from three separate longitudinal studies to identify risk and protective factors associated with subsequent neglect during early childhood. All three studies (Fragile Families and Child Wellbeing [FFCW]; Healthy Families New York [HFNY]; Illinois Families Study-Child Wellbeing [IFS]) involve probabilistic samples or subsamples of low-income families with young children. Multivariate logistic regressions predicting official reports of investigated neglect allegations and a dichotomous indicator of neglect from the Parent–child Conflict Tactics Scale (CTS-PC) were conducted separately for each study, using common sets of predictors derived from baseline or initial survey waves. Across the three studies, consistencies emerged with respect to the predictors of both neglect outcomes. Specifically, consistencies emerged related to indicators of economic resources and hardships, parent well-being, and parenting. Understanding the predictors of child neglect is of critical importance to the development of child maltreatment prevention strategies since a clearer understanding of the risk and protective factors associated with neglect would enable more effectively targeted and tailored interventions.

P03-40 - Different types of abuse of children with ADHD by parents

ObjectivesIt is well studied that children with attention deficit hyperactivity disorder (ADHD) are physically abused by their parent. However, there are few studies on different forms of abuse.MethodThe parents of a clinical sample of 108 children and adolescents with ADHD and 102 mothers of a control group were included in this study. The ADHD diagnosis was made according to DSM-IV diagnostic criteria, using K-SAD. The Parent-Child Conflict Tactics Scales (CTSPC) was used to assess the frequency of the three different forms of child abuse by their parents including “Nonviolence discipline”, “parental psychological aggression” and “parental physical aggression”.ResultsThe mean scores of “nonviolent discipline”, “parental psychological aggression” and “parental physical aggression” for the parents of children with ADHD were more than those of the control group. “Parental psychological aggression” and “Parental physical aggression” were significantly correlated with each other.ConclussionThe physical abuse of children with ADHD by their parents is very common. However, Child abuse in children with ADHD occurs in a cluster of different types of abuse irrespective of parental age or education. So, other types of abuse should be considered in the management of children with ADHD.

Study on the association between emotional abuse and other psychosocial factors with depressive symptom in junior high school students

To investigate the association between emotional abuse, family structure, family support, type D personality and depressive symptom in junior high school students. 3160 junior high school students were recruited with stratified sampling method in Guangzhou to complete a self-administered questionnaire including Depression Self-rating Scale for Children, Parent-Child Conflict Tactic Scale, Type D Scale-14, Family Structure Scale, Relative Support Scale and general information. Correlation and path analysis were performed to explore the association of emotional abuse, family structure, family support and type D personality with depressive symptom and their potential pathways. (1) The average level of depressive symptom was higher in girls than in boys, and age was positively related to depressive disorder (r = 0.06, P = 0.001). (2) Correlation analysis indicated that family support was a protective factor for depressive symptom, while emotional abuse, type D personality and family structure with single parent were risk factors for depressive symptom. (3) Data from Path analysis showed that the negative affection had the strongest impact on depressive symptom with a path coefficient of 0.37, followed by family support (-0.246), emotional abuse (0.203), social inhibition (0.075) and family structure (0.047). All the path coefficients were statistically significant. Emotional abuse indirectly impacted on depressive disorder through negative affectivity and family support (the path coefficients were 0.119 and 0.05, respectively), while family structure had the smallest indirect impact on depressive symptom. Depressive symptom in junior high school students was affected by multiple psychosocial factors, suggesting that comprehensive measures should be taken to prevent the occurrence and development of depressive symptom.

Parent–Child Aggression: Association With Child Abuse Potential and Parenting Styles

The present investigation predicted that greater use of corporal punishment as well as physical maltreatment would be associated with child abuse potential and selected parenting styles. Three independent studies were examined, two with community samples and a third with a clinical at-risk sample of parents. Parents across all studies anonymously completed the Child Abuse Potential Inventory, the Parent-Child Conflict Tactics Scale to assess physical discipline and maltreatment, as well as the Parenting Scale to measure dysfunctional parenting styles. Findings support that overall parent-child aggression, as well as physical maltreatment behaviors specifically, were associated with child abuse potential. Parent-child aggression was also related to dysfunctional parenting styles, particularly an overreactive, authoritarian parenting style. Permissive parenting was also identified as potentially associated with physical maltreatment, although the findings regarding such lax parenting styles are less clear. Intriguing findings emerged regarding the connection of psychological aggression to both child abuse potential and dysfunctional parenting style. Child abuse potential was also associated with dysfunctional parenting style, particularly harsh, overreactive approaches. Recommendations for future study with at-risk samples and additional research on permissive parenting and psychological aggression are discussed.

International Variations in Harsh Child Discipline

Although the history of recognition of child abuse in Europe and North America extends over 40 years, recognition and data are lacking in other parts of the world. Cultural differences in child-rearing complicate cross-cultural studies of abuse. To ascertain rates of harsh and less-harsh parenting behavior in population-based samples. We used parallel surveys of parental discipline of children in samples of mothers in Brazil, Chile, Egypt, India, Philippines, and the United States. Data were collected between 1998 and 2003. The instrument used was a modification of the Parent-Child Conflict Tactics Scale, along with a study-developed survey of demographic characteristics and other parent and child variables. Women (N=14 239) from 19 communities in 6 countries were surveyed. We interviewed mothers aged 15 to 49 years (18-49 years in the United States) who had a child younger than 18 years in her home. Sample selection involved either random sampling or systematic sampling within randomly selected blocks or neighborhoods. Nearly all parents used nonviolent discipline and verbal or psychological punishment. Physical punishment was used in at least 55% of the families. Spanking rates (with open hand on buttocks) ranged from a low of 15% in an educated community in India to a high of 76% in a Philippine community. Similarly, there was a wide range in the rates of children who were hit with objects (9%-74% [median: 39%]) or beaten by their parents (0.1%-28.5%). Extremely harsh methods of physical punishment, such as burning or smothering, were rare in all countries. It is concerning that >or=20% of parents in 9 communities admitted shaking children younger than 2 years. Physical and verbal punishments of children are common in high-, middle-, and low-income communities around the world. The forms and rates of punishment vary among countries and among communities within countries. A median of 16% of children experienced harsh or potentially abusive physical discipline in the previous year.

Family violence and risk of substance use among Mexican adolescents

Objective Determine the relationship between psychological and physical violence, exerted by fathers and/or mothers, and inter- or extra-familiar sexual violence with risk for consuming tobacco, alcohol and drugs among adolescents. Method A cross-sectional study was carried out with students in two secondary schools in Mexico City. A total of 936 students participated: 54.3% males and 45.7% females, ranging between 12 and 16 years of age. A self-administered questionnaire was applied. This included Straus’ Parent–Child Conflict Tactics Scales, as well as instruments to evaluate sexual violence and substance use, among other components. Results Over half of the adolescents reported psychological or physical violence exerted by their parents, and 1 in 10, sexual violence. The proportion of use of the 3 substances was similar in both sexes. Logistic regression analysis for males showed that psychological violence, exerted by either parent, implied twice the risk for the victims to use tobacco. For males, having suffered sexual violence increased the risk of consuming drugs various times. For females, being a victim of multiple forms of violence within the family increased the risk of consuming tobacco, alcohol and drugs notably, in comparison to non-victims. Conclusions Treatment programs for young people who have suffered family violence should consider adolescence not only as a stage of vulnerability for substance use but also as a critical time to implement preventive measures. For these measures, a joint strategy for both parents and adolescents should be considered, not only to stop the violence but also warn the parents about the serious consequences of the same.

Low-income single mothers' community violence exposure and aggressive parenting practices

This study examined the association between maternal community violence exposure and parenting practices, with a sample of low-income single mothers from the Fragile Families and Child Well-Being Study (FFCW) and related in-home child survey. Psychologically aggressive and physically aggressive parenting practices were measured with two subscales derived from the Parent–Child Conflict Tactics Scales (CTSPC). Community violence exposure was measured with items indicating being a witness to or victim of community violence. Bivariate analysis indicated that the intensity of community violence exposure was positively associated with both types of aggressive parenting practices. In the multivariate analysis, mothers with moderate and high levels of community violence exposure were 2.1 time and 2.4 times, respectively, more likely to engage in a higher level of physically aggressive parenting, when compared to mothers with no exposure to violence. Such rates were 1.7 and 1.8 times higher with respect to psychologically aggressive parenting practices. The findings highlight the need for expanding research to better understand the association between community violence and the wellbeing of children and families, and suggest the importance of supporting low-income single mothers who have been exposed to community violence through effective parenting programs and other community social services.

Adaptation and validation of the Parent-Child Conflict Tactics Scale for use in Sri Lanka

The purpose of the study was to validate the Parent-Child Conflict Tactics Scale (CTSPC) in Sri Lanka, for use with 12-year old children. A Delphi Process determined the consensual and content validity of the CTSPC. Test-retest reliability and internal consistency were determined by a large and a small group administration. Professionals from the social and behavioural sciences were the judges in the Delphi Process. Conveniently located schools in the Gampaha District were chosen for determining the test-retest reliability and internal consistency. This included original CTSPC and its Sinhala translation, a structured interview schedule and a focus group guide. The Sinhala version of the CTSPC showed adequate consensual and content validity. Its test-retest reliability and internal consistency were satisfactory. The instrument is best administered in small rather than in large groups of children. The Sinhala version of the CTSPC is appropriate to be used with 12-year old Sinhala speaking schoolchildren in Sri Lanka.

How Neglect and Punitiveness Influence Emotion Knowledge

To explore whether punitive parenting styles contribute to early-acquired emotion knowledge deficits observable in neglected children, we observed 42 preschool children's emotion knowledge, expression recognition time, and IQ. The children's mothers completed the Parent-Child Conflict Tactics Scales to assess the recent use of three types of discipline strategies (nonviolent, physically punitive, and psychological aggression), as well as neglectful parenting. Fifteen of the children were identified as neglected by Child Protective Services (CPS) reports; 27 children had no record of CPS involvement and served as the comparison group. There were no differences between the neglect and comparison groups in the demographic factors of gender, age, home language, minority status, or public assistance, nor on IQ. Hierarchical multiple regression modeling showed that neglect significantly predicted emotion knowledge. The addition of IQ contributed a significant amount of additional variance to the model and maintained the fit. Adding parental punitiveness in the final stage contributed little additional variance and did not significantly improve the fit. Thus, deficits in children's emotion knowledge may be due primarily to lower IQ or neglect. IQ was unrelated to speed of emotion recognition. Punitiveness did not directly contribute to emotion knowledge deficits but appeared in exploratory analysis to be related to speed of emotion recognition.

Screening for harsh punishment in a pediatric primary care clinic

Objectives To determine: (1) the prevalence of harsh punishment among parents in a pediatric clinic, and (2) the sensitivity, specificity, predictive values, and stability of a brief screening measure. Methods A subset of families involved in a study of child maltreatment prevention were recruited for this study. Two items in a parent screening questionnaire (PSQ) were related to child punishment. Comparisons were made between parents’ responses on the PSQ and on the Parent-Child Conflict Tactic Scale (CTSPC). Results On the PSQ, 7% of parents of infants and 32% of parents of toddlers/preschoolers reported that their child was difficult to take care of or needed to be hit or spanked. On the CTSPC, 14% of the infants had experienced physical assault and 21% psychological aggression. For older children, subscales were modified to exclude common discipline measures, resulting in 20% experiencing physical assault and 19% psychological aggression. Sensitivities for the PSQ were relatively poor for infants, but moderate for older children. Specificities were good. Stability was adequate. Conclusions Harsh punishment experienced by older children was similar to that in published studies. Punishment of infants is concerning. The PSQ can be used to screen out parents who are not using harsh discipline measures. Practice implications The PSQ has variable utility in determining which families are using harsh punishment. Until the measure can be further refined, universal counseling is needed.

Pediatric Primary Care to Help Prevent Child Maltreatment: The Safe Environment for Every Kid (SEEK) Model

Effective strategies for preventing child maltreatment are needed. Few primary care-based programs have been developed, and most have not been well evaluated. Our goal was to evaluate the efficacy of the Safe Environment for Every Kid model of pediatric primary care in reducing the occurrence of child maltreatment. A randomized trial was conducted from June 2002 to November 2005 in a university-based resident continuity clinic in Baltimore, Maryland. The study population consisted of English-speaking parents of children (0-5 years) brought in for child health supervision. Of the 1118 participants approached, 729 agreed to participate, and 558 of them completed the study protocol. Resident continuity clinics were cluster randomized by day of the week to the model (intervention) or standard care (control) groups. Model care consisted of (1) residents who received special training, (2) the Parent Screening Questionnaire, and (3) a social worker. Risk factors for child maltreatment were identified and addressed by the resident physician and/or social worker. Standard care involved routine pediatric primary care. A subset of the clinic population was sampled for the evaluation. Child maltreatment was measured in 3 ways: (1) child protective services reports using state agency data; (2) medical chart documentation of possible abuse or neglect; and (3) parental report of harsh punishment via the Parent-Child Conflict Tactics scale. Model care resulted in significantly lower rates of child maltreatment in all the outcome measures: fewer child protective services reports, fewer instances of possible medical neglect documented as treatment nonadherence, fewer children with delayed immunizations, and less harsh punishment reported by parents. One-tailed testing was conducted in accordance with the study hypothesis. The Safe Environment for Every Kid (SEEK) model of pediatric primary care seems promising as a practical strategy for helping prevent child maltreatment. Replication and additional evaluation of the model are recommended.

The relationship between emotional, physical abuse and Internet addiction disorder among middle school students

To study the relationship between emotional, physical abuse and internet addiction disorder (IAD) among middle school students, in order to lay foundation for the development of prevention and control programs on IAD. Students selected from 76 classes in Grade One and Grade Two, filled out the anonymous questionnaire, which including demographic characteristics of students, Young's Internet Addiction Scale, Parent-Child Conflict Tactics Scales, etc. Non-conditional multivariate logistic regression model was employed to explore the relationship between child abuse and IAD. Independent variable was child abuse while dependent variable was IAD. Covariant variables would include demographic characteristics, as sex, age, style of household, et al. Among 3798 students, the overall prevalence of emotional abuse was 81.1%, with 55.1% of them reported having experienced physical abuse. Among 3507 internet users, 5.2% was diagnosed as IAD. Results from the non-conditional multivariate logistic regression model showed that odds ratio of severe physical abuse and moderate physical abuse were 3.02 (1.63-5.58) and 4.00 (2.01-7.93). Moderate physical abuse and severe physical abuse were possible risk factors of IAD.

Parental physical and psychological aggression: Psychological symptoms in young adults

Objective The purpose of the present study was to evaluate the relationship between various levels of parent-child physical violence and psychological symptoms reported by college students, while controlling for demographic variables, severity and frequency of violence, and co-occurrence of parental psychological aggression. Method Participants included 298 college students ranging in age from 18 to 27 years. Participants completed a demographic information form, the Brief Symptom Inventory (BSI), and the Parent-Child Conflict Tactics Scale (CTSPC). Results Results of analysis of variance and multivariate analysis of variance indicated that individuals in the child physical abuse group obtained higher BSI scores compared to individuals in the corporal punishment and no violence groups. Few differences were observed between mild and severe corporal punishment groups. Multiple regression analyses indicated that when frequency of corporal punishment, child physical abuse, and psychological aggression, along with demographic variables, were considered simultaneously, psychological aggression was the most unique predictor of BSI scores. Conclusions The findings suggest that severe forms of physical violence were associated with long-term psychological symptoms. When demographic variables and the frequency of several parent aggression variables were considered simultaneously, however, psychological aggression was most predictive of psychological outcome. These findings suggest that messages communicated to a child via psychological aggression may be more important in contributing to psychological outcome than the actual occurrence of physical violence toward the child. Practice implications The current study supports the premise that severe physical aggression experienced in childhood is associated with serious psychological consequences in adulthood. In contrast, individuals who experienced less severe forms of parent-child violence, such as corporal aggression, exhibited similar symptom levels to those reporting no parent-child violence. When severe physical aggression, corporal aggression, and psychological aggression were considered simultaneously, however, psychological aggression emerged as the most unique predictor of psychological outcome. Researchers and clinicians who work with adults reporting childhood histories of severe parent-child violence should be aware of the importance of parent-child psychological aggression in contributing to psychological outcome.

Prevalence and determinants of child maltreatment among high school students in Southern China: A large scale school based survey

BackgroundChild maltreatment can cause significant physical and psychological problems. The present study aimed to investigate the prevalence and determinants of child maltreatment in Guangzhou, China, where such issues are often considered a taboo subject.MethodsA school-based survey was conducted in southern China in 2005. 24 high schools were selected using stratified random sampling strategy based on their districts and bandings. The self-administered validated Chinese version of parent-child Conflict Tactics Scale (CTSPC) was used as the main assessment tool to measure the abusive experiences encountered by students in the previous six months.ResultsThe response rate of this survey was 99.7%. Among the 6592 responding students, the mean age was 14.68. Prevalence of parental psychological aggression, corporal punishment, severe and very serve physical maltreatment in the past 6 months were 78.3%, 23.2%, 15.1% and 2.8% respectively. The prevalence of sexual abuse is 0.6%. The most commonly cited reasons for maltreatment included 'disobedience to parents', 'poor academic performance', and 'quarrelling between parents'. Age, parental education, places of origins and types of housing were found to be associated with physical maltreatments whereas gender and fathers' education level were associated with sexual abuse.ConclusionThough largely unspoken, child maltreatment is a common problem in China. Identification of significant determinants in this study can provide valuable information for teachers and health professionals so as to pay special attention to those at-risk children.