الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Adverse Childhood Experiences (ACEs) are an increasing international concern. There is a growing body of evidence that our experiences during childhood can affect health throughout the life course. ACEs correspond to sources of stress that people may suffer early in life, usually before the age of 18; they either directly harm a child or affect the environment in which they live.
The aim of the present work was to study the relationship between ACEs and child abuse perpetration among mothers attending the family health centers (FHCs) in Alexandria. The specific objectives were to assess exposure of mothers attending the FHCs in Alexandria to ACEs, assess child abuse perpetrated by mothers attending the FHCs in Alexandria and investigate the relation between ACEs and perpetration of child abuse among mothers attending the FHCs in Alexandria.
A cross-sectional study design was conducted in family health centers in Alexandria. Out of the eleven FHCs located in Alexandria city, three FHCs with the highest attendance rate were included in the study namely; Elsyoof, Sanistifano and Elamrawy FHCs. Using G. Power software, a minimum required sample of 350 mothers was determined, based on a prevalence rate of 18% for women‟s report about witnessing domestic violence during childhood years i.e. fathers’ beating to their mothers, and by using a power of 80%, to detect prevalence precision 4% and an error of 0.05
The predetermined sample size was equally allocated on the selected centers. Each center was visited by the researcher regularly (4 days a week) to recruit women fulfilling study eligibility criteria from the family health and pediatric clinics till the allocated sample size was completed. All sampled mothers were subjected to the following techniques and tools:
I) A pre-designed structured self-report questionnaire to collect the following data: (Appendix I (
1. Demographic data: including student’s name, age, marital status, living arrangements, age of marriage, duration of marriage, family size and residence.
2. Socioeconomic data: including educational of woman, education of husband, occupation of woman, occupation of husband, number of departments, crowding index, and income/month. These data were used to calculate the socio-economic score. Perceived relationship with family members (mother, father and siblings) during childhood years.
II. Adverse Childhood Experiences ACEs (Appendix II)
Mothers‟ ACEs were assessed using a predesigned questionnaire that included 12 different childhood adversities based on review of previous ACEs‟ studies (Rs). ACEs questionnaire included five items that received four likert scale responses (never, seldom, sometimes and always) and tapped ACEs of; physical and emotional abuse by a family member, witnessing domestic violence, sexual abuse by anyone and gender discrimination by a family member. In addition, seven items received dichotomous responses (yes/no) and included history of parental separation, divorce and death as well as history of mental illness, chronic disease, household substance abuse and suicide attempt and arrest of a family member.
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III. The Arabic version of HITS (Hurt, Insult, Threaten, Scream) tool.
HITS is a domestic violence screening tool that was originally designed for use in the community. It consists of 4 questions, each scored from 1-5. Thus, scores for this inventory range from 4-20. (84) The Arabic version of HITS was adapted and validated in a sample of pregnant women and a score greater than 10 was considered positive.
IV. The Arabic version of Conflict Tactics Scales Parent-Child
The CTSPC was originally developed to identify child psychological and physical maltreatment and neglect by parents, as well as non-violent modes of discipline. It comprises 3 scales namely; non – violent discipline (4 items); psychological aggression (5 items), and physical assault (5 items for corporal punishment and 4 items for severe physical assault, 4 items for very severe physical assault). In addition, it includes two supplement scales on neglect (5 items) and sexual maltreatment (2 items).
The study revealed the following important results:
The age of mothers ranged from 20 to 45 years of age with a mean of 30.37 ± 5.64 years. The highest percentages of mothers aged 30 to less than 40 years old (46.3%) followed by those aged 20 to less than 30 years (45.7%).
Concerning mothers’ total scores on HITS, 70.9% of the sample recorded low scores of ≤ 10, while 29.1% of the sample recorded high scores (>10) indicating exposure to domestic violence. In addition, sampled mothers recorded total mean score of 9.56 ± 2.702.
66.3 % of sampled mothers reported any ACE, 30.0% for one ACE, 17.7 % for two ACEs, 18.6% for three ACEs or more.
Concerning type of ACEs, the most frequently reported type of child abuse perpetrated by sampled mothers was psychological aggression (95.4%) followed by corporal punishment (79.0%), then neglect (52.0%), then severe physical assault (32.0%), while the least reported form of child abuse was very severe physical assault (21.0%).
There is statistically significance (positive correlation) between exposure of sampled mothers to childhood experiences and her child abuse behaviors.
According to psychological aggression, statistically significant differences were revealed regarding being exposed to physical abuse (p = < 0.001), psychological abuse (p = 0.003), witnessing domestic violence (p = < 0.001), exposure to gender discrimination (p = 0.038) and living with an addict family member (p = 0.002).
According to neglect, statistically significant differences were only revealed regarding witnessing domestic violence (p = 0.036), exposure to gender discrimination (p = 0.001) and living with a depressed family member (U= 2131.00, p = 0.012).
According to minor physical assault (corporal punishment statistically significant differences were revealed regarding being physically abused (p < 0.001), psychologically abused (p = <0.001), witnessing domestic violence (p = < 0.001), exposure to gender discrimination (p = 0.017), being sexually abused (p = 0.004), divorce of their parents (p = 0.006) and living with an addict family member (p = 0.001).
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According to severe physical assault, statistically significant differences were only revealed regarding being physically abused (p = < 0.001), psychologically abused (p = <0.001), witnessing domestic violence (p = <0.001), exposure to gender discrimination (p= 0.005), divorce of their parents (p = 0.032) and living with an addict family member (p = <0.001).
According to very severe physical assault, statistically significant differences were only revealed regarding being physically abused (p = < 0.001), psychologically abused (p = < 0.004), witnessing domestic violence (U = 5722.00, p = < 0.001), exposure to gender discrimination (p = 0.006) , being sexually abused (p = 0.019), divorce of their parents (p = 0.004) and living with an addict family member (p = <0.001).
Recorded positive correlation between number of ACEs and child abuse behaviors; increasing numbers of ACEs correlated with high score in TACTICS Scale.
Results indicate positive moderate significant correlation between number of ACEs of the studied mothers and their scores on minor and very severe physical assault (p = 0.000, p = 0.000 respectively), weak significant positive relationship regarding psychological aggression, neglect and severe physical assault (p = 0.000p = 0 .001 and p = 0.000 respectively) and non-significant correlation related to non-violent discipline.
It is evident that ACE of psychological abuse and older age of women proved to be significant predictors of psychological aggression perpetrated by mothers towards the child (OR = 5.751, p = .018 and 1.127, p = .026 respectively).
It is indicates that ACE of living with a depressed family member, current exposure to domestic violence, low socioeconomic status and older age of women were independent significant predictors of child neglect (OR = 3.360, p = .041, OR = 2.505, p = .001, OR= 0.394, p =.007 and OR = 1.051, p =.016 respectively).
ACE of sexual abuse, current exposure to domestic violence and older age of women were independent significant predictors of child minor physical assault (OR = 3.112, p = .030 , OR = 4.433, p = .001 and OR = .000, p = 1.151 respectively).
It is evident that ACE of witnessing domestic violence, current exposure to domestic violence and older age of women were independent significant predictors of severe child physical assault perpetrated by mothers (OR = 1.967, p = .031, OR= 2.627, p = .001 and OR 1.089, p =.000).
It is evident that ACE of current exposure to domestic violence, moderate and low socio economic scores and older age of women were independent significant predictors of very severe child physical assault perpetrated by mothers (OR = 2.592, p=.002, OR= 9.469, p =.00, OR = 3.339, p = 3.339 and OR= 1.080, p =.004 respectively).
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Accordingly, the following recommendations are suggested:
• Raising awareness of mothers attending FHCs about the cycle of family violence and how it adversely affects wellbeing of all family members particularly children. As well, improving their skills concerning effective parenting and supportive family relationships may contribute to breaking the cycle of maltreatment. `
• Screening of mothers for ACEs as well as husband violence is essential to the prevention of child maltreatment particularly during the vulnerable period of infancy and early childhood, when children‟s brains are developing at a rapid pace.
• Considering the significant relationship between domestic violence (DV) and child maltreatment, supportive marital relationship is becoming an important aspect in breaking the cycle of violence. Family health personnel have an important role in education of partners about healthy relationship, assessment of DV, and empowering victims with information about the available social, legal and mental health resources.
• Training of family health personnel is necessary to ensure their better understanding, responding and prevention of family violence.
• To effectively address multiple forms of family violence, prevention strategies by different sectors and parties including health care, education, social welfare, mass media as well as NGOs should be coordinated. Effective communication and dissemination of information against violence should be concerted at all levels and sectors.
• Further studies with longitudinal designs are greatly needed to fill gaps in our knowledge concerning type to type transmission of intergenerational violence, role of perpetrator identity in the transmission as well as the protective factors that promote resilience under risk conditions.