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The effect of left-behind phenomenon and physical neglect on behavioral problems of children
Child Abuse & Neglect 88 (2019) 144–151
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Research article
The effect of left-behind phenomenon and physical neglect on behavioral problems of children
T
Yu-Jie Wena, Xian-Bin Lia, Xi-Xi Zhaoa, Xue-Qi Wanga, Wen-Peng Houa, Qi-Jing Boa, ⁎ Wei Zhengb, Christine Paoc, Tony Tand, Chuan-Yue Wanga, a The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, 100088, China b The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China c Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA d Department of Educational and Psychological Studies, College of Education, University of South Florida, Tampa, USA
A R T IC LE I N F O
ABS TRA CT
Keywords: Left-behind children Behavioral problem Physical neglect
Objective: Left-behind children have a high incidence of behavioral problems in some Eastern countries, especially China. We sought to assess the combined effects of physical neglect, a major embodiment of the left-behind phenomenon, and the trauma of being left behind on subsequent behavioral problems. Method: 776 children (including 600 left-behind children) aged 12–16 years were chosen by cluster sampling in rural China. The Childhood Trauma Questionnaire-Short Form and the Conners Teacher Rating Scale were used to evaluate physical neglect and behavioral problems. Results: Left-behind children experienced more physical neglect (mean difference = 0.63; 95%CI 0.15–1.10; P = 0.01) and were more inattentive (mean difference=0.11; 95%CI 0.03–0.19; P = 0.009) than non-left-behind children. Physically neglected left-behind children had higher scores for conduct problems, inattention, and hyperactivity index than non-left-behind without physical neglect group (P < 0.05 for each). Among left-behind children, physical neglect group had significantly more conduct problems than those of controls (mean difference=0.14; 95%CI 0.05–0.23; P = 0.008). Physically neglected non-left-behind children had higher scores for conduct problems than those of left-behind children without physical neglect (mean difference=0.31; 95%CI 0.13–0.47; P = 0.003). Among physically neglected children, left-behind children had significantly higher scores for inattention than those of non-left-behind children (mean difference=0.13; 95%CI 0.04–0.22; P = 0.037). Conclusion: Left-behind children have more behavioral problems than non-left-behind children. Physical neglect may result in more severe conduct problems than those associated with staying behind, and staying behind may lead to inattention. Exposure to both may lead to more obvious behavioral problems. Therefore, we should accord more attention to physically neglected and left-behind children.
⁎ Corresponding author at: Beijing Anding Hospital, Capital Medical University, No. 5 Ankang Lane, Dewai Avenue, Xicheng District, Beijing, 100088, China. E-mail address: [email protected] (C.-Y. Wang).
https://doi.org/10.1016/j.chiabu.2018.11.007 Received 6 August 2018; Received in revised form 4 November 2018; Accepted 12 November 2018 0145-2134/ © 2018 Elsevier Ltd. All rights reserved.
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1. Introduction Since China’s Reform and Opening-up in 1978, the unprecedented and uneven economic growth in China has created a major income disparity between rural and urban residents over the past three decades. As a result, large numbers of rural residents migrate to economically prosperous cities to work each year. In most cases, the nature of work in the city, financial constraints, and movement restrictions placed on rural household registration make it nearly impossible for migrant workers to bring their children to cities where they have found employment; consequently, children are left to remain in their rural hometowns (Chan, 2010; Luo et al., 2008). According to a 2014 Chinese national survey, 22% of children (about 61 million) were left at home by their migrant parents (National-Women’s-Federation-of-children’s-Work-Department, 2014). These left-behind children (LBC), known as liu-shou-er-tong in China, stay at their original residence for at least six months while one or both of their parents migrate to other locations to work (Duan & Zhou, 2005; Fan, Su, Gill, & Birmaher, 2010). Generally, the children are left in the care of extended family members such as grandparents, uncles/aunts, or even on their own. According to a survey study (Dai & Chu, 2016), 74% of left-behind children lived with their grandparents, 12.8% lived with their uncles/aunts, and 13.2% were left to take care of themselves. The guardians are often unable to fulfill all of the parenting responsibilities (Hu, Lonne, & Burton, 2014; Yoon, 2005) because they have to do more farm work after the main laborers of the family left to work in the cities, and therefore, often lack the time to adequately care for the left-behind children. While it is not the intention of the migrant parents, their absence, by definition, creates a form of child neglect (Chen & Chan, 2016; Feldman, Case, & Sparks, 1992). Existing literature has shown that lack of care and supervision increases left-behind children’s risk for poor nutrition, accidents, and injuries (Luo et al., 2008). For left-behind children in rural China, physical neglect (PN), defined as a failure of caregivers to provide necessities like food, clothing, and shelter, is the most prevalent and characteristic type of childhood trauma (Gu et al., 2011; Li, Zhong, Pan, Zhong, & Sun, 2014; Pan, 2015; Zhang et al., 2017; Zhong et al., 2015, 2012). Left-behind children may suffer more than one type of childhood victimization, including the trauma of being “left-behind” and its common consequence of physical neglect; this results in subsequent developmental issues (Hildyard & Wolfe, 2002; Millett, Kohl, Jonson-Reid, Drake, & Petra, 2013). Although it is evident that early victimization increases susceptibility to psychiatric disorders in later life, the mechanism is still unclear. Some studies suggest that exposure to specific types of victimization may lead to certain psychiatric symptoms. For example, separation of children from parents is associated with a paranoid state, while neglect is more closely associated with depression (Bentall, Wickham, Shevlin, & Varese, 2012; Kennedy, Tripodi, & Pettus-Davis, 2013; Sitko, Bentall, Shevlin, O’Sullivan, & Sellwood, 2014). However, a dose-effect relationship between accumulative multi-victimization and mental symptoms has been proposed by some researchers (Edwards, Holden, Felitti, & Anda, 2003; Varese et al., 2012). Nonetheless, a definitive link between multi-victimization and mental illness is yet to be demonstrated (Varese et al., 2012). Few studies have determined the relationship between physical neglect and behavioral problems (BP) among left-behind children. The relationship between specific types of behavioral problems and multi-victimization has not been elucidated. Several studies have shown that left-behind children frequently exhibit a propensity for violent, anti-social, and aggressive behaviors (Chen, Sun, Chen, & Chan, 2017). However, there is conflicting research on left-behind children’s attention and hyperactivity. Some studies have suggested that these problems are related to psychological experiences such as parent-child separation and have a prominent impact on the children’s mental illnesses (Zhao et al., 2014). However, findings are not consistent (Cheng et al., 2010; Jiang, 2013). We believe this is the first study to assess the combined effects of physical neglect and the trauma of being left behind on behavioral problems among Chinese children. The hypotheses were: (1) left-behind children would have more behavioral problems than non-left-behind children (NLBC), (2) the incidence of physical neglect in left-behind children would be higher than non-leftbehind children, there might be multi-victimization in left-behind children, and (3) the combined effect of physical neglect and leftbehind phenomenon would be related to behavioral problems. 2. Methods 2.1. Participants Children aged 12–16 were selected as a group from 24 classes in three grades as the unit from a junior high school in Dayang Town, Bozhou, Anhui, China in February and March 2017. In sampling the participants, five classes from each grade were randomly selected for status survey. All subjects provided informed consent to participate, which was approved by the Institutional Review Board, Beijing Anding Hospital, Capital Medical University, Beijing, China. Inclusion criteria for left-behind children were: (1) age 12–16 years; (2) parent(s) working in another location for at least six months per year (currently or previously); and (3) parent or guardian signed informed consent. Exclusion criteria included: (1) history of neuropsychiatric issues; and (2) parents are divorced. 2.2. Demographic data The students were provided basic information (e.g., name, sex, age, migrant parent(s), duration of separation, guardian(s), monthly family income). There were no missing data for basic information. 2.3. Main variables The Childhood Trauma Questionnaire-Short Form and the Conners Teacher Rating Scale were used to evaluate physical neglect 145
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and behavioral problems. Less than 2.6% data for CTRS were missing and corrected using the linear difference method (Linsay, 1991). 2.3.1. Conners Teacher Rating Scale (CTRS) CTRS (Fan & Du, 2016) is a widely-used assessment tool for teachers’ perceptions of students’ behavior. Reponses to the 28-item scale are rated on a four-point scale ranging from 0 to 3 (from 0=not at all true to 3=very much true). Sample items from the four subscales include “sassy” (conduct problems); “daydream” (inattention); “excitable, impulsive” (hyperactivity); and “short attention span” (hyperactivity index). We calculated the Z score for each subscale by taking the total subscale score and dividing it by the item numbers of the subscale. If the Z score of hyperactivity index was over 1.5, children are likely to have attention deficit hyperactivity disorder (ADHD). We used the Chinese version of CTRS, which has satisfactory validity and reliability (Cronbach’s α coefficient: 0.9455) (Su, Li, Huang, Luo, & Zhang, 2001). 2.3.2. Childhood Trauma Questionnaire-Short Form (CTQ-SF) CTQ-SF (Bernstein, Fink, & Bernstein, 1998) is a self-assessment tool to evaluate childhood trauma prior to the age of 17 years. The Chinese version of CTQ-SF has good validity and reliability (Cronbach’s α coefficient: 0.77) (Zhao, Zhang, Li, & Zhou, 2005). There are five types of trauma, namely emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. This questionnaire contains five items for measuring physical neglect, such as “I didn’t have enough to eat” and “I knew that there was someone to take care of me and protect me.” Respondents rated responses on a five-point scale ranging from “never true" to "very often true". The following criteria was used to assess total physical neglect score: none = 5–7, low = 8–9, moderate = 10–12, severe = 13+ (Liao, Deng, & Pan, 2007). The severe cutoff method can improve the identification specificity of physical neglect to 93% for adolescents (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997). In the current study, we categorized children who scored≥13 as physically neglected. 2.4. Statistical analysis SPSS version 20.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. First, χ2 test and independent samples t-test were used to compare sex and age distribution. Second, participants were divided into four groups, namely left-behind children with physical neglect, non-left-behind children with physical neglect, left-behind children without physical neglect, and non-left-behind children without physical neglect. Third, the mixed-design analysis of variance was conducted using 2 (LBC/PN) ×4 (conduct problem/hyperactivity/inattention/hyperactivity index). Independent samples test was also applied to compare the behavioral problems and trauma of children. Last, multivariate analysis of variance (MANOVA) was adopted through 4 (four groups) × 4 (conduct problem/hyperactivity/inattention/hyperactivity index) for the cross comparison between physical neglect and behavioral problems, and the statistical results were examined by two-tailed test. P < 0.05 was considered statistically significant. Bonferroni correction was used to correct multiple comparisons in the results. 3. Results 3.1. Sample characteristics Cluster sampling resulted in a sample of 885 children aged 12–16 years. However, 109 were excluded, including 68 whose guardians did not sign informed consent, 11 with a history of neuropsychiatric problems, and 30 whose parents had divorced. In total, 776 junior high school students (LBC n = 600, NLBC n = 176) were included in the analysis (Tables 1 and 2). Table 1 Demographic characteristics of study subjects. Characteristic
LBC n = 600
NLBC n = 176
χ2 (t), P
Gender (male) Age (years) Family incomea < 1000 1000–5000 5000–10,000 10,000–20,000 > 20,000
308 (51.3) 14.46 ± 1.20
100 (56.8) 14.42 ± 1.12
85 (14.2) 440 (73.3) 60 (10) 12 (2) 3 (0.5)
45 (25.6) 116 (65.9) 11 (6.3) 2 (1.1) 2 (1.1)
1.642, 0.229 0.439, 0.661 15.116, 0.004** – – – – –
Data presented as frequency (percentage) or mean ± standard deviation. Note. LBC=left-behind children; NLBC = non-left-behind children. a Measurement = yuan/month. ** P < 0.01. 146
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Table 2 Demographic characteristics of left-behind children. Factors
Total (%)
Migrate parent(s) Father Mother Father and mother
87(14.5) 13(2.2) 500(83.3)
Age at separation < 0.5 0.5–3 3–6 >6
a
9 (1.5) 108(18.0) 161(26.8) 230(38.3)
Duration of separation in Years <3 3–6 >6
a
147 (24.5) 123(20.5) 320(53.3)
Guardian Father Mother Grandparent Uncle/Aunt Older brother or sister
81(13.5) 9(1.5) 495(82.5) 10(1.7) 5(0.8)
Note. ameasurement = year.
3.2. Comparison of BP between LBC and NLBC We found that LBC scored significantly higher on inattention than NLBC (mean difference = 0.11; 95%CI 0.03–0.19; P = 0.009). Also, LBC suffered more serious PN than NLBC (mean difference=0.63; 95%CI 0.15–1.10; P = 0.01) (Table 3).
3.3. Comparison of BP between the four groups On comparing the BP of children in the four groups based on physical neglect and left-behind status, significant differences in conduct problems [F (3,772) = 7.697, P < 0.001], hyperactivity [F (3,772) = 3.347, P = 0.019], inattention [F (3,772) = 4.107, P = 0.007], and hyperactivity index [F (3,772) = 4.242, P = 0.006] were discovered. The effect of other types of childhood trauma on BP were insignificant (Appendix 1). Among the four groups, the LBC with PN group and NLBC without PN group showed significant differences in conduct problems, inattention, and hyperactivity index (P < 0.05 for each). The LBC without PN group did not show a significantly higher level of conduct problems as compared to that in the NLBC without PN group (mean difference=0.14; 95%CI 0.05–0.23; P = 0.008); however, the NLBC with PN group showed even more serious conduct problems than those in group LBC without PN (mean difference=0.31; 95%CI 0.13–0.47; P = 0.003). Besides, there were significant differences between NLBC without PN group and NLBC Table 3 Comparison of behavioral problems and trauma between LBC and NLBC. Behavioral problems & childhood trauma
LBC n = 600
NLBC n = 176
TRS Conduct problem Hyperactivity Inattention Hyperactivity index
0.574 0.605 0.813 0.879
CTQ Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect
6.911 ± 2.189 6.248 ± 2.185 5.688 ± 1.801 12.328 ± 4.050 10.629 ± 2.710
± ± ± ±
0.473 0.469 0.4940 0.593
0.569 0.592 0.705 0.814
± ± ± ±
T, P
0.503 0.521 0.447 0.580
6.793 ± 2.420 6.403 ± 2.291 5.813 ± 1.748 12.486 ± 4.914 10.017 ± 2.868
0.132, 0.321, 2.608, 1.272,
0.895 0.748 0.009# 0.204
0.615, 0.819, 0.810, 0.390, 2.593,
0.539 0.413 0.418 0.697 0.010*
Data presented as mean ± standard deviation. Note. TRS = Conner’s Teacher Rating Scale; CTQ = Childhood Trauma Questionnaire; LBC = left-behind children; NLBC = non-left-behind children. * P < 0.05. # P < 0.01. 147
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Fig. 1. Comparison of behavioral problems between four groups. Note. LBC = left-behind children; NLBC = non-left-behind children; PN = physical neglect. * P < 0.05, #P < 0.01. After Bonferroni correction.
with PN group, and between the LBC without PN and LBC with PN groups with respect to conduct problems. The inattention score in LBC without PN group was significantly higher than that in NLBC without PN group (mean difference=0.13; 95%CI 0.04–0.22; P = 0.037); however, no significant difference was observed between NLBC with PN and NLBC without PN, or between LBC with PN group and LBC without PN group in this respect (Fig. 1).
4. Discussion Although the left-behind phenomenon rarely occurs in western countries, it is a prevalent issue in rural China. Left-behind children represent an unintended consequence of rural parents’ effort to improve their family's financial situation; unable to bring their children with them to their new places of work, these migrant parents must leave their children to the care of others. A deeper understanding of the experiences of left-behind children can improve our insight into the role of parental absence in youth development. While there is existing literature studying the individual effects of physical neglect and the trauma of being left behind, our study is the first to evaluate the combined effects of this dual-victimization on resulting behavioral problems. In this study, we compared the behavioral differences between LBC and NLBC in rural China, and evaluated the effect of PN from staying behind on resulting BP. We also evaluated the effect of a single exposure and accumulation of dual-victimization. Our results suggest that the differences between LBC and NLBC mainly pertain to inattention. Multi-victimization may be involved in developing more obvious BP, while serious PN may result in more significant conduct problems, and the single factor of staying behind may lead to inattention. Like previous studies (Zhang et al., 2011; Zhao, Li, Wen, Hou, & Wang, 2017), our study showed that LBC exhibit more inattention problems as compared to NLBC. However, the results might be due to effect of multiple exposure factors of “left-behind” phenomenon on behavioral problems. It is noteworthy that we first observed that the single factor of staying behind may lead to inattention. The mechanism of being “left-behind” impacting attention remains unclear. It is reported that the unhealthy personality traits, inattention, and academic disability of LBC showed a strong correlation with their incomplete family environment (Fan & Sang, 2005). Research on ADHD showed that early life stress can impair dopamine function and cause attention deficits (Johansen, Sagvolden, Aase, & Russell, 2005). Attention has a significant influence on education of adolescents. LBC were shown to have poor academic performance and they were also unable to concentrate on listening to lectures and finish their homework on time (Ye, Wang, Zhang, & Lu, 2006). Inconsistent of most previous studies but two researchers, our studies found no significant difference on conduct problems between the left-behind and non-left-behind groups. Graham and Jordan (2011) conducted research on LBC in Southeast Asia, and found that LBC showed more conduct problems in Thailand, but not in the Philippines. Huang, Wu, Du, Liu, and Huang (2010) did not find a higher prevalence of conduct problems among LBC in Hunan province in China. These inconsistencies might be largely attributable to differences in social and cultural factors such as the specific region’s history of migration, support of government, economical and education levels, and cultural norms (Deater-Deckard & Dodge, 1997; Graham & Jordan, 2011). Our findings suggest that serious PN may result in more severe conduct problems than ordinary staying behind in LBC. Like previous studies conducted in rural China (Chang et al., 2017; Liu et al., 2012; Zhao et al., 2017, 2014; Zhong et al., 2015, 2012), we also observed that a higher proportion of LBC suffer from serious PN than NLBC. Improper guardianship may be a potential cause of higher PN among LBC as they are usually raised by grandparents or other relatives (Jia & Tian, 2010). Researchers have found that caregivers with lower education levels and unhealthy lifestyles were more likely to have substantiated PN (Carter & Myers, 2007; Hussey, Chang, & Kotch, 2006; Kaplan, Pelcovitz, & Labruna, 1999). Children exposed to physical neglect tend to be undernourished, experience poor peer relationships and difficulties in psychological adaptation, and exhibit social withdrawal and poor language skills (Moreno-Manso et al., 2017; Norman et al., 2012). All these factors will have a negative impact on their neuropsychological development in adulthood (Viola, Tractenberg, Pezzi, Kristensen, & Grassioliveira, 2013; Wang et al., 2016). Researchers have found that the ill effects of physical neglect on social aggression, violence, and substance use were not limited to children in poor families, but were mediated by the children’s experiences with peer rejection (Carter & Myers, 2007; Chapple, Tyler, & Bersani, 2005; Kaplan et al., 1999). 148
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Among the LBC and the NLBC, the conduct problems were more prominent in the severe PN groups, while inattention was more prominent in the LBC. Dual-victimization did not show any remarkably higher effect than that of a single exposure on inattention, which suggests that different types of trauma may have different effects on BP. This observation is consistent with previous findings stating that the type of exposure has a specific influence on the mental and psychological effects (Schreier & Chen, 2013). We also observed that exposure to both left-behind phenomenon and PN led to more severe conduct problems, inattention, and hyperactivity compared with a single factor which is consistent with the findings of Bentall (Bentall et al., 2012) pertaining to psychosocial symptoms; they showed that this kind of aggravation exhibits a dose-response relation. A meta-analysis also revealed that exposure to an adversity increases the risk of exposure to another adversity (Varese et al., 2012). The parent-child separation inculcates unhealthy attachment relationships of LBC, which is aggravated by PN; the combined effect influences the stress response. Attachment insecurity is associated with hyperactivity (Johnston & Mash, 2001). In addition, studies have shown a significant association between hyperactivity and child maltreatment (Ouyang, Fang, Mercy, Perou, & Grosse, 2008). A similar association has not been found between PN and hyperactivity yet. Our research supports the dual effects of trauma on behavior problems. Multi-victimization may have a higher impact and result in more obvious BP. Our results showed that no effects of other types of trauma on BP. That might be because the sample size of LBC suffered abuse in this study were too small to get reliable statistical results. And CTRS might be insensitive or lacking to measure actual behavioral problems (e.g. anxiety, depression) caused by emotional neglect. 4.1. Limitations The current study has several limitations. First, we only assessed children older than 12 years old; this is because CTQ-SF is restricted to children over 12 years and there are currently no satisfactory evaluation tools to assess physical neglect for children under 12. Second, teacher assessments could have missed information about behavioral problems compared to parent’s evaluation; this may be due to the fact that physically neglected or left-behind students may not fully engage with teachers, or the fact that teachers have many students to monitor. However, we thought it was difficult to reliably assess parents because of parent-child separation; also, high rates of illiteracy among rural intergenerational individuals would make assessing guardians challenging. Moreover, children’s self-assessment of behavior would be less effective. We would like to have multiple assessments on BP in the future studies. Third, as a cross-sectional study, our results can only prove correlations; causal relationships between being leftbehind, physically neglect, and behavioral problems will require further follow-up studies. Last, our hypothesis and design mainly focused on physical neglect and being left behind; we did not examine all the factors that may influence on BP. Hence, regression analysis was not performed. However, we can include multiple factors and perform regression analysis to analyze the factors that influence behavioral problems in future studies. 5. Conclusion In conclusion, LBC exhibit more BP compared to NLBC. Serious PN may result in more severe conduct problems than those caused by the left-behind phenomenon alone. The single factor of staying behind may lead to inattention. Double victimization of PN and staying behind may lead to more obvious BP. Therefore, it is important to recognize the overlap of different types of exposures in LBC and understand the effect of cumulative stressors on BP. Funding This work was supported by the National Natural Science Foundation of China (81601169, 81471365), the Beijing Municipal Administration of Hospital Youth Program (QML20161901), and Neuroscience research program of the Beijing science and technology plan (Z161100002616017) for the design and collection of the study. This work was supported by the Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (ZYLX201807, XLMX201807), and Capital’s Funds for Health Improvement and Research (2018-2-2123) for the analysis, and interpretation of data and in writing the manuscript. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.chiabu.2018. 11.007. References Bentall, R. 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Childhood adversities increase the risk of psychosis: A metaanalysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, 38(4), 661–671. https://doi.org/10.1093/schbul/sbs050. Viola, T. W., Tractenberg, S. G., Pezzi, J. C., Kristensen, C. H., & Grassioliveira, R. (2013). Childhood physical neglect associated with executive functions impairments in crack cocaine-dependent women. Drug & Alcohol Dependence, 132(1–2), 271–276. Wang, L., Yang, L., Yu, L., Song, M., Zhao, X., Gao, Y., ... Wang, X. (2016). Childhood physical neglect promotes development of mild cognitive impairment in old age – A case-control study. Psychiatry Research, 242(4), 13–18.
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Child Abuse & Neglect journal homepage: www.elsevier.com/locate/chiabuneg
Research article
The effect of left-behind phenomenon and physical neglect on behavioral problems of children
T
Yu-Jie Wena, Xian-Bin Lia, Xi-Xi Zhaoa, Xue-Qi Wanga, Wen-Peng Houa, Qi-Jing Boa, ⁎ Wei Zhengb, Christine Paoc, Tony Tand, Chuan-Yue Wanga, a The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders & Beijing Institute for Brain Disorders Center of Schizophrenia, Beijing Anding Hospital, Capital Medical University, Beijing, 100088, China b The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China c Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA d Department of Educational and Psychological Studies, College of Education, University of South Florida, Tampa, USA
A R T IC LE I N F O
ABS TRA CT
Keywords: Left-behind children Behavioral problem Physical neglect
Objective: Left-behind children have a high incidence of behavioral problems in some Eastern countries, especially China. We sought to assess the combined effects of physical neglect, a major embodiment of the left-behind phenomenon, and the trauma of being left behind on subsequent behavioral problems. Method: 776 children (including 600 left-behind children) aged 12–16 years were chosen by cluster sampling in rural China. The Childhood Trauma Questionnaire-Short Form and the Conners Teacher Rating Scale were used to evaluate physical neglect and behavioral problems. Results: Left-behind children experienced more physical neglect (mean difference = 0.63; 95%CI 0.15–1.10; P = 0.01) and were more inattentive (mean difference=0.11; 95%CI 0.03–0.19; P = 0.009) than non-left-behind children. Physically neglected left-behind children had higher scores for conduct problems, inattention, and hyperactivity index than non-left-behind without physical neglect group (P < 0.05 for each). Among left-behind children, physical neglect group had significantly more conduct problems than those of controls (mean difference=0.14; 95%CI 0.05–0.23; P = 0.008). Physically neglected non-left-behind children had higher scores for conduct problems than those of left-behind children without physical neglect (mean difference=0.31; 95%CI 0.13–0.47; P = 0.003). Among physically neglected children, left-behind children had significantly higher scores for inattention than those of non-left-behind children (mean difference=0.13; 95%CI 0.04–0.22; P = 0.037). Conclusion: Left-behind children have more behavioral problems than non-left-behind children. Physical neglect may result in more severe conduct problems than those associated with staying behind, and staying behind may lead to inattention. Exposure to both may lead to more obvious behavioral problems. Therefore, we should accord more attention to physically neglected and left-behind children.
⁎ Corresponding author at: Beijing Anding Hospital, Capital Medical University, No. 5 Ankang Lane, Dewai Avenue, Xicheng District, Beijing, 100088, China. E-mail address: [email protected] (C.-Y. Wang).
https://doi.org/10.1016/j.chiabu.2018.11.007 Received 6 August 2018; Received in revised form 4 November 2018; Accepted 12 November 2018 0145-2134/ © 2018 Elsevier Ltd. All rights reserved.
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1. Introduction Since China’s Reform and Opening-up in 1978, the unprecedented and uneven economic growth in China has created a major income disparity between rural and urban residents over the past three decades. As a result, large numbers of rural residents migrate to economically prosperous cities to work each year. In most cases, the nature of work in the city, financial constraints, and movement restrictions placed on rural household registration make it nearly impossible for migrant workers to bring their children to cities where they have found employment; consequently, children are left to remain in their rural hometowns (Chan, 2010; Luo et al., 2008). According to a 2014 Chinese national survey, 22% of children (about 61 million) were left at home by their migrant parents (National-Women’s-Federation-of-children’s-Work-Department, 2014). These left-behind children (LBC), known as liu-shou-er-tong in China, stay at their original residence for at least six months while one or both of their parents migrate to other locations to work (Duan & Zhou, 2005; Fan, Su, Gill, & Birmaher, 2010). Generally, the children are left in the care of extended family members such as grandparents, uncles/aunts, or even on their own. According to a survey study (Dai & Chu, 2016), 74% of left-behind children lived with their grandparents, 12.8% lived with their uncles/aunts, and 13.2% were left to take care of themselves. The guardians are often unable to fulfill all of the parenting responsibilities (Hu, Lonne, & Burton, 2014; Yoon, 2005) because they have to do more farm work after the main laborers of the family left to work in the cities, and therefore, often lack the time to adequately care for the left-behind children. While it is not the intention of the migrant parents, their absence, by definition, creates a form of child neglect (Chen & Chan, 2016; Feldman, Case, & Sparks, 1992). Existing literature has shown that lack of care and supervision increases left-behind children’s risk for poor nutrition, accidents, and injuries (Luo et al., 2008). For left-behind children in rural China, physical neglect (PN), defined as a failure of caregivers to provide necessities like food, clothing, and shelter, is the most prevalent and characteristic type of childhood trauma (Gu et al., 2011; Li, Zhong, Pan, Zhong, & Sun, 2014; Pan, 2015; Zhang et al., 2017; Zhong et al., 2015, 2012). Left-behind children may suffer more than one type of childhood victimization, including the trauma of being “left-behind” and its common consequence of physical neglect; this results in subsequent developmental issues (Hildyard & Wolfe, 2002; Millett, Kohl, Jonson-Reid, Drake, & Petra, 2013). Although it is evident that early victimization increases susceptibility to psychiatric disorders in later life, the mechanism is still unclear. Some studies suggest that exposure to specific types of victimization may lead to certain psychiatric symptoms. For example, separation of children from parents is associated with a paranoid state, while neglect is more closely associated with depression (Bentall, Wickham, Shevlin, & Varese, 2012; Kennedy, Tripodi, & Pettus-Davis, 2013; Sitko, Bentall, Shevlin, O’Sullivan, & Sellwood, 2014). However, a dose-effect relationship between accumulative multi-victimization and mental symptoms has been proposed by some researchers (Edwards, Holden, Felitti, & Anda, 2003; Varese et al., 2012). Nonetheless, a definitive link between multi-victimization and mental illness is yet to be demonstrated (Varese et al., 2012). Few studies have determined the relationship between physical neglect and behavioral problems (BP) among left-behind children. The relationship between specific types of behavioral problems and multi-victimization has not been elucidated. Several studies have shown that left-behind children frequently exhibit a propensity for violent, anti-social, and aggressive behaviors (Chen, Sun, Chen, & Chan, 2017). However, there is conflicting research on left-behind children’s attention and hyperactivity. Some studies have suggested that these problems are related to psychological experiences such as parent-child separation and have a prominent impact on the children’s mental illnesses (Zhao et al., 2014). However, findings are not consistent (Cheng et al., 2010; Jiang, 2013). We believe this is the first study to assess the combined effects of physical neglect and the trauma of being left behind on behavioral problems among Chinese children. The hypotheses were: (1) left-behind children would have more behavioral problems than non-left-behind children (NLBC), (2) the incidence of physical neglect in left-behind children would be higher than non-leftbehind children, there might be multi-victimization in left-behind children, and (3) the combined effect of physical neglect and leftbehind phenomenon would be related to behavioral problems. 2. Methods 2.1. Participants Children aged 12–16 were selected as a group from 24 classes in three grades as the unit from a junior high school in Dayang Town, Bozhou, Anhui, China in February and March 2017. In sampling the participants, five classes from each grade were randomly selected for status survey. All subjects provided informed consent to participate, which was approved by the Institutional Review Board, Beijing Anding Hospital, Capital Medical University, Beijing, China. Inclusion criteria for left-behind children were: (1) age 12–16 years; (2) parent(s) working in another location for at least six months per year (currently or previously); and (3) parent or guardian signed informed consent. Exclusion criteria included: (1) history of neuropsychiatric issues; and (2) parents are divorced. 2.2. Demographic data The students were provided basic information (e.g., name, sex, age, migrant parent(s), duration of separation, guardian(s), monthly family income). There were no missing data for basic information. 2.3. Main variables The Childhood Trauma Questionnaire-Short Form and the Conners Teacher Rating Scale were used to evaluate physical neglect 145
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and behavioral problems. Less than 2.6% data for CTRS were missing and corrected using the linear difference method (Linsay, 1991). 2.3.1. Conners Teacher Rating Scale (CTRS) CTRS (Fan & Du, 2016) is a widely-used assessment tool for teachers’ perceptions of students’ behavior. Reponses to the 28-item scale are rated on a four-point scale ranging from 0 to 3 (from 0=not at all true to 3=very much true). Sample items from the four subscales include “sassy” (conduct problems); “daydream” (inattention); “excitable, impulsive” (hyperactivity); and “short attention span” (hyperactivity index). We calculated the Z score for each subscale by taking the total subscale score and dividing it by the item numbers of the subscale. If the Z score of hyperactivity index was over 1.5, children are likely to have attention deficit hyperactivity disorder (ADHD). We used the Chinese version of CTRS, which has satisfactory validity and reliability (Cronbach’s α coefficient: 0.9455) (Su, Li, Huang, Luo, & Zhang, 2001). 2.3.2. Childhood Trauma Questionnaire-Short Form (CTQ-SF) CTQ-SF (Bernstein, Fink, & Bernstein, 1998) is a self-assessment tool to evaluate childhood trauma prior to the age of 17 years. The Chinese version of CTQ-SF has good validity and reliability (Cronbach’s α coefficient: 0.77) (Zhao, Zhang, Li, & Zhou, 2005). There are five types of trauma, namely emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. This questionnaire contains five items for measuring physical neglect, such as “I didn’t have enough to eat” and “I knew that there was someone to take care of me and protect me.” Respondents rated responses on a five-point scale ranging from “never true" to "very often true". The following criteria was used to assess total physical neglect score: none = 5–7, low = 8–9, moderate = 10–12, severe = 13+ (Liao, Deng, & Pan, 2007). The severe cutoff method can improve the identification specificity of physical neglect to 93% for adolescents (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997). In the current study, we categorized children who scored≥13 as physically neglected. 2.4. Statistical analysis SPSS version 20.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. First, χ2 test and independent samples t-test were used to compare sex and age distribution. Second, participants were divided into four groups, namely left-behind children with physical neglect, non-left-behind children with physical neglect, left-behind children without physical neglect, and non-left-behind children without physical neglect. Third, the mixed-design analysis of variance was conducted using 2 (LBC/PN) ×4 (conduct problem/hyperactivity/inattention/hyperactivity index). Independent samples test was also applied to compare the behavioral problems and trauma of children. Last, multivariate analysis of variance (MANOVA) was adopted through 4 (four groups) × 4 (conduct problem/hyperactivity/inattention/hyperactivity index) for the cross comparison between physical neglect and behavioral problems, and the statistical results were examined by two-tailed test. P < 0.05 was considered statistically significant. Bonferroni correction was used to correct multiple comparisons in the results. 3. Results 3.1. Sample characteristics Cluster sampling resulted in a sample of 885 children aged 12–16 years. However, 109 were excluded, including 68 whose guardians did not sign informed consent, 11 with a history of neuropsychiatric problems, and 30 whose parents had divorced. In total, 776 junior high school students (LBC n = 600, NLBC n = 176) were included in the analysis (Tables 1 and 2). Table 1 Demographic characteristics of study subjects. Characteristic
LBC n = 600
NLBC n = 176
χ2 (t), P
Gender (male) Age (years) Family incomea < 1000 1000–5000 5000–10,000 10,000–20,000 > 20,000
308 (51.3) 14.46 ± 1.20
100 (56.8) 14.42 ± 1.12
85 (14.2) 440 (73.3) 60 (10) 12 (2) 3 (0.5)
45 (25.6) 116 (65.9) 11 (6.3) 2 (1.1) 2 (1.1)
1.642, 0.229 0.439, 0.661 15.116, 0.004** – – – – –
Data presented as frequency (percentage) or mean ± standard deviation. Note. LBC=left-behind children; NLBC = non-left-behind children. a Measurement = yuan/month. ** P < 0.01. 146
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Table 2 Demographic characteristics of left-behind children. Factors
Total (%)
Migrate parent(s) Father Mother Father and mother
87(14.5) 13(2.2) 500(83.3)
Age at separation < 0.5 0.5–3 3–6 >6
a
9 (1.5) 108(18.0) 161(26.8) 230(38.3)
Duration of separation in Years <3 3–6 >6
a
147 (24.5) 123(20.5) 320(53.3)
Guardian Father Mother Grandparent Uncle/Aunt Older brother or sister
81(13.5) 9(1.5) 495(82.5) 10(1.7) 5(0.8)
Note. ameasurement = year.
3.2. Comparison of BP between LBC and NLBC We found that LBC scored significantly higher on inattention than NLBC (mean difference = 0.11; 95%CI 0.03–0.19; P = 0.009). Also, LBC suffered more serious PN than NLBC (mean difference=0.63; 95%CI 0.15–1.10; P = 0.01) (Table 3).
3.3. Comparison of BP between the four groups On comparing the BP of children in the four groups based on physical neglect and left-behind status, significant differences in conduct problems [F (3,772) = 7.697, P < 0.001], hyperactivity [F (3,772) = 3.347, P = 0.019], inattention [F (3,772) = 4.107, P = 0.007], and hyperactivity index [F (3,772) = 4.242, P = 0.006] were discovered. The effect of other types of childhood trauma on BP were insignificant (Appendix 1). Among the four groups, the LBC with PN group and NLBC without PN group showed significant differences in conduct problems, inattention, and hyperactivity index (P < 0.05 for each). The LBC without PN group did not show a significantly higher level of conduct problems as compared to that in the NLBC without PN group (mean difference=0.14; 95%CI 0.05–0.23; P = 0.008); however, the NLBC with PN group showed even more serious conduct problems than those in group LBC without PN (mean difference=0.31; 95%CI 0.13–0.47; P = 0.003). Besides, there were significant differences between NLBC without PN group and NLBC Table 3 Comparison of behavioral problems and trauma between LBC and NLBC. Behavioral problems & childhood trauma
LBC n = 600
NLBC n = 176
TRS Conduct problem Hyperactivity Inattention Hyperactivity index
0.574 0.605 0.813 0.879
CTQ Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect
6.911 ± 2.189 6.248 ± 2.185 5.688 ± 1.801 12.328 ± 4.050 10.629 ± 2.710
± ± ± ±
0.473 0.469 0.4940 0.593
0.569 0.592 0.705 0.814
± ± ± ±
T, P
0.503 0.521 0.447 0.580
6.793 ± 2.420 6.403 ± 2.291 5.813 ± 1.748 12.486 ± 4.914 10.017 ± 2.868
0.132, 0.321, 2.608, 1.272,
0.895 0.748 0.009# 0.204
0.615, 0.819, 0.810, 0.390, 2.593,
0.539 0.413 0.418 0.697 0.010*
Data presented as mean ± standard deviation. Note. TRS = Conner’s Teacher Rating Scale; CTQ = Childhood Trauma Questionnaire; LBC = left-behind children; NLBC = non-left-behind children. * P < 0.05. # P < 0.01. 147
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Fig. 1. Comparison of behavioral problems between four groups. Note. LBC = left-behind children; NLBC = non-left-behind children; PN = physical neglect. * P < 0.05, #P < 0.01. After Bonferroni correction.
with PN group, and between the LBC without PN and LBC with PN groups with respect to conduct problems. The inattention score in LBC without PN group was significantly higher than that in NLBC without PN group (mean difference=0.13; 95%CI 0.04–0.22; P = 0.037); however, no significant difference was observed between NLBC with PN and NLBC without PN, or between LBC with PN group and LBC without PN group in this respect (Fig. 1).
4. Discussion Although the left-behind phenomenon rarely occurs in western countries, it is a prevalent issue in rural China. Left-behind children represent an unintended consequence of rural parents’ effort to improve their family's financial situation; unable to bring their children with them to their new places of work, these migrant parents must leave their children to the care of others. A deeper understanding of the experiences of left-behind children can improve our insight into the role of parental absence in youth development. While there is existing literature studying the individual effects of physical neglect and the trauma of being left behind, our study is the first to evaluate the combined effects of this dual-victimization on resulting behavioral problems. In this study, we compared the behavioral differences between LBC and NLBC in rural China, and evaluated the effect of PN from staying behind on resulting BP. We also evaluated the effect of a single exposure and accumulation of dual-victimization. Our results suggest that the differences between LBC and NLBC mainly pertain to inattention. Multi-victimization may be involved in developing more obvious BP, while serious PN may result in more significant conduct problems, and the single factor of staying behind may lead to inattention. Like previous studies (Zhang et al., 2011; Zhao, Li, Wen, Hou, & Wang, 2017), our study showed that LBC exhibit more inattention problems as compared to NLBC. However, the results might be due to effect of multiple exposure factors of “left-behind” phenomenon on behavioral problems. It is noteworthy that we first observed that the single factor of staying behind may lead to inattention. The mechanism of being “left-behind” impacting attention remains unclear. It is reported that the unhealthy personality traits, inattention, and academic disability of LBC showed a strong correlation with their incomplete family environment (Fan & Sang, 2005). Research on ADHD showed that early life stress can impair dopamine function and cause attention deficits (Johansen, Sagvolden, Aase, & Russell, 2005). Attention has a significant influence on education of adolescents. LBC were shown to have poor academic performance and they were also unable to concentrate on listening to lectures and finish their homework on time (Ye, Wang, Zhang, & Lu, 2006). Inconsistent of most previous studies but two researchers, our studies found no significant difference on conduct problems between the left-behind and non-left-behind groups. Graham and Jordan (2011) conducted research on LBC in Southeast Asia, and found that LBC showed more conduct problems in Thailand, but not in the Philippines. Huang, Wu, Du, Liu, and Huang (2010) did not find a higher prevalence of conduct problems among LBC in Hunan province in China. These inconsistencies might be largely attributable to differences in social and cultural factors such as the specific region’s history of migration, support of government, economical and education levels, and cultural norms (Deater-Deckard & Dodge, 1997; Graham & Jordan, 2011). Our findings suggest that serious PN may result in more severe conduct problems than ordinary staying behind in LBC. Like previous studies conducted in rural China (Chang et al., 2017; Liu et al., 2012; Zhao et al., 2017, 2014; Zhong et al., 2015, 2012), we also observed that a higher proportion of LBC suffer from serious PN than NLBC. Improper guardianship may be a potential cause of higher PN among LBC as they are usually raised by grandparents or other relatives (Jia & Tian, 2010). Researchers have found that caregivers with lower education levels and unhealthy lifestyles were more likely to have substantiated PN (Carter & Myers, 2007; Hussey, Chang, & Kotch, 2006; Kaplan, Pelcovitz, & Labruna, 1999). Children exposed to physical neglect tend to be undernourished, experience poor peer relationships and difficulties in psychological adaptation, and exhibit social withdrawal and poor language skills (Moreno-Manso et al., 2017; Norman et al., 2012). All these factors will have a negative impact on their neuropsychological development in adulthood (Viola, Tractenberg, Pezzi, Kristensen, & Grassioliveira, 2013; Wang et al., 2016). Researchers have found that the ill effects of physical neglect on social aggression, violence, and substance use were not limited to children in poor families, but were mediated by the children’s experiences with peer rejection (Carter & Myers, 2007; Chapple, Tyler, & Bersani, 2005; Kaplan et al., 1999). 148
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Among the LBC and the NLBC, the conduct problems were more prominent in the severe PN groups, while inattention was more prominent in the LBC. Dual-victimization did not show any remarkably higher effect than that of a single exposure on inattention, which suggests that different types of trauma may have different effects on BP. This observation is consistent with previous findings stating that the type of exposure has a specific influence on the mental and psychological effects (Schreier & Chen, 2013). We also observed that exposure to both left-behind phenomenon and PN led to more severe conduct problems, inattention, and hyperactivity compared with a single factor which is consistent with the findings of Bentall (Bentall et al., 2012) pertaining to psychosocial symptoms; they showed that this kind of aggravation exhibits a dose-response relation. A meta-analysis also revealed that exposure to an adversity increases the risk of exposure to another adversity (Varese et al., 2012). The parent-child separation inculcates unhealthy attachment relationships of LBC, which is aggravated by PN; the combined effect influences the stress response. Attachment insecurity is associated with hyperactivity (Johnston & Mash, 2001). In addition, studies have shown a significant association between hyperactivity and child maltreatment (Ouyang, Fang, Mercy, Perou, & Grosse, 2008). A similar association has not been found between PN and hyperactivity yet. Our research supports the dual effects of trauma on behavior problems. Multi-victimization may have a higher impact and result in more obvious BP. Our results showed that no effects of other types of trauma on BP. That might be because the sample size of LBC suffered abuse in this study were too small to get reliable statistical results. And CTRS might be insensitive or lacking to measure actual behavioral problems (e.g. anxiety, depression) caused by emotional neglect. 4.1. Limitations The current study has several limitations. First, we only assessed children older than 12 years old; this is because CTQ-SF is restricted to children over 12 years and there are currently no satisfactory evaluation tools to assess physical neglect for children under 12. Second, teacher assessments could have missed information about behavioral problems compared to parent’s evaluation; this may be due to the fact that physically neglected or left-behind students may not fully engage with teachers, or the fact that teachers have many students to monitor. However, we thought it was difficult to reliably assess parents because of parent-child separation; also, high rates of illiteracy among rural intergenerational individuals would make assessing guardians challenging. Moreover, children’s self-assessment of behavior would be less effective. We would like to have multiple assessments on BP in the future studies. Third, as a cross-sectional study, our results can only prove correlations; causal relationships between being leftbehind, physically neglect, and behavioral problems will require further follow-up studies. Last, our hypothesis and design mainly focused on physical neglect and being left behind; we did not examine all the factors that may influence on BP. Hence, regression analysis was not performed. However, we can include multiple factors and perform regression analysis to analyze the factors that influence behavioral problems in future studies. 5. Conclusion In conclusion, LBC exhibit more BP compared to NLBC. Serious PN may result in more severe conduct problems than those caused by the left-behind phenomenon alone. The single factor of staying behind may lead to inattention. Double victimization of PN and staying behind may lead to more obvious BP. 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