The impact of Adverse Childhood Experiences on social determinants among Saudi adults.

Background: Early exposure to violence has deleterious effect on the child's brain development. The aims for this project were to assess the prevalence of Adverse Childhood Experiences (ACEs) and their impact on social determinants in Saudi Arabia (SA). Methods: A cross-sectional, national study conducted in all regions of SA using the World Health Organization-ACE-International Questionnaire to determine the association between ACEs and socioeconomic outcomes. Results: A total of 10 156 participants completed the questionnaire with five main ACE categories (abuse, neglect, family dysfunction, peer and community violence). Over half of the sample (52%) experienced emotional abuse, followed by physical abuse (42%), bullying (39%), neglect (29%) and sexual abuse (21%). The most common family dysfunction was witnessing domestic violence against any household member (57%) and the least prevalent was living with a substance abuser (9%). Low educational attainment, disruption in marital life and substance abuse were significantly affected by all ACE categories. However, unemployment was marginally affected only by neglect and household dysfunction. Conclusions: ACEs are highly prevalent in SA and have significant negative impact on life opportunities. National preventive programs should be implemented to reduce ACE and their deleterious outcomes.

Prevalence of Sexual Abuse Among Secondary School Students in Saudi Arabia.

Child sexual abuse (CSA) is a public health problem that has been found to be linked to negative health outcomes. Data on CSA in Saudi Arabia are limited, and there are many gaps in research in this field. The aim of this study is to examine the prevalence of sexual abuse among children in Saudi Arabia. A cross-sectional, national survey (N = 16,010) utilizing International Society for Prevention of Child Abuse and Neglect Child Abuse Screening Tool Children's Version was conducted at secondary high schools in Saudi Arabia. Participant's mean age was 16.8 ± 0.9 years, and 50.8% were boys. Sixteen percent of the participants reported exposure to any type of CSA during their lives. Boys and those who lived with step-parent were more likely to be sexually abused compared to those who didn't (p < .05). Ordinary least squares regression analysis revealed that gender was the predictor significantly associated with CSA. Evidence-based prevention programs targeting mainly the high-risk groups should be implemented.

Professionals' Attitude Toward Reporting Child Sexual Abuse in Saudi Arabia.

Child sexual abuse (CSA) requires specialized knowledge and training that includes forensic interview skills. The aim of this study was to determine variations in professionals' attitudes toward CSA by measuring three aspects of forensic attitudes (sensitivity, specificity, and skepticism) and evaluating disagreements concerning the assessment of CSA cases in Saudi Arabia. A cross-sectional, web-based study, in which the Child Forensic Attitude Scale was used to measure professionals' attitudes, was conducted. Professionals who dealt with suspected cases of CSA as part of their jobs or were in professions that necessitated involvement with such cases, were selected as participants. Of 327 participants, 53% were aged ≤40 years, and 54% were men. In addition, 24% were doctors/nurses, 20% were therapists/psychiatrists, 24% were social workers, 17% were educators, 9% were law enforcement professionals, and 5% were medical examiners. Attitude subscale scores differed significantly according to participants' sex, specialty, and training. Women, healthcare professionals, and those who had participated in more than five training courses were more concerned about the underreporting of abuse (high sensitivity) relative to other professionals. In comparison, men, medical examiners, law enforcement officers, and undertrained professionals tended to underreport suspected sexual abuse cases (high specificity). High specificity in attitudes toward suspected cases of CSA could affect professionals' judgment and contribute to low reporting rates. Certain strategies, including increasing self-awareness of personal bias, specific CSA recognition courses, and team approaches to case assessment and management, should be implemented to control the influence of subjective factors.

Gender-based disparities in the impact of adverse childhood experiences on adult health: findings from a national study in the Kingdom of Saudi Arabia.

BACKGROUND: Adverse Childhood Experiences (ACEs) have been linked to an increased risk of health and social problems throughout life. Studies on gender differences from developing countries are scarce. In this paper, we will examine gender variations in the types of reported ACEs and gender-specific relationships between cumulative ACEs and physical and mental health, and Risky Health Behaviors (RHB) in adulthood in the Kingdom of Saudi Arabia (KSA). METHODS: A cross sectional national study was conducted in all of the 13 regions in KSA in 2013 using the ACE- International Questionnaire (ACE-IQ). We used multivariate logistic regression to examine the relationship between 4 + ACEs and physical, mental health and RHBs for both men and women separately after adjusting for age, education, marital status and current employment. RESULTS: The total number of participants was 10,156 and women comprised 48% of the sample. The majority of respondents (80%) reported at least one ACE. Women had higher percentages of < =2 ACEs (65% vs 55%; p <0.05) while men were more likely to have 4+ ACEs (33% vs 25%; p < 0.05). When compared to participants with 0 ACE, men who reported 4+ ACEs were associated with the highest likelihood of using drugs (OR = 9.7; 95% CI: 6.4-14.5) and drinking alcohol (OR = 9.2; 95% CI: 6.3-13.6). On the other hand, women who experienced 4+ ACEs were associated with the highest likelihood of depression (OR = 7.0; 95% CI: 5.2-9.4), anxiety (OR = 6.4; 95% CI: 5.0-8.2) and other mental illnesses (OR = 7.4; 95% CI: 5.2-10.6). As for chronic diseases, abused men and women in childhood showed similarly a twofold increased risk of developing diabetes, hypertension, coronary heart disease and obesity when compared to non-abused participants. CONCLUSION: Findings highlight the need to consider gender specific differences in the development of preventive strategies to address ACEs in KSA.

International issues in abusive head trauma.

In the decades since Dr. John Caffey described a series of children with chronic subdural hematoma and long bone fractures, there has been a substantial increase in the medical recognition of various forms child abuse. In the United States, the term shaken baby syndrome was coined to explain a constellation of injuries assumed to be the result of violent shaking of infants. After improved understanding of the variety of mechanisms that occur when children are abused, abusive head trauma (AHT) has become the recommended terminology. AHT is a more comprehensive term that reflects the brain injuries that children suffer as the result of abuse. AHT continues to include shaking as a mechanism of injury as well as shaking with impact, impact alone, crushing injuries or combinations of several mechanisms. The medical community in the United States has led the way in developing new terminology and research to describe this unique and devastating form of abuse. The globalization of medicine and rapid information transfer has resulted in AHT becoming well-recognized internationally as a form of serious and fatal child abuse. This paper will review the historical basis in the United States for the diagnosis of AHT. We will also review some of the current international issue in epidemiology, diagnosis, legal processes and outcomes in selected countries/regions where child abuse physicians are actively involved in the evaluation of AHT.

Measuring Nurses' and Physicians' Attitudes and Perceptions of the Appropriate Interventions towards Intimate Partner Violence in Saudi Arabia.

Background: Intimate partner violence (IPV) is considered the most common form of violence against women worldwide, concerning public health, safety, and human rights. However, little to no studies in Saudi Arabia have explored the attitude and perception of health care providers working in emergency departments toward IPV. This study aimed to measure the attitude and perception of Emergency Room (ER) health care providers towards the appropriate intervention for IPV. Methods: This is a cross-sectional quantitative study. Data was collected from a convenient sample of nurses (n = 88) and physicians (n = 18) working in ER, using Readiness to Manage Intimate Partner Violence Survey (PREMIS). Data was collected from two hospitals in Riyadh, Saudi Arabia, and descriptive analysis was used to analyze the data. Results: The majority of the respondents were aged 18−40 (n = 106, 78%), while 22% were 41−60 years old, 69% were female, and 31% were male. Eighty-five percent were nurses and 15% were physicians. The majority of the respondents did not have any training on IPV and had gained knowledge or skills mostly during their medical/nursing classroom and clinical training. The analysis revealed that the participants had moderate levels of overall preparedness, knowledge about IPV, and perceived knowledge, with a mean score of 2.30, 18.62, and 2.18, respectively. The respondents had low scores in practice issues in new diagnosis (0.91), current screening (1.69), and actions when IPV is identified (0.91). The perceived preparedness and knowledge have a significant positive correlation, as shown by an r value of 0.8476 and a p-value of <0.05. Conclusion: The study shows that participants stated minimal previous IPV knowledge and training. It is necessary to put in place adequate resources and specific training programs to overcome this issue for both ER nurses and physicians.

Domestic Violence Against Married Women During the COVID-19 Quarantine in Saudi Arabia.

Background  Before the coronavirus disease 2019 (COVID-19) pandemic, cases of domestic abuse and aggressive behaviour between Saudi married couples were increasing annually, a topic of growing concern both socially and medically. With the forced indoor confinement enacted as a containment measure, international studies regarding domestic abuse indicated an almost unanimous increase in prevalence. This cross-sectional national study aimed to assess the change between the pre-and intra-pandemic prevalence of abuse in Saudi Arabia.  Material and methods  Anonymous data were gathered using a web-based Arabic version of the World Health Organization (WHO) multi-country instrument measuring violence against women residing in Saudi Arabia. The previously validated questionnaire included a series of multiple-choice questions related to demographic information, family infrastructure, experienced situations of abuse, and the severity and form of abuse during the quarantine period, from March 23, 2020, to June 21, 2020. Associations were tested using a two-tailed Pearson's Chi-square test and odds ratios. A binary multivariate logistic regression was used to identify the independent factors associated with domestic violence.  Results  In total, 2254 participants were included in the present study. The majority (n=2129, 94.7%) were Saudi nationals. The highest proportion (n=1022, 45.3%) was in the 30 to 40 years age group. The self-reported prevalence of domestic violence before COVID-19 pandemic and quarantine was 25.4% and 16.6% during the confinement, indicating an overall decrease of 8.8% in the reported cases. Regarding the type of violence, of the 315 (16.6%) women who endured violence since the confinement, the majority (n=301, 95.6%) experienced multiple forms of violent abuse, 264 (87.7%) suffered from psychological/emotional violence, 114 (37.9%) from physical violence, and 50 (16.6%) from sexual violence. Of the group who experienced multiple forms of violence, 120 (39.9%) reported an increase in the frequency and perceived intensity of the violence since the confinement. The only variable that directly increased the likelihood of suffering domestic violence had more than three children [OR = 1.59, P = 0.018]. Conclusions  Contrary to trends observed in other countries, the national prevalence of abusive conduct towards married women showed a marked decrease during the quarantine period-more children directly correlated with a higher reported frequency of being abused. Further studies in neighbouring countries with comparable societies and structures must be conducted to assess the validity of our findings in the context of the global trends of violence in the marital home.

Epidemiology of Abusive Head Trauma Among Children in Saudi Arabia.

BACKGROUND AND OBJECTIVES: To examine abusive head trauma (AHT) trends using data obtained from hospital-based child protection centers (CPCs) and the distribution of age in months among young children in Saudi Arabia. METHODS: A retrospective study was conducted that includes data obtained from 58 hospital-based CPCs in all 13 regions of Saudi Arabia registered in the National Family Safety Registry from 2010 to 2020. AHT cases (n=106) were identified for inclusion in the registry by a daily review of the emergency department logbooks. RESULTS: Over the 11-year period, there was a sharp increase in the number of cases, specifically after 2014, from seven cases per year in 2010 to 16 cases in 2020. AHT affects predominantly children aged 0-12 months (72.6%), followed by 13-24 months (17.9%), 25-36 months (3.8%), 37-48 months (3.8%), and 49-60 months (1.9%). Victims were characterized by a predominance of crying infants (23.6%), past history of abuse (13.2%), a child's chronic disease and disability (7.6%), and prematurity (2.8%). CONCLUSION: Different training and educational programs need to be performed to raise awareness of AHT. Enacting the pediatrician's mandatory reporting law will improve the rate of reporting cases.

Child maltreatment prevention readiness in Bahrain.

BACKGROUND AND OBJECTIVES: Child maltreatment (CM) is a major public health problem worldwide. Despite the well-documented cases of all forms of CM and the improvement of the national response to CM in Bahrain, efforts on the prevention of CM are still limited. The objective of this study was to assess the readiness to implement a national evidence-based CM prevention (CMP) program in Bahrain. METHODS: The cross-sectional study was conducted with 45 key informants who had influence and decision-making power over CMP. RESULTS: The overall score indicated low to moderate readiness. The key informants scored the highest on legislation, mandates, and policies (7.9), which was followed by the knowledge of CM prevention (7.2), institutional resources and links (5.2), and informal social resources (noninstitutional) (5.2). However, the lowest scores were the human and technical resources (1.2), attitudes toward CM prevention (3.3), will to address the problem, and material resources (3.8), current programs implementation and evaluation, and scientific data on CM prevention (4.5). CONCLUSION: This research has identified strengths and gaps in the country that needs to be addressed to develop programs that are responsive to the needs of the community. The development of a comprehensive well-resourced CMP program requires the collaborative efforts of legislators, political leaders, and professionals.

Readiness assessment for implementation of a large scale child maltreatment prevention program in Qatar.

BACKGROUND AND OBJECTIVES: Child maltreatment is a worldwide problem, with lifelong consequences for the survivors. The focus is shifting from Child Maltreatment Protection to Child Maltreatment Prevention. The objective of this descriptive study was to assess readiness for child maltreatment among stakeholders before implementation of large-scale prevention programs in Qatar. METHODS: The study involved structured interviews with 45 representatives of various stakeholders in sectors of national and local entities of Qatar. A survey was conducted among these stakeholders, to explore their perception and level of awareness of child maltreatment in Qatar. All of them responded, with a response rate of 100%. A multidimensional tool, developed by WHO and collaborators from several middle and low-income countries, was used to assess ten dimensions of readiness. RESULTS: Child maltreatment prevention readiness in Qatar is low with a total score of 37.8 on a scale of 0-100. The respondents scored high (≥ 5) in knowledge of child maltreatment (5.3), legislation, mandates and policies (6.8) and informal social resources (non-institutional) (5.6). Participants, however, scored low (≤ 5) in their knowledge about current program implementation and evaluation (1.1), human and technical resources (1.7), institutional resources and links (2.3), material resources (2.8), scientific data on child maltreatment prevention (3.1), attitude towards child maltreatment prevention (4.3) and will to address the problem (4.8). CONCLUSION: Child maltreatment prevention readiness in Qatar is low and requires improvement in some of the areas. It highlighted the need for capacity building among organizations across Qatar for a large scale CMP program to be successfully implemented.

Child mortality in Saudi Arabia: Time for action at all levels.

BACKGROUND AND OBJECTIVES: Although child mortality is declining in Saudi Arabia, new trends and causes are emerging. The objective of the study is to determine the causes of child death in a tertiary care hospital in Saudi Arabia and to identify its preventable causes and associated risk factors. METHODS: A modified UNICEF Multiple Indicator Cluster Survey (MICS) was used to analyze all deaths among children under the age of 18 which occurred at the King Abdullah Specialized Children's Hospital (KASCH) between 2010 and 2016. RESULTS: After reviewing all the death charts of 1138 children, the team determined that 15% (172) of all deaths could have been prevented and the preventability increased with age. Only 2% of the neonates died of preventable causes, while 53% of the children of 6 years of age or older died of preventable causes. The highest percentage of preventable deaths occurred in children aged 13-18 years (39.3%), followed by the age group of 6-12 years (32.4%) and the age group of 29 days to 5 years (13.9%). All 966 (85%) deaths from biological causes were considered to be unpreventable. Among the preventable causes, 142 (82.5%) had injuries and 30 (17.4%) were sudden unexpected infant death (SUID) with no documented autopsy or death scene investigation, and thus it was considered preventable by the researchers. The 5 major causes of deaths secondary to injuries were motor vehicle accidents (MVA) accounting for 86 deaths (60.6%), followed by drowning accounting for 19 deaths (13.4%), child maltreatment accounting for 13 deaths (9.2%), fire and weapon accounting for 12 deaths (8.5%), and finally home accident (fall, poisoning, suffocation) accounting for 12 deaths (8.5%). CONCLUSION: The State Child Death Reviews Board should thoroughly investigate deaths due to SUID and injuries by identifying the factors that contribute to the implementation of preventive strategies.

Examining the Relationship Between Witnessing Intimate Partner Violence and Victimization Among Children in Saudi Arabia.

Childhood exposure to violence can lead to physical, mental, and emotional harm, whether a child is a direct victim or a witness to violent events. The aim of this study is to examine the relationship between witnessing intimate partner violence (IPV) and victimization among children. A cross-sectional, national study was conducted in secondary high schools in the five main provinces of Saudi Arabia (SA) using International Society for Prevention of Child Abuse and Neglect (ISPCAN) ISPCAN Child Abuse and Neglect Screening Tool-Child: Home version. Boys and girls, public and private schools were selected to participate. Students (N = 16,939) aged 15 to 18 years completed the survey instrument which included demographics, different types of abuse (physical, psychological, and sexual), neglect, and witnessing IPV. Mean age of the participants was 16.8 ± 0.9 years, and 51% were boys. Eighty-one percent lived with both parents, 6% with single parent, and 2% with step-parent. Fifty-two percent of the participants witnessed IPV. Those who witnessed IPV were more likely to be abused compared with those who did not (p < .01). Among those who witnessed physical IPV, girls had a significantly greater likelihood of experiencing psychological abuse (odds ratio [OR] = 3.7, confidence interval [CI] = [1.9, 6.8]), physical abuse (OR = 1.3, CI = [1.0, 1.6]), and neglect (OR = 1.6, CI = [1.4, 1.9]) but less likelihood of experiencing sexual abuse (OR = 0.6, CI = [0.5, 0.7]) than boys. Among those who witnessed psychological IPV, girls had a significantly greater likelihood of experiencing neglect (OR = 1.3, CI = [1.2, 1.5]) but less likelihood of experiencing sexual abuse (OR = 0.5, CI = [0.5, 0.6]) than boys. Boys who witnessed physical IPV and psychological IPV had a significantly greater likelihood of experiencing sexual abuse compared with girls. Witnessing IPV increases the chances of child and adolescent victimization. Multidisciplinary approaches involving social workers, law enforcement personnel, and domestic violence and child protection workers could effectively respond to this problem.

Child Maltreatment Prevention Readiness Assessment in Oman.

OBJECTIVES: This study aimed to evaluate Oman's readiness for implementing large-scale child maltreatment prevention (CMP) programmes. METHODS: This cross-sectional study was conducted between May and August 2016 in Oman. Participants, referred to as key informants, were individuals with influence and decision-making powers over CMP. The multidimensional Readiness Assessment for the Prevention of Child Maltreatment tool, developed by the World Health Organization with the help of collaborators from middle- and low-income countries, was used to assess 10 dimensions of readiness, each with a maximum score of 10. RESULTS: A total of 49 participants were included in this study (response rate = 98%). The mean total score for the 10 dimensions was 50.17 out of 100 possible points. The participants showed high mean readiness scores on legislation, mandates and policies (9.08) followed by knowledge of CMP (7.55), institutional resources and links (6.12), willingness to address the problem (5.35), informal social resources (5.15) and current programme implementation and evaluation (5.10). Participants had low scores in readiness in association with human and technical resources (2.44), attitudes towards CMP (2.90), scientific data on CMP (3.06) and material resources (3.46). CONCLUSION: The results of this study indicate that Oman has a moderate level of readiness to implement large-scale evidence-based prevention programmes against child maltreatment; however, several dimensions still need to be strengthened. It is important to develop a national strategy that outlines a framework for organising and prioritising efforts towards CMP.

Understanding the needs of the Kingdom of Saudi Arabia: Child maltreatment prevention program development.

BACKGROUND: Global efforts are being made to combat child maltreatment (CM); however, in 2011 the Kingdom of Saudi Arabia's (KSA) response to this issue was found to be mediocre. Several developments have been implemented in KSA since then, and reevaluation is now necessary. OBJECTIVE: To assess the CM-prevention readiness (CMPR) of KSA in regard to implementing large-scale, evidence-based CM-prevention programs. PARTICIPANTS AND SETTING: Key informants based in KSA who were decision makers and senior managers in the CM field; face-to-face interviews were conducted in the participants' offices. METHODS: This was a cross-sectional study. We used the multi-dimensional tool "Readiness Assessment for the Prevention of Child Maltreatment - short version," which examines 10 dimensions concerning this topic. Comparison between the results of this study and those of the 2011 examination was performed to determine how the situation in KSA has changed. RESULTS: Sixty informants were interviewed; the majority being females (57%) and from governmental institutions (56%). The average total score for the 10 dimensions was 47.4%, an increase from the 43.7% reported in 2011. The strongest dimensions were legislations and mandates (8.3/10), followed by knowledge (7.1/10) and institutional links and resources (5.8/10). The lowest scores concerned human and technical resources (1.7/10) and attitude towards CM (2.8/10). Compared to the 2011 results, some dimensions showed significant improvements, but the majority had remained consistent. CONCLUSIONS: Time and commitment are necessary to secure CMPR improvement. Periodic assessment of CMPR is required to provide proper recommendations to the government regarding the progress of CM-prevention strategies.

Child maltreatment prevention readiness in Gulf Cooperation Council (GCC) countries.

BACKGROUND AND OBJECTIVES: Child maltreatment (CM) is a global public health problem that has received growing attention over the past five decades. There have been many recent advances in child maltreatment prevention (CMP). The objective of this study is to assess CMP readiness to implement large-scale evidence-based CMP programs in Gulf Cooperation Council (GCC) countries. METHODS: This cross-sectional study (n = 244) was conducted in the GCC countries. Participants were key decision makers and senior managers in the field of CM. The Readiness Assessment for the Prevention of Child Maltreatment (RAP-CM) was used to assess 10 dimensions of CMP readiness. RESULTS: The key informants gave CMP readiness scores of 47.8 out of 100. Four of the dimensions (knowledge of CMP; legislation, mandates, and policies; institutional resources and links; and informal social resources) had high readiness scores (≥5), while six dimensions (attitudes towards CMP; scientific data on CMP; current program implementation and evaluation; will to address the problem; material resources; and human and technical resources) had low readiness scores (<5). CONCLUSION: GCC countries have moderate-to-fair readiness to implement large-scale evidence-based CMP programs. Strengthening their material, human, and technical resources, and improving the quality of scientific data, collaboration, and attitudes towards CMP are required to improve each country's readiness.

Child maltreatment prevention strategies: Saudi youth perspectives.

BACKGROUND AND OBJECTIVES: Child maltreatment (CM) is a global problem that has long-term negative outcomes. The objective of this study is to explore the knowledge and perceptions of youth regarding CM prevention. METHODS: The study was conducted in Saudi Arabia using International Child Abuse Screening Tool (ICAST). Answers to open-ended questions were analyzed and a list of CM prevention strategies was generated. RESULTS: Participants identified a range of preventive strategies that were grouped into three main themes: 1) collective preventive efforts; 2) recognizing and responding to CM; 3) gaining closure. For each overarching theme, a list of subthemes were derived. Subthemes included raising awareness through the mass media; school professionals' capacity building and curriculum advancement; strengthening family relationships; enact CM preventive legislations and policies; monitoring media content and video games and limiting access to firearms for the first theme. The second theme comprised the subthemes reporting services and protective services. As for the third theme it included rehabilitation; punishment for CM crimes and connection to spirituality. CONCLUSION: Gathering youth perspectives on CM prevention will help us in designing future prevention strategies.

Relationship between childhood bullying and addictive and anti-social behaviors among adults in Saudi Arabia: a cross-sectional national study.

Background Bullying is a widespread public health problem among youth with potentially far reaching negative implications. Objective To determine the prevalence of childhood bullying and its association with addictive and anti-social behaviors among adults. Subjects Adults (n = 10,156) aged ≥18 years were invited to participate. Methods A cross-sectional, national study utilizing Adverse Childhood Experiences International Questionnaire (ACE-IQ) was conducted in Saudi Arabia (SA). Odds ratios (OR) and 95% confidence intervals (CIs) were calculated for bullying in relation to the outcome. Results Participant's mean age was 34.3 ± 11.3 years and 52% were male. Thirty-nine percent of the participants reported being bullied. Significant gender differences were found in terms of prevalence of different types of bullying. Men reported higher prevalence of physical (40% vs. 33%, p < 0.01) and sexual (19% vs. 10%, p < 0.01) types of bullying. In contrast, women tend to report higher prevalence of psychological (16% vs. 9%, p < 0.01) and social (14% vs. 10%, p < 0.01) types of bullying. Bullying victims were 1.8 (95% CI 1.6-2.1) times more likely to smoke, 2.3 (95% CI 1.9-2.7) times more likely to drink alcohol, 2.9 (95% CI 2.4-3.4) times more likely to use drugs, 2.1 (95% CI 1.8-2.4) times more likely to have ever had out of wedlock sexual relations, and 2.5 (95% CI 2.1-3.0) times more likely to have suicidal thoughts compared to those who were not bullied. Conclusion Childhood bullying increases the chances of risky behaviors among adults in SA. Prevention of bullying should be in the national agenda of the Ministry of Education.

Bullying in early adolescence: An exploratory study in Saudi Arabia.

BACKGROUND AND OBJECTIVES: This study aimed to gain a deeper understanding of bullying among intermediate school students in Saudi Arabia to inform preventive measures. MATERIALS AND METHODS: Qualitative methods were applied. The study was conducted at four intermediate schools. Students, parents, and school professionals participated, and data were collected through observations, interviews, and focus groups. Emergent themes and subthemes were identified through coding. RESULTS: A total of 91 individuals participated: 40 students, 31 school professionals, and 20 parents/caregivers. Three main themes and multiple subthemes were identified: 1) types of bullying, 2) factors encouraging bullying, and 3) the impact of bullying. The lack of safe environments, recreational facilities, and inconsistencies in addressing problematic behaviors were subthemes that were found to be conducive to bullying, whereas dislike of school, racism, aggressiveness, and social isolation were emergent subthemes that were reflective of the potential impact of bullying. With this process, a model for bullying practices is described. CONCLUSION: A better understanding of the bullying experiences among adolescents has been obtained. Preventive measures need to target the factors that the participants identified as conducive to bullying.

Adverse childhood experiences and association with health, mental health, and risky behavior in the kingdom of Saudi Arabia.

BACKGROUND: The aim of this study is to determine if ACEs impact the health and risk behavior burden among Kingdom of Saudi Arabia (KSA) adults. METHODS: In 2013, a cross-sectional study was conducted across KSA to identify the retrospective prevalence of ACEs and their association with high risk behaviors and chronic diseases. Surveys from 10,156 adults in all 13 Saudi regions were obtained using an Arabic version of the WHO ACE-IQ (KSA ACE-IQ). RESULTS: Compared to respondents reporting no ACEs, even just one ACE contributed significantly to the odds of experiencing diabetes mellitus (OR=1.3), depression (OR=1.32), or anxiety (OR=1.79) outcomes. Two ACEs were necessary for statistically significant, higher odds to emerge for hypertension (OR=1.46), mental illness (OR=1.93), smoking (OR=1.17), alcohol use (OR=1.75), and drug use (OR=1.45). Respondents who reported four or more ACEs had greater odds of coronary heart disease (OR=1.94), and obesity (OR=2.25). Compared to those reporting no ACEs, respondents reporting four or more ACEs had over four times the odds of Alcohol or Drug Use, Mental Illness, Depression, and/or Anxiety outcomes and more than twice the odds of diabetes, hypertension, obesity, and/or smoking outcomes. CONCLUSION: Findings from this analysis underscore the potential benefit of providing focused preventative approaches to mitigating ACEs in KSA in relation to both the specific and cumulative burden of health and risky behavior outcomes.

Non-suicidal self-strangulation among adolescents in Saudi Arabia: Case series of the choking game.

Adolescence is known to be a time of exploration and initiation of risky behaviors. Much attention has been given to risk behaviors such as smoking, violence, and sexual promiscuity; other serious behaviors such as self-strangulation or the choking game, which is carried out by adolescents in response to peer pressures or to gain a transient sense of euphoria, have received little attention, with the available literature coming from the developed world. This is the first report of cases of non-suicidal self-strangulation from the Arab World. In this case series, we report 5 cases of non-suicidal self-strangulation that presented to the Emergency Department of a tertiary care hospital in Riyadh, Saudi Arabia during 2010-2012. All of the 5 cases were young male adolescents aged 10-13 years. This activity resulted in the death of 2 boys; one boy sustained hypoxic ischemic insult to the brain with clinical deficits; and the remaining 2 were fortunate to be discharged home in healthy condition. None of the cases had underlying mental health problems, and multidisciplinary involvement ruled out suicide and homicide activities. Non-suicidal self-strangulation is a fatal behavior that adolescents engage in. Increased efforts are needed to address this serious and preventable public health issue. Awareness and education of adolescents and their parents is crucial. Awareness of healthcare providers is also necessary in order to avoid misdiagnosis of such cases.