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Download date:27 Sep 2021 Child abuse & neglect in Suriname

Inger Willemijne van der Kooij

CHILD ABUSE & NEGLECT IN SURINAME

INGER WILLEMIJNE VAN DER KOOIJ The research described in this dissertation was financially supported by: Stichting Blaka Rosoe Stichting Maan Stichting Tot Steun Stichting Weeshuis der Doopsgezinden

Cover design I.W. van der Kooij Layout Renate Siebes | Proefschrift.nu Printed by Proefschriftmaken.nl ISBN 978-94-90791-57-5

© 2017 I.W. van der Kooij All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage or retrieval system, without permission in writing from the author. CHILD ABUSE & NEGLECT IN SURINAME

ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. dr. ir. K.I.J. Maex ten overstaan van een door het College voor Promoties ingestelde commissie, in het openbaar te verdedigen in de Agnietenkapel op woensdag 6 september 2017, te 10.00 uur door

Inger Willemijne van der Kooij geboren te Heerenveen PROMOTIECOMMISSIE

Promotores: Prof. dr. R.J.L. Lindauer AMC – Universiteit van Amsterdam Prof. dr. T.L.G. Graafsma Anton de Kom Universiteit, Suriname

Copromotor: Dr. S. Bipat AMC – Universiteit van Amsterdam

Overige leden: Prof. mr. J.E. Doek Vrije Universiteit Amsterdam Prof. dr. G.J. Overbeek Universiteit van Amsterdam Prof. dr. N.W. Slot Vrije Universiteit Amsterdam Prof. dr. G.J.J.M. Stams Universiteit van Amsterdam Prof. dr. E.M.W.J. Utens Universiteit van Amsterdam

Faculteit: Geneeskunde THE STARFISH POEM

Once upon a time there was a wise man who used to go to the ocean to do his writing. He had a habit of walking on the beach before he began his work. One day he was walking along the shore. As he looked down the beach, he saw a human fi gure moving like a dancer. He smiled to himself to think of someone who would dance to the day. So he began to walk faster to catch up. As he got closer, he saw that it was a young man and the young man wasn’t dancing, but instead he was reaching down to the shore, picking up something and very gently throwing it into the ocean. As he got closer he called out, “Good morning! What are you doing?” The young man paused, looked up and replied, “Throwing starfi sh in the ocean.” “I guess I should have asked, why are you throwing starfi sh in the ocean?” “The sun is up and the tide is going out. And if I don't throw them in they’ll die.” “But, young man, don’t you realize that there are miles and miles of beach and starfi sh all along it. You can’t possibly make a difference!” The young man listened politely. Then bent down, picked up another starfi sh and threw it into the sea, past the breaking waves and said, “It made a difference for that one.”

Anonymous

TABLE OF CONTENTS

Chapter 1 Introduction 9

Chapter 2 A national study on the prevalence of child abuse and neglect 23 in Suriname

Chapter 3 Child sexual abuse in Suriname 45

Chapter 4 Perceptions of corporal punishment among Creole and 67 Maroon professionals and community members in Suriname

Chapter 5 Perceptions of adolescents and caregivers of corporal 87 punishment: a qualitative study among Indo Caribbean in Suriname

Chapter 6 Implementation and evaluation of a parenting program to 117 prevent child maltreatment in Suriname

Chapter 7 Use of a screening tool for posttraumatic stress disorder in 143 children in Suriname

Chapter 8 Summary & general discussion 157

Chapter 9 Samenvatting 176 List of co-authors 183 Contributors’ statement 184 PhD portfolio 186 Dankwoord 188

1

Introduction My earliest memory of my mum’s temper is from when I was a toddler and she was throwing books down the stairs at my dad. I was so young at the time that I thought it was a game. When my dad moved out, when I was 5 or 6, her aggression turned on me. Over the years, my mum kicked and beat me, throttled me, threw me down the stairs and pushed me into a scalding hot bath. She once held my head under water and another time she shoved a full bar of soap in my mouth. There are too many incidents to recount. Even though she could be really nasty, she could be loving too. I didn’t misbehave and it was always something petty that would trigger her violent outbursts. It would usually start with her yelling and swearing and I would normally try to go to my room to escape her but she would follow me in and overpower me. I’d get thrown against a wall and she would hit and kick me. My neighbours must 10 have heard the raised voices all the time, but no-one complained or did anything about it. It wasn’t until I was around 12 that I started to realise that it wasn’t normal and that other people’s parents didn’t hit them like this. Over the next few years I got stronger and started to fight back so it would happen less regularly. I still find it difficult to trust people and I have flashbacks, especially if I see something on TV which triggers a memory. I find everyday things, like walking down a street, difficult as I worry that making eye contact with someone will cause them to be physically violent towards me. For a long time, I accepted what was going on at home as normal. But no child should have to live in fear or on edge in their own home – that’s the place they should feel safest.

Letter from Orlando, 17 years The aim of this thesis is to provide scientific knowledge on the current situation of child abuse and neglect in Suriname. It provides information on the (year) prevalence of child abuse and neglect in Suriname, with particular attention to sexual abuse of children. It also gives insight into perceptions of the use and function of corporal punishment among young people and parents/caregivers from different ethnic backgrounds. Furthermore, it pays attention to the prevention of child abuse through the implementation and evaluation of a parenting program. Finally, a tool that screens for posttraumatic stress disorder – one of the possible negative outcomes of child abuse – is examined in order to identify children at risk in an early stage after a (potential) traumatic event.

CHILDREN’S RIGHTS

The United Nations decided that children needed special protection under the Universal Declaration of Human Rights and worked for many years to develop the Convention on the Rights of the Child (CRC). Adopted by the United Nations in 1989, the CRC covers Chapter 1 the basic human rights belonging to all children, ratified in Suriname in 1999. They include the right to survival, to develop to the fullest, to protection from harm, abuse, and exploitation and to participate fully in family, cultural and social life. The CRC’s four key principles are: no discriminating against children, acting in the child’s best interests, 11 respecting children’s rights to survival and development, and respecting the views of Introduction the child (Committee on the Rights of the Child, 2016; UNICEF, 2016). Children are characterized by their vulnerability – because still in development – and dependency of others (Perry, 2005). Legislative measures force adults to respect the rights of children, as the Lancet recently described: “law: an underused tool to improve health and wellbeing for all” (The Lancet, 2017). The CRC implements a view in which children and adults are both seen as citizens with individual rights (Lyle, 2014) and emphasizes that children are human beings fully worthy of moral and intellectual respect (UNICEF, 2016).

CHILD MALTREATMENT

Child maltreatment, sometimes also referred to as child abuse and neglect, is defined by the World Health Organization as: “all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that result in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power” (World Health Organization, 2017). Child maltreatment is the abuse and neglect that occurs to children under 18 years of age. It includes all types of physical and/or emotional ill-treatment, sexual abuse, neglect, negligence and commercial or other exploitation, which results in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power. Exposure to intimate partner violence is also sometimes included as a form of child maltreatment (World Health Organization, 2017). In this thesis, the definition of the World Health Organization will be used.

SURINAME AND THE CARIBBEAN

Suriname is an upper middle-income country and member of the Caribbean Community (CARICOM). With an area just under 64,000 sq. mi, it is the smallest sovereign state in South America. To the north, Suriname’s coastline is adjacent to the Atlantic Ocean. The country shares borders with Guyana to the west, French Guiana to the east, and Brazil to the south. Suriname is an independent republic since 1975. Like other Caribbean countries, it has a history of slavery (exploitation) and colonization. Slavery by the Dutch was abolished in 1863, but Suriname remained a colony until its full autonomy. Despite its relatively small population (around 585,000 inhabitants), Suriname is characterized by a high cultural and linguistic diversity. Its multi-ethnic population consists of people of African, Indo, Javanese, and mixed-ethnic ancestry. There are also smaller numbers 12 of individuals of the original inhabitants of Suriname known as Indian, and inhabitants of European, Chinese, and Brazilian origin (Sobhie, De Abreu-Kisoensingh, & Dekkers, 2016). The majority of the population is settled on the coastal plain. The official language is Dutch, but Sranan Tongo is the widely spoken lingua franca (World Factbook, 2017). Since its commitment to the implementation of the CRC in 1993, the Government of the Republic of Suriname has planned, executed, and evaluated programmes to set and improve the basic conditions for its implementation. In 2016, however, the United Nations Committee on the Rights of the Child (UNCRC) expressed in her ‘Concluding Observations’ on the implementation of the combined third and fourth periodic reports of Suriname a serious concern about child abuse and neglect in Suriname, the lack of shelters for child victims and information on investigations of cases of child abuse and neglect. The Committee urged the State party to ensure the development of appropriate legislation, policies, and services for prevention and recovery (Committee on the Rights of the Child, 2016).

PREVALENCE

Worldwide, child maltreatment is recognized as a significant public health concern (Finkelhor, Turner, Shattuck, & Hamby, 2013; Vachon, Krueger, Rogosch, & Cicchetti, 2015). However, there is no consensus among researchers on the extent of the problem and whether nationally or globally rates of maltreatment are increasing or declining (Finkelhor, Shattuck, Turner, & Hamby, 2014; Gilbert et al., 2012). It is acknowledged that prevalence rates of child maltreatment recorded by child protection services are lower than the prevalence in the general population, because many cases are not identified, reported, nor given a service response (Munro, 2011). The extent of the gap between the recorded and/or reported cases and levels of prevalence in the general child population, however, is hard to assess. Child maltreatment is hard to talk about and developmental factors will influence the extent to which abuse or neglect is recognized and named as such by the victim. Furthermore, child maltreatment often occurs in private settings where both disclosure and detection are difficult (Radford, 2013). Furthermore, data describing the general prevalence of child maltreatment are unavailable in many low- and middle-income countries, where malnutrition and infection are considered the major pediatric problems. According to UNICEF, more than 80% of the Surinamese children between the ages 2 and 14 reported to have experienced violent physical disciplines Chapter 1 in the month prior to the interview (UNICEF, 2010). Suriname is no exception in the Caribbean region: a cross-national regional study involving 34 countries found that a majority of mothers in Jamaica, Belize, Trinidad and Tobago and Guyana uses corporal punishment on children between 2 and 12 years of age (Cappa & Kahn, 2011). 13 Introduction RISK AND PROTECTIVE FACTORS

It can be assumed that risk factors for child maltreatment occur across multiple developmental domains or levels of a person’s social ecology (Bronfenbrenner, 1988). Factors found to have an increased risk for child maltreatment include individual characteristics related to the parents (e.g., substance abuse, mental health, relatively low levels of education, and early parenting) and child (e.g., disability, lower or retarded mental development), family circumstances (e.g., family structure, parenting skills, and intimate partner violence), and contextual factors (e.g., (stress of) poverty, neighborhoods, and poor social network; Coulton, Crampton, Irwin, Spilsbury, & Korbin, 2007; Gilbert et al., 2009; MacKenzie, Kotch, & Lee, 2011; Sedlak et al., 2010). Situation-bound risk factors, such as poverty, inadequate housing, single-parent families, substance abuse problems, and lower levels of education are more common in low- and middle-income countries (LMICs; Bernal & Saez-Santiago, 2006), such as Suriname. Furthermore, societies, communities, and families differ in their views on the acceptability of the use of violence in conflict resolution and in helping children conform to the wishes of parents. Sometimes religious motives (‘save the rod and spoil the child’) are used in rationalizing these practices. In many communities it was, and often still is, accepted that husbands use physical and psychological violence towards their spouses, as well as towards their children. Violence towards children appears to be common in Suriname. Its prevalence may be the result of both cultural and socio- economic factors. In the Caribbean, harsh and authoritarian types of discipline have often been described as commonplace child- rearing strategies; ‘beatings’ (with a hand, belt or instrument) are, in fact, defended as essential tools of the responsible parent. Caribbean parents often expect obedience, compliance, and respectful behavior from their children toward adults, even when such behavior is unrealistic in terms of age and circumstance (Williams, Brown, & Roopnarine, 2006). Intergenerational transmission of child maltreatment has been found as a risk factor for child maltreatment as well (Heyman & Slep, 2002; Pears & Capaldi, 2001). However, this might be a debatable matter since a recent study showed that the extent of intergenerational transmission of child maltreatment is a complex phenomenon that depends largely on the methodology used (Widom, Czaja, & DuMont, 2015). There is growing scientific evidence that substantiates the role of supportive family environment and social networks as protective factors for child maltreatment (Schelbe & Geiger, 2017).

CONSEQUENCES 14 For over 50 years, clinicians have described the effects of child maltreatment on the physical, psychological, cognitive, and behavioural development of children (Kempe, Silverman, Steele, Droegemuller, & Silver, 1962; Kempe, Silverman, Steele, Droegemuller, & Silver, 2013). While some stress in life is normal - and even necessary for development - the type of stress that results when a child experiences maltreatment may become toxic when there is strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the protection of a supportive, adult relationship. The biological response to this toxic stress can be incredibly destructive and last a lifetime by inducing a toxic stress response leading to permanent changes of the brain (Shonkoff & Garner, 2012). Child maltreatment is associated with mental health problems, decreased physical health, lower education and employment, and increased aggression and crime rates (Gilbert et al., 2009). Rates of fatal child maltreatment are more than twice as high in low- and middle-income countries (World Health Organization, 2013). The Adverse Childhood Experiences (ACE) study, one of the largest investigations of childhood abuse and neglect and later-life health and well being, showed a strong relationship between maltreatment and household dysfunction during childhood and the leading causes of death in adulthood (Felitti et al., 1998). Beyond the health and social consequences of child maltreatment it has an economic impact on healthcare costs (Brown, 2014). Not all children, however, experience negative outcomes as a consequence of maltreatment (Tlapek et al., 2017). The ability to cope, and even thrive, following a negative experience is often referred to as ‘resilience’. Stable family environment and supportive relationships appear to be consistently linked with resilience following childhood maltreatment (Afifi & MacMillan, 2011; Shulman, 2016).

PREVENTION

Increasing numbers of organizations are working at an international level on the topics of child maltreatment (Butchart, Harvey, Mian, & Fürniss, 2006; News Centre, U.N., 2013). Many of the recent international organizations and funders in the field have a priority of supporting low- and middle-income (LMIC) countries. There is growing evidence that maltreatment is more severe in LMIC environments, particularly given findings that maltreatment thrives under conditions of social disorganization and dislocation (Finkelhor & Lannen, 2015). Four types of universal and selective interventions to prevent Chapter 1 actual child maltreatment are promising, i.e. home visiting, parent education, abusive head trauma prevention, and multi-component interventions (Mikton & Butchart, 2009). There are, however, many challenges to mobilizing child maltreatment activity in LMIC environments. One challenge is that most of the visible programs and accumulated 15 experience have been developed in high resource environments (Wessells et al., 2012). Introduction These do not necessarily correspond to rearing goals and values in developing and non-western cultures, or with longstanding local styles of parenting (Baumrind, 1971; Berry, 2016; Roe, 2012). Therefore, one of the key issues to consider when implementing a parenting program in non-western or developing countries is the modification of the program to fit the local cultural situation (Baumann et al., 2015; Mejia, Calam, & Sanders, 2012). Not adapting a program to the local context, education goals and language is likely to compromise both engagement and outcomes (Lau, 2006). Socialization practices may be different from those in Western and – in terms of the Human Development Index (United Nations Development Programme, 2011) – more developed countries. This certainly poses a challenge to the development of parenting programs in Suriname: the region consists of many cultural groups and ethnicities that speak many different languages. Besides, many LMICs lack fundamental capacities for doing work in the field of child maltreatment because other kinds of programming (e.g., improving education and combatting malnutrition and infections) may get priority given limited resources. LMICs may be environments with high social change pay-offs, but may also entail much higher costs and likelihood of failure (Wessells et al., 2012). Furthermore, research on the effectiveness of parenting programs in LMICs is limited (Knerr, Gardner, & Cluver, 2013). Parenting programs are available in Suriname, but conducted on a small scale. Thus far no evidence-based programs have been implemented, adapted and evaluated. At this moment, the government in Suriname is involved in developing strategies addressing child maltreatment, within the framework of a multidisciplinary child mental health approach, targeting all violence against children (UNICEF, 2010).

AIM AND STRUCTURE OF THE THESIS

The aim of this thesis is to provide scientific knowledge on the current situation of child abuse and neglect in Suriname. In this regard, we establish the lifetime and year prevalence of child abuse and neglect in Suriname, with a focus on child sexual abuse. Furthermore, the thesis aims to gain deeper insight in community perceptions of the prevalence of corporal punishment in Suriname, responses to and feelings about its use as a discipline strategy and perspectives of the rationales for and against corporal punishment, and views on banning it. It also focuses on the prevention of child maltreatment by implementing and evaluating a parenting program. Finally, a tool that screens for posttraumatic stress disorder – one of the possible negative outcomes of child abuse – is examined in order to identify children at risk in an early stage after a 16 (potential) traumatic event.

GENERAL OUTLINE

Chapter 2 presents the lifetime and year prevalence rates of child abuse and neglect in Suriname, based on a national representative study among 1,391 adolescents and young adults.

Chapter 3 presents the lifetime and year prevalence rates of child sexual abuse in Suriname, and gains deeper insight in these prevalence rates.

Chapter 4 describes a qualitative study that reflects perspectives of corporal punishment of community members as well as professionals of Creole and Maroon background in Suriname.

Chapter 5 describes a qualitative study that reflects perspectives of corporal punishment among adolescents and caretakers of Indo Caribbean background in Suriname.

Chapter 6 presents the results of the implementation and evaluation of a parenting program called ‘Lobi Mi Pikin’ to reduce corporal punishment and prevent child maltreatment in Suriname. Chapter 7 evaluates the reliability and validity of the Children’s Revised Impact of Event Scale – 13 (CRIES-13) in Suriname, a brief self-report measure designed to screen children for posttraumatic stress disorder.

Chapter 8 summarizes all previous chapters and discusses the findings in the context of recent literature. The chapter ends with the conclusions of the thesis.

Chapter 9 provides a summary and conclusion in Dutch, as well as a list of co-authors, contributors’ statement, a PhD portfolio, and acknowledgements. Chapter 1

17 Introduction REFERENCES

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21 Introduction 22 2

A national study on the prevalence of child abuse and neglect in Suriname

Inger W. van der Kooij Josta Nieuwendam Shandra Bipat Frits Boer Ramón J.L. Lindauer Tobi L.G. Graafsma

Child Abuse & Neglect 47 (2015) 153-161 ABSTRACT

The prevalence of child maltreatment in Suriname has never been subjected to a reliable assessment. The only data available include rough estimates of a range of internationally comparable indicators extrapolated from child protection and police corps statistics for offenses against children. This study aimed to provide a reliable estimate of the prevalence of all forms of child maltreatment in Suriname. One thousand three hundred and ninety-one (1,391) adolescents and young adults of different ethnicities completed a questionnaire about child maltreatment. The study sample, obtained by random probability sampling, consisted of students (ages 12 through 22) from five districts in Suriname. A significant proportion of Surinamese children experienced maltreatment. In total, 86.8% of adolescents and 95.8% of young adults reported having been exposed to at least one form of child maltreatment during their lives. Among the adolescents, 57.1% were exposed to child maltreatment in the past year. When the definition of the National Incidence Study was applied, 58.2% of adolescents and 68.8% of young adults had been exposed to at least one form of maltreatment. Among adolescents, 36.8% reported having experienced at least one form of maltreatment in the past year. The results indicate the (extremely) high lifetime and year prevalence of child maltreatment in Suriname. The serious and often lifelong consequences of such maltreatment indicate 24 that a national approach to child abuse and neglect, including the development of a national strategic plan, a national surveillance system and changes to the state’s programmatic and policy response, is urgently needed. INTRODUCTION

Child maltreatment is a global public health concern because of its severe, lasting physical and mental health effects, which often persist into adulthood (Anda et al., 2006; Felitti, Anda, & Nordenberg, 1998; Gilbert et al., 2009; Mills et al., 2013). It is estimated that approximately 40 million children worldwide under the age of 15 are subjected to child maltreatment each year and that 25–50 percent of all children have been physically abused (World Health Organization, 2001).

Although child abuse and neglect occurs in families of all income levels, a dispro- portionately high number of reported cases of abuse occur in lower income families (Sedlak & Broadhurst, 1996). Unfortunately, data describing the general prevalence of child maltreatment are unavailable in many low- and middle-income countries, where malnutrition and infection are considered major pediatric problems (Stoltenborgh, Van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). This is the case in Suriname, a developing country in northern South America with an estimated population of Chapter 2 530,000. More than half of Suriname’s population lives in the capital city of Paramaribo. In Suriname, 70% of all households live below the poverty line. Approximately 21.5% of the Surinamese population between ages 15 and 24 is unemployed, and approximately 6% of the population is illiterate. The number of highly educated people in Suriname 25 is low (IndexMundi, 2014). Estimates indicate that 34% of children who enter primary Prevalence of child abuse and neglect in Suriname school do not pass any exam (Ministry of Education and Development, 2005). Suriname has no mandatory child maltreatment reporting system or standard protocol response to suspected maltreatment.

Despite the lack of reliable prevalence data in this country, interest in child abuse and neglect is increasing (Doek & Graafsma, 2012). Currently, rough estimates of the prevalence of child maltreatment in Suriname are derived from a range of internationally comparable indicators of child protection (Multiple Indicator Cluster Survey (MICS); UNICEF; MICS-3, 2006; MICS-4, 2010) and police corps statistics on offenses against children. In the MICS-4 (2010) survey, respondents to household questionnaires were asked a series of questions assessing how adults tended to discipline children during the month preceding the survey. The results showed that 86% of children between the ages of 2 and 14 were subjected to at least one form of violent psychological or physical punishment by parents, other caregivers or family members, with 60% being subjected to any physical punishment and 12% being subjected to severe punishment. 2010 police corps statistics showed that 240 children (there are approximately 40,000 10–18-year-olds in Paramaribo; General Bureau Statistics, Suriname, 2014) in Paramaribo were the victims of at least two forms of child maltreatment, i.e., physical and sexual abuse. Another systematic survey has been conducted on the prevalence of child abuse in Nickerie (Van den Berg, Visser, Lamers-Winkelman, & Graafsma, 2009), a district in northwestern Suriname with approximately 34,000 inhabitants (General Bureau Statistics, Suriname, 2012). Data were gathered using 345 questionnaires, which were completed by children and young people under the age of 19. The results indicated a year prevalence of 37.4% and a lifetime prevalence of 61.2% (Van den Berg et al., 2009). Lifetime prevalence rates indicate the number of individuals who have been maltreated at some point in their lives; year prevalence refers to all cases of child maltreatment during the past year.

This research presents the results of a national self-report study undertaken to assess the year prevalence and lifetime prevalence of maltreatment (physical, sexual, and emotional) and neglect in Suriname. The first purpose of the study was to provide more precise information about the lifetime prevalence and year prevalence of child maltreatment by surveying a large-scale nationally representative sample in Suriname. The second purpose was to compare our data with the sentinel data (reports from professionals) of the National Incidence Study – 4 (NIS-4; Sedlak et al., 2010) and the Netherlands’ Prevalence Study on Maltreatment of Children and Youth (Euser et al., 2013). Based on previous results, we expected high rates of both lifetime prevalence and year prevalence 26 of child maltreatment. To the best of our knowledge, this study is the first to specifically produce a valid measurement of the lifetime prevalence and year prevalence of child maltreatment in Suriname.

METHODS

Studied area

The study was conducted in five areas of Suriname: Paramaribo, Nickerie, Sipaliwini, Marowijne and Brokopondo. These five areas are located throughout the country and are therefore geographically and culturally representative. Furthermore, Paramaribo and Nickerie are urban areas, while Brokopondo, Marowijne and Sipaliwini are rural. Suriname, officially known as the Republic of Suriname, is situated on the northeastern Atlantic coast of South America. It is bordered by French Guyana to the east, Guyana to the west, and Brazil to the south. First explored by the Spaniards in the 16th century and later settled by the English in the mid-17th century, Suriname was colonized by the Dutch in 1667. When slavery was abolished in 1863, workers were brought in from India and Java. Suriname’s independence from the Netherlands was granted in 1975. With an area just under 64,000 sq. mi, Suriname is the smallest sovereign state in South America. Currently, approximately seven ethnicities are represented in Suriname, all of which have their own cultural characteristics. The official language is Dutch, but Sranan Tongo is a widely spoken lingua franca (World Factbook, 2014).

Participants

The participants were 1,391 secondary and vocational education students in Suriname, of which 1,120 were adolescents (12–17 years old, boys: 42.9%; M = 15.04 years, SD = 1.42) and 246 were young adults (18–22 years old, boys: 43.5%, M = 18.53 years, SD = 0.91). The age data were missing for 25 of the children. These children were excluded from the analyses. Data collection was conducted in July 2013 (Paramaribo, Marowijne and Brokopondo) and February 2014 (Sipaliwini). Data from the study conducted earlier (Nickerie) was collected during June and July 2008. The demographic characteristics of the total sample are summarized in Table 2.1. Chapter 2 Table 2.1 Demographics of the participants

Adolescents Young adults Missing age N = 1,120 N = 246 N = 25 n %n %n %27 a

Gender (n/boys) 480 42.9 107 43.5 13 59.1 Prevalence of child abuse and neglect in Suriname

Ethnicity Afro Surinamese 336 30.0 123 50.0 13 52.0 Javanese 113 10.1 12 4.9 1 4.0 Indo Caribbean 280 25.0 21 8.5 2 8.0 Mix 280 25.0 56 22.8 4 16.0 Other 104 9.3 34 13.8 - - Missing 7 0.6b - - 5 20.0

Education Lower vocational education 192 17.1 59 24.0 8 32.0 Extensive primary education 879 78.5 115 46.7 17 68.0 General secondary education 20 1.8 35 14.2 - - Pre-university education 29 2.6 37 15.0 - -

District Paramaribo 543 48.1 107 43.5 13 52.0 Brokopondo 87 7.8 24 9.8 2 8.0 Marowijne 90 8.0 65 26.4 6 24.0 Nickerie 303 27.1 35 14.2 2 8.0 Sipaliwini 97 8.7 15 6.1 2 8.0 a Missing gender, N = 2. b Missing ethnicity, N = 4. Instrument

Child maltreatment A 57-item self-report questionnaire (Euser et al., 2013; Lamers-Winkelman, Slot, Bijl, & Vijlbrief, 2007) was used to assess exposure to a broad range of maltreatment experiences. The questionnaire consisted of 31 items assessing five forms of abuse: (1) sexual abuse within and outside the family (7 items); (2) physical abuse within the family (8 items); (3) parental psychological aggression (1 item); (4) experienced conflicts between parents (7 items); and (5) neglect (8 items). These items were derived from the Dating Violence Questionnaire (DVQ; Douglas and Straus, 2006) and the Parent-Child Conflict Tactics scales (CTSPC; Straus, Hamby, Finkelhor, Moore, & Runyan, 1998; for details, see Supplement 2.1). The self-report questionnaire is the first Dutch questionnaire investigating the extent to which adolescents are exposed to child maltreatment. The DVQ and CTSPC have been shown to be valid and reliable measures (Douglas and Straus, 2006; Straus, 2004; Straus et al., 1998). Lifetime prevalence and year prevalence were assessed by asking participants to rate how many times a certain event had occurred in previous years or in the past twelve months using a seven-point Likert scale (1 = never; 7 = more than 20 times). Scores of 2 (not in the past year, but before) through 7 (at least once) established the prevalence of the maltreatment. Year prevalence was 28 indicated by scores of 3 (once in the past year) through 7 (at least once). Items measuring neglect were rated on a four-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). This measurement was used because neglect is often long-term, and it is therefore difficult to measure the number of times that neglect occurs.

Because a child is defined by the UN Convention on the Rights of the Child as anyone under 18, year prevalence percentages were based on the scores collected from adolescents between the ages of 12 and 18. Lifetime prevalence rates were based on reports from all participants, who were divided into an adolescent group and a young adult group.

Socio demographics and social desirability The questions about child maltreatment were embedded in a series of questions about the socio demographic characteristics of the children and their families (13 items, e.g., ‘What is your age?’) and social desirability (13 items, also derived from the DVQ, Douglas and Straus, 2006, and adapted by Reynolds (1982) from the Malowe-Crowne Social Desirability Scale; for details, see Supplement 2.2). Research that uses self-report data must take into account respondents’ defensiveness, minimization of socially undesirable behavior, and tendency to project favorable images of themselves. Social desirability items were rated on a four-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree).

Sample size

A stratified sample of students from 57 secondary and vocational education classes in Suriname was selected. According to the population rates reported by the World Factbook (2014) and the number of participants (age: 12–17 and 18–22 years) in our study, 1.2% of the children and young adults in Suriname were included in our study. The sample was representative of the total population of Surinamese students, according to information released by the Inspection of Education (Nickerie) and the Ministry of Education and Development (Paramaribo, Marowijne, Sipaliwini, and Brokopondo). During the sampling, school year, school type, gender, residence, and the size of the participating school were taken into account. A list of all of the schools in the participating districts, divided by type of school and grades taught, was provided by the Ministry of Education. Using random probability sampling, schools with different Chapter 2 religious backgrounds were selected from each group. The numbers of boys and girls attending the selected schools were gathered prior to the data collection. These numbers were essentially equal. Data from the study in Nickerie was used to enhance the study population and its cultural diversity and thereby improve the representativeness of the 29 sample. Because the questionnaires used in both studies were identical, the data from Prevalence of child abuse and neglect in Suriname the studies could be combined.

Defi nition

The definition of child abuse used in our study consisted of the above-mentioned five forms of abuse (for details, see Supplement 2.1). In the National Incidence Study – 4 (NIS-4; Sedlak et al., 2010), any of the following occurrences meets the definition of child abuse: (1) physical assault (including excessive corporal punishment); (2) sexual abuse or exploitation; (3) close confinement; (4) any other pattern of assaultive, exploitative, or abusive treatment; (5) abandonment or other refusal to maintain custody; (6) permitting or encouraging chronic maladaptive behavior; (7) refusal to allow needed treatment for a professionally diagnosed physical, educational, emotional, or behavioral problem or failure to follow the advice of a competent professional who recommended that the caregiver obtain or provide the child with such treatment when the child’s primary caregiver was physically and financially able to do so; (8) failure to seek or unwarranted delay in seeking competent medical care for a serious injury, illness, or impairment; (9) consistent or extreme inattention to the child’s physical or emotional needs; and (10) failure to register or enroll the child in school, as required by state law. To compare our data with the sentinel data (reports from professionals) of the National Incidence Study – 4 and the Netherlands’ Prevalence Study of Maltreatment of Children and Youth (NPM-2010, Euser et al., 2013), a selection of items from the questionnaire was used. To select these items, NPM-2010 sentinels, trained as reliable coders, were presented the 32 items of the original self-report study (Pupils on Abuse Study (SOM); Lamers-Winkelman et al., 2007) in random order. The coders were asked how well (well, somewhat well, not well) the items fit the definition used in the sentinel study (based on the definition used by the NIS-4). All of the items were considered to be ‘security threatening events,’ but not all of them could be considered child abuse. In total, 13 items were considered by all seven coders to match the NIS definition and therefore the definition of child abuse used by the NIS-4. The selection consisted of items assessing sexual and physical abuse and items assessing experienced conflicts between parents. Intimate Partner Violence (IPV) was included in the NIS-4’s definition, but IPV-related items were not included in the selection. Furthermore, the items regarding neglect were not included in the selection because they asked only about the respondents’ childhood, though they are included in the NIS-4’s definition.

30 Procedure The study used a method similar to that used in studies on the prevalence of child maltreatment previously conducted in Nickerie, Suriname (Nickerian Pupils on Abuse Study; Van den Berg et al., 2009), and The Netherlands (Pupils on Abuse Study; Lamers- Winkelman et al., 2007; Netherlands’ Prevalence Study on Maltreatment of Children and Youth; Euser et al., 2013). Data from the study in Nickerie (Van den Berg et al., 2009), which used the same instrument, were combined with this study’s data. The study received ethical approval from the Ministry of Education and Development in Paramaribo and the Inspection of Education in Nickerie. All participating school directors and children were informed about the study aims (JN). On average, the participants took 45 minutes to complete the questionnaire.

Consent procedure

School directors received a letter to distribute to parents. This letter contained a response form that parents could use to refuse permission for their child’s participation. A letter distributed prior to the data collection informed each participant about the nature of the research, including information about the possibility of receiving help in cases of need and the procedures used to secure confidentiality. This procedure was repeated in person before the data collection (JN, IWvdK). Respondents were given the option of stopping or of continuing at another time or in another place if they wished. All respondents were given a contact name and information regarding the Child Protection Helpline should they wish to discuss anything arising from the research. All respondents were told that their teacher and school director had been extensively informed about the procedures and that they could contact them in case of need. All children gave verbal consent before participating. During and after the data collection, no children requested help or referrals.

Statistics

Means and SDs of the socio-demographic characteristics (e.g., sex) were calculated. To control for answer tendencies and social desirability, we used Z-scores (Z > -3.29 or Z < 3.29; Tabachnick & Fidell, 2001). Questionnaires were included based on their Z-score (Z > -3.29 or Z < 3.29). Outliers (Z < -3.29 or Z > 3.29) were removed. Lifetime prevalence and year prevalence rates were presented in numbers and percentages. All data were calculated using SPSS Statistics 19 (Chicago, IL, USA). Chapter 2

RESULTS

The social desirability items were answered completely by 1,200 respondents; two 31 outliers (Z > 3.29) were removed. This reduced the sample size to n = 1,198, with a mean Prevalence of child abuse and neglect in Suriname social desirability score of 34.05 (SD = 4.87, range = 18–50). Of the 191 questionnaires whose social desirability items were not completed, 136 questionnaires were missing a response to only 1 item. These 136 questionnaires were, based on their Z-scores (Z > -3.29 or Z < 3.29) included in the sample, which resulted in a sample size of n = 1,334. Gender data were missing from four respondents; age data were missing from 19 respondents. Their questionnaires were excluded, resulting in a final sample size of n = 1,311.

More than 86% (n = 930) of the adolescents and 95% (n = 229) of the young adults indicated that they had been exposed to child maltreatment at least once in their lives. The most prevalent experiences reported were physical abuse (adolescents: 53.4%; young adults: 63.2%), parental psychological aggression (adolescents: 53.1%; young adults: 61.9%) and neglect (adolescents: 49.4%; young adults: 60.7%). In addition, 57.1% of adolescents (n = 612) indicated they had been exposed to child maltreatment during the past twelve months (see Tables 2.2 and 2.3). Because of the long-term nature of neglect, this type of maltreatment was excluded from the year prevalence rates. Overall N = 239 Girls N = 132 Boys N = 107 Overall N = 1,072

32 Girls N = 615 Adolescents adults Young Boys N = 457 n% n% n% n% n% n% icts between parents 139 30.4 194 31.5 333 31.1 40 37.4 58 43.9 98 41.0 Lifetime prevalence of child maltreatment in Suriname of child maltreatment Lifetime prevalence Within familyOutside family 52 81 11.4 17.7 81 90 13.2 14.6 133 171 12.4 16.0 22 28 20.6 26.2 26 23 19.7 17.4 48 51 20.1 21.3 Type of maltreatment of maltreatment Type Sexual abusePhysical abuse (by parent) of parentsPsychological aggression Experienced confl Neglect (by parent) 218TOTAL 47.7 233 97 51.0 351 21.2 57.1 339 125 55.1 569 20.3 53.1 572 236 222 53.4 51.6 20.7 73 68.2 68 304 34 49.9 63.6 75 31.8 391 540 56.8 83 85.6 32 50.4 62.9 148 539 24.4 61.9 151 66 87.6 66 63.2 61.7 930 27.6 86.8 79 59.8 105 98.1 145 60.7 124 93.9 229 95.8 Table 2.2 Table Table 2.3 Year prevalence of child maltreatment in Suriname

Adolescents

Boys Girls Overall N = 457 N = 615 N = 1,072

Type of maltreatment n% n% n%

Sexual abuse 73 16.0 90 14.6 163 15.2 Within family 35 7.7 55 8.9 90 8.4 Outside family 59 12.9 62 10.1 121 11.3

Physical abuse (by parent) 132 28.9 211 34.3 343 32.0

Psychological aggression of parents 136 29.8 248 40.3 384 35.8

Experienced confl icts between parents 72 15.8 114 18.5 186 17.4

Neglect (by parent) ------

TOTAL 243 53.2 369 60.0 612 57.1 Chapter 2

The self-report data were compared with the sentinel data (reports from professionals) of the National Incidence Study – 4 (NIS-4; Sedlak et al., 2010) and the Netherlands’ Prevalence Study on Maltreatment of Children and Youth (Euser et al., 2013). The results 33 showed that more than 58% of the adolescents and 68% of the young adults had been Prevalence of child abuse and neglect in Suriname exposed to at least one form of child abuse during their lives. In addition, 36.8% of the adolescents reported that they had been exposed to at least one form of child abuse during the past twelve months (see Tables 2.4 and 2.5).

The year prevalence rates calculated from the 13 selected items indicated that 36.8% (n = 394; a proportion of 367 in 1,000) of children in Suriname had been abused during the past 12 months. Overall N = 239 Girls N = 132 Boys N = 107 Overall N = 1,072 34 3.2 7 6.5 6 4.5 13 5.4 a nition of the NIS-4) Girls

34 N = 615 Adolescents adults Young Boys N = 457 n% n% n% n% n% n% 25 5.5 47 7.677 72 38.7 6.7 259 42.1 9 436 8.4 40.7 12 5130 9.1 47.7 6.6 21 60 26 45.5 8.8 4.2 111 46.4 56 5.2 7 6.5 6 4.5 13 5.4 140 30.6 204 33.2 344 32.1 49 45.8 45 34.1 94 39.3 st or being kicked hard (by parent)st or being kicked hard 75 16.4 104 16.9 179 16.7 28 26.2 25 18.9 53 22.2 Lifetime prevalence of child maltreatment in Suriname (according to defi in Suriname (according of child maltreatment Lifetime prevalence Adult had sex with me (within family)Hit with a fi or knocked down (by parent) Thrown object (by Hit at bottom with belt or other hard parent) 17Beat up (by parent) 3.7Hit on some other part of the body besides 47bottom with something like a belt, hairbrush, stick, 22 10.3 object (by parent) or some other hard 3.6 the neck and choked (by parent)Grabbed around 89 with knife or gun (by parent) Threatened 22 14.5 39Burned or scalded on purpose by glowing object 4.8 3.6 136(by parent) 12.7 has kicked, bitten or punched the otherParent 26 19 7 has beaten up the otherParent 4.2 23 89 4.2 6.5 45 used knife or gun to the otherParent 21.5 19.5 48 9.8 14 132 12 23 4.5 31.5 2.3 17.4 9.1 58 221 13 9.4 33 46 19 20.6 23 65 12.1 19.2 3.1 103 7.9 5.0 14.2 31 9.6 6 11 5 29.0 79 4.5 15 12.8 1.8 4.7 23 14.0 19 144 17.4 4 13.4 7.9 13 54 3.0 9.8 22.6 24 22.4 9 28 11.7 3.8 19 14.4 43 18.0 Type of maltreatment of maltreatment Type by adult to look at/touch his/her private Forced parts or he/she tried to do this me TOTAL 260 56.9 364 59.2 624 58.2 77 72.0 87 56.9 164 68.8 alpha = .005. Table 2.4 Table a Table 2.5 Year prevalence of child maltreatment in Suriname (according to defi nition of the NIS-4)

Adolescents

Boys Girls Overall N = 457 N = 615 N = 1,072

Type of maltreatment n% n% n%

Forced by adult to look at/touch his/her 16 3.5 32 5.2 48 4.5 private parts or he/she tried to do this to me

Adult had sex with me (within family) 12 2.6 12 2.0 24 2.2

Hit with a fi st or being kicked hard (by 37 8.1 68 11.1 105 9.8 parent)

Thrown or knocked down (by parent) 25 5.5 56 9.1 81 7.6

Hit at bottom with belt or other hard 71 15.5 132 21.5 203 18.9 object (by parent)

Beat up (by parent) 41 9.0 74 12.0 115 10.7 Chapter 2 Hit on some other part of the body 68 14.9 110 17.9 178 16.6 besides the bottom with something like a belt, hairbrush, stick, or some other hard object (by parent)

Grabbed around the neck and choked (by 13 3.8 21 3.4 34 3.2 parent) 35 Prevalence of child abuse and neglect in Suriname Threatened with knife or gun (by parent) 11 2.8 11 1.8 22 2.1

Burned or scalded on purpose by glowing 16 3.5 22 3.6 38 3.5 object (by parent)

Parent has kicked, bitten or punched the 22 4.8 33 5.4 55 5.1 other

Parent has beaten up the other 33 7.2 44 7.2 77 7.2

Parent used knife or gun to the other 13 2.8 7 1.1 20 1.9

TOTAL 159 34.8 235 38.2 394 36.8

DISCUSSION

The main objective of this study was to assess the lifetime prevalence and year prevalence of child maltreatment in Suriname. The findings indicate that more than 85% of the adolescents and 95% of the young adults had been exposed to at least one type of maltreatment in their lives. During the past 12 months, 57.1% of the adolescents had been victims of child maltreatment. According to the definition of child abuse used in the sentinel study of the National Incidence Study – 4 (NIS-4; Sedlak et al., 2010), more than 58% of the adolescents and 68% of the young adults had been exposed to at least one form of maltreatment. Based on these standards, more than 36% (a proportion of 368 in 1,000) of the adolescents reported having experienced at least one form of maltreatment during the past 12 months.

The Netherlands’ Prevalence Study on Maltreatment of Children and Youth (Euser et al., 2013) and the National Incidence Study – 4 (Sedlak et al., 2010), which was conducted in the United States, reported that 34 in 1,000 children and 39.5 in 1,000 children had been abused during the past year, respectively. Compared to these results, the rates in Suriname are alarmingly high, especially because there is no comprehensive national approach towards preventing child maltreatment in Suriname.

Violence towards children appears to be common in Suriname. Its prevalence may be the result of both cultural and socio-economic factors. In the Caribbean, harsh and authoritarian types of discipline have often been described as commonplace child-rearing strategies; ‘beatings’ (with a hand, belt or instrument) are, in fact, defended as essential tools of the responsible parent. Physical punishment remains a frequently employed method of parental control and is exercised even on young children. Caribbean parents often expect obedience, compliance and respectful behavior from their children 36 toward adults, even when such behavior is unrealistic in terms of age and circumstance (Williams, Brown, & Roopnarine, 2006). In addition, in Suriname, violence seems to be an acceptable form of disciplining children (UNICEF; MICS-4, 2010). Furthermore, the continuous stress of poverty is a socio-economic risk factor that predicts increased violence towards children (Coulton, Crampton, Irwin, Spilsbury, & Korbin, 2007; Gilbert et al., 2009). Relatively low levels of education are also a risk factor (MacKenzie, Kotch, & Lee, 2011). High stress levels, inadequate parenting skills and limited knowledge of child development are often observed in abusive parents (MacKenzie et al., 2011; Ronan, Canoy, & Burke, 2009; Wilson, Rack, Shi, & Norris, 2008).

Limitations

Several limitations hindered the establishment of true prevalence rates in this study. First, the study relied upon children’s self-reported victimization and did not include any independent verification. A more objective, external evaluation however, would be difficult because the surveillance system in most districts is deficient. Professional help and documentation in cases of suspected maltreatment are underdeveloped and usually unavailable. A sentinel study would be difficult to organize and might under-represent the actual situation because of the lack of infrastructure, professionals and services. Second, the data were collected solely from children in school, and the children who may be most at risk of being exposed to child maltreatment (e.g., drop-outs and children not sent to school) were therefore not included. The young adults we included were also all students. Therefore, our data cannot be generalized to non-students or other young adults. The high number of children who repeat vocational education classes in Suriname leads to older cohorts of students; we therefore extended the maximum age to 22 years. Because some young adults may have been exposed to violence after the age of 18 and have therefore had experiences that can no longer be considered child abuse, we divided the participants into two groups: adolescents and young adults.

Third, it is likely that the lack of absolute confidentially in the classroom setting could have influenced children’s willingness to report some (more shameful) experiences of maltreatment.

Moreover, there are some important theoretical problems with measuring child mal- treatment. First, there is no valid, global child abuse measurement (Forrester & Harwin, Chapter 2 2000). Second, there is a lack of social consensus about what constitutes dangerous and unacceptable forms of parenting (Korbin, 2002). Some define abuse or neglect based solely on parents’ behaviors, whereas others include parental intention or physical consequences in their definitions (Southall, Samuels, & Golden, 2003; Straus et al., 1998). Recent research shows that in Guyana, a Caribbean country in which harsh 37 Prevalence of child abuse and neglect in Suriname punishment is normative, maternal warmth can be effectively expressed through the justness and not the harshness of physical punishment to lower negative childhood behavioral outcomes (Roopnarine, Jin, & Krishnakumar, 2014). In addition, many cases of child maltreatment are neither identified nor reported (Munro, 2011a,b). Because some forms of child maltreatment, such as the sexual abuse of minors under age 12, is inherently prohibited everywhere, the extent of the gap between reported cases and actual prevalence in the general child population is difficult to assess reliably. One objective of our study was to compare the current data from Suriname with data from the Netherlands (Netherlands’ Prevalence Study of Maltreatment of Children and Youth; NPM-2010; Euser et al., 2013) and the United States (National Incidence Study – 4; NIS-4; Sedlak et al., 2010). The NPM-2010 used the same study design as the NIS-4. Its estimates include children investigated by the CPS and maltreated children who were identified by professionals in a wide range of agencies in representative communities. These professionals, called ‘sentinels,’ were asked to identify children they believed were maltreated during the study period. Children identified by sentinels and those whose alleged maltreatment was investigated by the CPS during the same period were evaluated against a standardized definition of abuse and neglect. The NPM-2010 also included a self-report study; the NIS-4 did not. One of the goals of the NPM-2010 was to compare its self-reports with its sentinel reports and with the sentinel reports of the NIS-4. Instead of making our own selection, we used the selection chosen by the trained NPM-2010 coders, and the items therefore do not exactly match the NIS-4 definition. Moreover, we are aware that we compared self-report data with sentinel data. Suriname is linked to the Netherlands through its colonial history. Both countries speak the same language. Most Surinamese families in the Netherlands have family members in Suriname and visit Suriname regularly. Based on these facts, we decided to use the items selected for the NPM-2010 and compare our data with the sentinel studies of the NPM-2010 and NIS-4. For financial and logistic reasons, it was not possible to collect this amount of data in one year. MICS data from Suriname showed only a slight increase – from 84% in 2006 to 86% in 2010 – of children who were subjected to at least one form of psychological or physical punishment (UNICEF; MICS-3, 2006; MICS-4, 2010). In other words, no major differences were found between these years. However, only the topic of punishment was investigated. We decided to select a nationally representative sample and combined the data collected in 2008 and 2012–2013. We are aware that, for this reason, the rates might not provide a fully representative picture of the year prevalence of child abuse in Suriname.

38 Some limitations regarding the questionnaire should also be acknowledged. Several of the questionnaire items seemed to be difficult for the younger and less educated children among the adolescents. This might be a result of the low education level of children in Suriname (Ministry of Education and Community Development in Suriname, 2004). Therefore, one of the researchers was always present to provide assistance to the children. Differences between Suriname’s lingua franca (Sranan Tongo; General Bureau Statistics, 2012) and the language of the questionnaire (Dutch) may have led the participants to misunderstand some of the items. Because of the difficulty of the questionnaire and the participants’ level of education, we decided to only include children aged 12 years and older. Although children of all ages can be victims of abuse or neglect, infants and young children are particularly vulnerable (DeVooght, McCoy- Roth, & Freundlich, 2011). These children are not included in our study. Despite the high percentages reflected in our results, the numbers of children that are or have been victims of child maltreatment are presumably even higher. Given the survey design, definitional issues, and sample characteristics, caution should be taken in generalizing our results to a different time period and different age groups. Strengths

Some clear strengths of the study should also be acknowledged. First, the 12–22 age range was selected on the assumption that the experience of childhood was sufficiently recent among this group and that they would be less likely than older adults to have experienced other major events in their lives, minimizing the risk of recall bias. Second, this self-report study yields reports of child maltreatment that would not conventionally come within the purview of child welfare or child protection services. It is recognized that rates of child abuse recorded by the police corps and child protection services are substantially lower than the prevalence in the population (Gilbert et al., 2009). The above- mentioned numbers of child abuse cases reported to the police corps in Paramaribo are arguably the ‘tip of the iceberg.’ This study made use of a broad assessment. Third, the total number of participants is representative of the population in Suriname.

Conclusions Chapter 2 This study was the first to address lifetime prevalence and year prevalence rates of child maltreatment in Suriname on a national and representative scale. Year prevalence rates based on the definition of child abuse adopted in the sentinel study of the NIS-4 show that 368 in 1,000 (36.8%) children had been abused during the past 12 months. 39 Compared to proportions in the United States and the Netherlands, the rates in Suriname Prevalence of child abuse and neglect in Suriname are high. The results suggest that prevention programs for child abuse and neglect are urgently needed in Suriname, especially because child maltreatment may have serious and often lifelong consequences. These consequences may justify a national approach, including a national strategic plan, a national surveillance system and changes to the state’s programmatic and policy response. REFERENCES

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B., & Lee, L. (2011). Toward a cumulative ecological risk model for the etiology of child maltreatment. Children and Youth Services Review, 33, 1638-1647. Mills, R., Scott, J., Alati, R., O’Callaghand, M., Najman, J. M., & Strathearn, L. (2013). Child maltreatment and adolescent mental health problems in a large birth cohort. Child Abuse & Neglect, 37(5), 292-302. Ministry of Education Community Development. (2004). Educational Development in the Republic Suriname. A report prepared for the 47th session of the international conference on education. Ministry of Education Development. (2005). Department Research, Planning and Monitoring. Multiple Indicator Cluster Survey-3 Suriname. (2006). Monitoring the situation of children and women. UNICEF. Retrieved from: http://www.childinfo.org/files/MICS3 Suriname FinalReport 2006 En.pdf (accessed August 2014). Multiple Indicator Cluster Survey-4 Suriname. (2010). Monitoring the situation of children and women. UNICEF. 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maltreatment with the Parent-Child Conflict Tactics Scales: Development and psychometric Prevalence of child abuse and neglect in Suriname data for a national sample of American parents. Child Abuse & Neglect, 22(4), 249-270. Straus, M. A. (2004). Cross-cultural reliability and validity of the Revised Conflict Tactics Scales: A study of university student dating couples in 17 nations. Cross Cultural Research, 38(4), 407-432. Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics. Boston: Allyn and Bacon. Van den Berg, L. M., Visser, K. C., Lamers-Winkelman, F., & Graafsma, T. L. G. (2009). Omvang van kindermishandeling in het district Nickerie, Suriname. Onderzoek onder middelbare scholieren [Extent of child abuse in the district Nickerie, Suriname. Study among pupils of vocational education]. Child and Adolescent, 32(2), 84-100. Williams, S., Brown, J., & Roopnarine, J. L. (2006). Childrearing in the Caribbean. Bridgetown, Barbados: Caribbean Child Support Initiative. Wilson, S. R., Rack, J. J., Shi, X., & Norris, A. M. (2008). Comparing physically abusive, neglectful, and non-maltreating parents during interactions with their children: A meta-analysis of observational studies. Child Abuse & Neglect, 32, 897-911. World Factbook. (2014). Retrieved from: https://www.cia.gov/library/publications/the-world- factbook/geos/ns.html (accessed August 2014). World Health Organization. (2001). Retrieved from: http://www.who.int/mediacentre/factsheets/ fs241 (accessed August 2014). SUPPLEMENT 2.1 TYPE OF MALTREATMENT

Sexual abuse

Within family . Forced by adult to look at/touch his/her private parts or he/she tried to do this to me . Adult had sex with me . Sexual abuse by person under age . Forced by person under age to look at/touch his/her private parts or he/she tried to do this to me

Outside family . Sexual abuse by person under age . Forced by adult to look at/touch his/her private parts or he/she tried to do this to me . Forced by person under age to look at/touch his/her private parts or he/she tried to do this to me

Physical abuse (physical assault by parent) . Hit with a fist or being kicked hard 42 . Thrown or knocked down . Hit at bottom with belt or other hard object . Beat up (hit the child over and over as hard as they could) . Hit on some other part of the body besides the bottom with something like a belt, hairbrush, stick, or some other hard object . Grabbed around the neck and choked . Threatened with knife or gun . Burned or scalded on purpose by glowing object

Emotional abuse (psychological aggression of parents) . Parent threatened to spank or hit but did not actually do it

Confl icts between parents . Parent has pushed the other (hard) or had gripped the other . Parent has beaten the other . Parent has kicked, bitten or punched the other . Parent has tried to beaten the other with an object . Parent has beaten up the other . Parent has threaten the other with knife or gun . Parent has used knife or gun to the other

Neglect . No help of parent with homework . Not stimulated by performance by parents . Parents indifferent for problems at school . Not reassured by grief by parents . No help of parents when having problems . Parents did not look after child looking properly . Parents did not look after personal hygiene of child . Parents did not look after regular schooling

SUPPLEMENT 2.2 SOCIAL DESIRABILITY Chapter 2

. I am always courteous even to people who are disagreeable . There have been occasions when I took advantage of someone . No matter who I’m talking to, I’m always a good listener . I have never been irked when people expressed ideas very different from my own 43

. I am sometimes irritated by people who ask favors of me Prevalence of child abuse and neglect in Suriname . It is sometimes hard for me to go on with my work if I am not encouraged . I am always willing to admit it when I make a mistake . I sometimes feel resentful when I don’t get my way . There have times when I was quite jealous of the good fortune of others . I sometimes try to get even rather than forgive and forget . There have been times when I felt like rebelling against people in authority even though I knew they were right . On a few occasions, I have given up doing something because I thought too little of my ability . I have never deliberately said something that hurt someone’s feelings 44 3

Child sexual abuse in Suriname

Inger W. van der Kooij Josta Nieuwendam Shandra Bipat Ramón J.L. Lindauer Tobi L.G. Graafsma

Child Abuse & Neglect, under review ABSTRACT

Child sexual abuse (CSA) is a global public health problem with the potential for a lifelong impact on victims without proper treatment. Theoretical and empirical studies conducted to ascertain the prevalence of CSA in the Latin America and Caribbean region are inconsistent and poorly synthesized. Earlier estimates of CSA among adolescents in Suriname showed a lifetime prevalence of 20.7% and a year prevalence of 15.2%. This present study aimed to gain deeper insight in these prevalence rates. One thousand hundred and twenty (1,120) adolescents of different ethnicities completed a questionnaire on child maltreatment, including CSA. The study sample, obtained by random probability sampling, consisted of students (ages 12 to 17) from five districts in Suriname. More than 16% of all boys and 15% of all girls indicated that they had been exposed to some form of CSA in the past 12 months. Girls reported significantly more intrafamilial CSA by a minor than boys. Boys reported significantly more experiences of being touched or forced by a minor outside the family to look at/touch the abuser’s private parts than girls (both lifetime and year prevalence). Furthermore, an increased risk of CSA (year prevalence) was found as adolescence progresses. A significant portion of CSA constitutes peer-to-peer sexual victimization. The recent Concluding Observations (2016) of the United Nations Committee on the Rights of the Child (UNCRC) 46 expressed serious concern about CSA in Suriname and urged the government to ensure the development of appropriate legislation, policies, and services for prevention and recovery. INTRODUCTION

Child sexual abuse (CSA) is a global public health problem with the potential for a lifelong impact on victims without proper treatment (Hillis, Mercy, Amobi, & Kress, 2016; Papalia, Luebbers, Ogloff, Cutajar, & Mullen, 2016). Victims of CSA are likely to develop different types of internalizing and externalizing problem behaviors, are at increased risk of recurring sexual victimization, and may as parents place their own children at risk of abuse and neglect (Cashmore & Shackel, 2013; Cutajar et al., 2010). The most recent extensive meta-analysis on the prevalence of CSA across the world showed an overall prevalence rate of 13%, with a rate for girls (18%) being more than twice that of boys (8%; Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). Most cases of CSA, however, are not disclosed due to several factors related to the child’s vulnerability, the perpetrator’s influence and abuse of power, the social circumstances, and the types of acts. The hidden nature of CSA means that these children are vulnerable to further abuse (Seto, Babchishin, Pullman, & McPhail, 2015). Given the fact that CSA is both underreported and underrecorded, prevalence rates probably represent only Chapter 3 the tip of the iceberg (Reitsema & Grietens, 2015).

Theoretical and empirical studies conducted to ascertain the prevalence and char- acteristics of CSA in the Latin America and Caribbean (LAC) region are inconsistent 47 and poorly synthesized (UNICEF, 2014). Population-based studies employ various Child sexual abuse in Suriname methodologies and definitions, challenging any comparisons of estimates calculated for CSA across settings and countries (Wirtz et al., 2016). CSA often occurs alongside other forms of abuse or neglect, and in family environments with possible low family support and/or high stress, such as high poverty, low parental education, absent or single parenting, parental substance abuse, domestic violence, or low caregiver warmth (Butler, 2013; Pérez-Fuentes, et al. 2013; Turner, Shattuck, Finkelhor, & Hamby, 2016).

Suriname is an upper middle-income country and the smallest in South America (World Factbook, 2017). Our previous investigation of the lifetime and year prevalence of CSA in Suriname showed that a total of 20.7% of adolescents (aged 12 to 17 years) and 27.6% of young people (aged 18 to 22 years) reported suffering CSA at some point in their lives. The prevalence of CSA within the previous 12 months of adolescents was 15.2% (Van der Kooij et al., 2015). In 2014 the police registered 191 cases of CSA. Almost 90% of registered CSA victims were girls; most prevalent in the age range 0 to 14 years. Almost all offenders were male, including boys (Universal Periodic Review of Suriname, 2016). Most recent data in Suriname showed 212 registered cases of CSA from January till September 2015 (Human Rights Report, Suriname, 2015), suggesting that less than 1% of all Surinamese children reportedly experience a form of CSA.

Suriname has no mandatory child maltreatment reporting system or standard protocol response to suspected maltreatment. Despite laws criminalizing CSA and the ratification of the Convention on the Rights of the Child, the number of prosecutions in these cases in Suriname remains low. The majority of CSA prevalence rates remain unreported due to poor early detection and severe limitations of qualified service providers to counsel and treat child victims (Universal Periodic Review of Suriname, 2016). In 2016 a UNICEF supported national study on Violence Against Children (VAC) began in Suriname. One of its main issues is the development of useful strategies on the prevention of CSA (UNICEF, the National Assembly Suriname, & the Institute for Graduate Studies and Research Suriname, 2016). Recently, the ‘Concluding Observations on the implementation of the combined third and fourth periodic reports of Suriname’ of the United Nations Committee on the Rights of the Child (UNCRC) expressed serious concern about CSA, the lack of shelters for child victims and information on investigations of CSA cases. The Committee strongly advised the government of Suriname to take a number of measures in order to reduce CSA (United Nations Committee on the Rights of the Child, 2016, Concluding Observations, Suriname, para. 21).

48 This research presents the results of a national self-report study undertaken to assess the lifetime prevalence and year prevalence of CSA in Suriname. The purpose of the study was to gain deeper insight in earlier estimated prevalence rates of CSA according to gender, age, and ethnicity drawing from self-report measures from a representative sample of students (ages 12 to 17) from five different districts in Suriname. In addition, the type of CSA (by a minor vs. adult, intrafamilial vs. extrafamilial) was examined. Based on previous results, we expected high rates of both lifetime prevalence and year prevalence of CSA. To the best of our knowledge, this study is the first that addresses these topics in Suriname.

METHOD

Studied area

The study was conducted in five areas of Suriname: Paramaribo, Nickerie, Sipaliwini, Marowijne, and Brokopondo. These five areas are located throughout the country and are therefore geographically and culturally representative. Paramaribo and Nickerie are the most urbanized areas, while Brokopondo, Marowijne and Sipaliwini are rural. Suriname, officially known as the Republic of Suriname, is situated on the northeastern Atlantic coast of South America. With an area just under 64,000 square miles, Suriname is the smallest sovereign state in South America. Suriname’s multi-ethnic population of around 585,000 inhabitants consists of people of Afro Surinamese, Indo Caribbean, Javanese, and mixed-ethnic ancestry. There are also smaller numbers of individuals of European, Chinese, and Brazilian ancestry. The official language is Dutch, but Sranan Tongo is the lingua franca (World Factbook, 2017).

Participants

A stratified sample of students from secondary and vocational education classes in Suriname was selected. Based on the population rates reported by the World Factbook (2014), the number of participants (aged 12 to 17 years) in our study comprised 1.2% of the children in Suriname. In total 1,120 adolescents of secondary and vocational education in Suriname (12 to 17 years old, boys: 42.9%; M = 15.04 years, SD = 1.42) participated in the study. Data collection was conducted in July 2013 (Paramaribo, Marowijne and Chapter 3 Brokopondo) and February 2014 (Sipaliwini). Data from the study conducted earlier in Nickerie (Van den Berg, Visser, Lamers-Winkelman, & Graafsma, 2009) were collected during June and July 2008. Demographics of the total sample are summarized in Table 3.1. 49 Instrument Child sexual abuse in Suriname

Child sexual abuse A 57-item self-report measure (Euser et al., 2013; Lamers-Winkelman, Slot, Bijl, & Vijlbrief, 2007) – designed to establish the exposure to a broad range of maltreatment experiences – included eight items regarding child sexual abuse (CSA), within and outside the family. The items ‘a minor did things to me that I would consider sexual abuse’, ‘forced by adult to look at/touch his/her private parts or he/she tried to do this to me’, and ‘forced by person under age to look at/touch his/her private parts or he/ she tried to do this to me’ were asked at the intrafamilial and extrafamilial level. The item ‘adult had sex with me’ was excluded from analyses at extrafamilial level for minors aged 16 and 17 years. This exclusion was made because the age at which an individual is considered legally old enough to consent to participation in sexual activity (the age of consent) in Suriname is 16 years (Age of Consent Suriname, 2017) and the item did not clearly formulate whether this was with or without consent of the adolescent. The items regarding CSA were all derived from the Dating Violence Questionnaire (DVQ), which has shown to be a valid and reliable measure (Douglas & Straus, 2006). The self- report questionnaire is the first Dutch questionnaire to investigate the extent to which Table 3.1 Demographics of the participants

N = 1,120

n%

Gender (n/boys) 480a 42.9

Ethnicity Afro Surinamese 336 30.0 Indo Caribbean 280 25.0 Javanese 113 10.1 Mix 280 25.0 Other 104b 9.3 Missing 7 0.6

Education Lower vocational education 192 17.1 Extensive primary education 879 78.5 General secondary education 20 1.8 Pre-university education 29 2.6

District Paramaribo 543 48.1 Brokopondo 87 7.8 Marowijne 90 8.0 50 Nickerie 303 27.1 Sipaliwini 97 8.7

a Missing gender, N = 2. b Missing ethnicity, N = 4.

adolescents (12 to 17 years) are exposed to CSA, among other things. We examined both lifetime prevalence and year prevalence of CSA in Suriname. The lifetime prevalence rates indicate the total number of children abused in a given time period, irrespective of the time of onset, while the year prevalence of CSA refers to all new cases in a given time period. Lifetime prevalence and year prevalence were assessed by asking participants to rate how many times a certain event had occurred in previous years or in the past 12 months using a seven-point Likert scale (1 = ‘never’; 7 = ‘more than 20 times past year’). Scores of 2 (‘not in the past year, but before’) to 7 (‘more than 20 times past year’, so at least once) established the lifetime prevalence of the maltreatment. Year prevalence was indicated by scores of 3 (‘once in the past year’) to 7 (‘more than 20 times past year’, so at least once). Sociodemographics and social desirability A series of questions about the sociodemographic characteristics of the children and their families (13 items, e.g., ‘What is your age?’) were included in the questionnaire. Furthermore, social desirability items (13 items, also derived from the DVQ, Douglas & Straus, 2006, and adapted by Reynolds (1982) from the Malowe-Crowne Social Desirability Scale) were included. Social desirability items (e.g., ‘I am always willing to admit when I make a mistake’; See Supplement 3.1) were rated on a four-point Likert scale ranging from 1 (‘strongly disagree’) to 4 (‘strongly agree’).

Procedure

Sample size Sampling was done through a multistage stratified sampling technique. A list of secondary high schools for boys and girls, arranged by type of school, grades taught, and numbers of boys and girls, was accessed through the Inspection of Education

(Nickerie) and the Ministry of Education and Development (Paramaribo, Marowijne, Chapter 3 Sipaliwini and Brokopondo). Based on student populations in each of the five selected regions of the country, a weighted student sample size from each of these regions was identified. Geographical boundaries within each of the major districts were identified to ensure that demographic differences in the districts were addressed. In addition to 51 district, schooltype (level and religious background) and year, size of the participating Child sexual abuse in Suriname school, and gender of the participants were taken into account. Data from the study in Nickerie was used to enhance the study population and its cultural diversity and thereby improve the representativeness of the sample. As both studies used the same questionnaire, the data from the studies could be combined.

Defi nitions

Child For the purpose of this study, and in the light of the Convention on the Rights of the Child, article 1, a child is defined as a human being below the age of 18 years.

Child sexual abuse (CSA) As UNICEF has noted previously, none of countries in the Caribbean Community (CARICOM) have a standard definition of child sexual abuse used for child protection purposes, seeing that the definition used by the various child protection agencies varies from how it is defined in the law, as well as in policy documents (UNICEF, 2012). In our study, CSA is defined as every form of sexual interaction with a child between 0 and 18 years of age against the will of the child or without the possibility for the child to refuse the interaction. Such interactions can be with or without physical contact, such as penetration, molestation with genital contact, child prostitution, involvement in pornography or voyeurism (Sedlak et al., 2010), and refers to sexual acts by adults as well as peers.

Age of consent The age of consent is the age at which an individual is considered legally old enough to consent to participation in sexual activity. The Age of Consent in Suriname is 16 years. Individuals aged 15 or younger in Suriname are not legally able to consent to sexual activity, and such activity may result in prosecution for statutory rape or the equivalent local law. Suriname statutory rape law is violated when an individual has consensual heterosexual sexual contact with a person under the age of 16, or has consensual homosexual sexual contact with a person under the age of 18. Suriname does not have a close-in-age exemption. Close-in-age exemptions, commonly known as ‘Romeo and Juliet laws’ in the United States, are put in place to prevent the prosecution of individuals who engage in consensual sexual activity when both participants are significantly close in age to each other, and one or both partners are below the age of consent. Because there is no close-in-age exemption in Suriname, both individuals who willingly engage 52 in intercourse with each other and are both under the age of 16 could potentially be prosecuted for statutory rape. However, this is rare. Similarly, no protections are reserved for individuals participating in sexual relations in which one participant is 15 years old and the other is 16 or 17 years old (Age of Consent Suriname, 2017).

Intrafamilial and extrafamilial The traditional definition of intrafamilial CSA includes biological parents as the offenders, for example, when fathers are the CSA offenders (Reitsema & Grietens, 2015). In the present study, we consider ‘intrafamilial’ those cases in which a parental figure or another family member (e.g., father, mother, parent’s partner, or cousin) was the CSA offender. We consider ‘extrafamilial’ those cases in which someone outside the household or non-family member (e.g., babysitter, family friend, teacher, neighbor, peer, or stranger) was the CSA offender.

Procedure The study used a method similar to that used in studies on the prevalence of child maltreatment previously conducted in Nickerie, Suriname (Nickerian Pupils on Abuse Study; Van den Berg et al., 2009), the Pupils on Abuse Study (Lamers-Winkelman et al., 2007), and the Netherlands’ Prevalence Study on Maltreatment of Children and Youth; Euser et al., 2013) conducted in the Netherlands. The study received ethical approval from the Ministry of Education and Development in Paramaribo and the Inspection of Education in Nickerie. All participating school directors and children were informed about the study aims (JN). On average, the participants took 45 minutes to complete the questionnaire. One of the researchers was present to provide assistance to the children.

Consent procedure Prior to the study, all school principals received a letter to distribute to parents. This letter contained extensive information regarding the aim and procedures of the study. It also contained a response form at the bottom of the page that parents could fill in and hand over to the principal to refuse permission for their child’s participation. Prior to the data collection each participant received a letter about the nature of the research, including information about the possibility of receiving help in cases of need and the procedures used to secure confidentiality. Respondents were given the option of either stopping or Chapter 3 continuing at another time or another location if they wished. All respondents were given a contact name and information regarding the Child Protection Helpline (123) should they wish to discuss anything arising from the research. This procedure was repeated in person by JN or IWvdK before the data collection (“It is possible to leave the classroom at any moment, without having to explain. If you do not feel well or need to talk to 53 Child sexual abuse in Suriname someone confidentially, you are welcome to contact us at any moment or you may call the Child Protection Helpline (123). We also will discuss what kind of institutions exist in Suriname for people that need help”). All respondents were also told that their teacher and school director had been extensively informed about the procedures and that they could contact them in case of need. All children gave verbal assent before participating. During and after the data collection, no children requested help or referrals.

Statistics

Means and SD’s of the socio-demographic characteristics (e.g., sex) were calculated. To control for answer tendencies and social desirability, we used Z-scores (Z > -3.29 or Z < 3.29; Tabachnick & Fidell, 2007). Questionnaires were included based on their Z-score (Z > -3.29 or Z < 3.29; a score of 18–50). Outliers (Z < -3.29 or Z > 3.29) were removed. Lifetime prevalence and year prevalence rates were presented in numbers and percentages. All data were calculated using SPSS Statistics 19 (Chicago, IL, USA). RESULTS

The social desirability items were answered completely by 971 respondents; two outliers (Z > 3.29) were removed. This reduced the sample size to n = 969, with a mean social desirability score of 34.14 (SD = 4.89, range = 18–50). Of the 149 questionnaires whose social desirability items were not completed, 105 questionnaires were missing a response to only 1 item. Based on their Z-scores (Z > −3.29 or Z < 3.29), these 105 questionnaires were included in the sample, which resulted in a sample size of n = 1,074. Gender data were missing from two respondents. Their questionnaires were excluded, resulting in a final sample size of n = 1,072.

More than 21% (n = 230) of the adolescents indicated that they had been exposed to a form of CSA at least once in their lives, with 22.3% (n = 102) of all boys and 20.8% (n = 128) of all girls. Furthermore, almost 16% (n = 170) of the adolescents indicated that they had been exposed to a form of CSA in the past 12 months, with 16.8% (n = 77) of all boys and 15.1 (n = 93) of all girls. In addition, girls had been significantly more exposed to CSA by a minor within the family than boys during their lives (2 (1) = 9.94; p = 0.002) and in the past 12 months (2 (1) = 9.82; p = 0.002), while boys had been significantly more forced by a minor outside the family to look at/touch the other’s private parts or 54 he/she tried to do this to him than girls during their lives (2 (1) = 10.62; p = 0.001) and in the past 12 months (2 (1) = 8.56; p = 0.003). See Table 3.2.

Boys between 16 and 17 years had been significantly more exposed to CSA (sexual abuse and/or touched or forced to look at/touch the other’s private parts) by a minor outside the family in the past 12 months than girls (2 (1) = 12.89; p = 0.000). Furthermore, an increased risk of CSA (year prevalence) was found as adolescence progresses, with older boys and girls being more vulnerable to fall victim to intrafamilial and extrafamilial (IF vs. EF) CSA than younger boys and girls (boys total: 2 (1) = 14.27; p = 0.000; girls total: 2 (1) = 12.19; p = 0.000; boys total IF: 2 (1) = 18,20; p = 0.000; girls total IF: 2 (1) = 9.38; p = 0.002; boys total EF: 2 (1) = 5.55; p = 0.019; girls total EF: 2 (1) = 7.90, p = 0.005). See Table 3.3 and Figure 3.1.

Afro Surinamese adolescents proved to be more vulnerable to being a victim of CSA than Indo Caribbean (total IF: 2 (1) = 11.95; p = 0.001; total EF: 2 (1) = 31.08; p = 0.000) and Javanese (total IF: 2 (1) = 3.84; p = 0.050; total EF: 2 (1) = 7.56; p = 0.006) adolescents. See Table 3.4 and Figure 3.2. Overall N = 1,072 3.6 25 2.3 Girls a N = 615 8.3 25 4.1 63 5.9 Boys a N = 457 Overall Chapter 3 N = 1,072 5.5 42 3.9 3 0.7 22 Girls a N = 615 55 Child sexual abuse in Suriname 11.6 37 6.0 90 8.4 38 Boys a N = 457 8 1.8 34 n %n %n %n %n %n % %n %n %n %n %n n 1428 5.5 6.142 12 30 9.2 3.3 4.9 26.8 58 4.2 58 9.4 5.4 100 12 9.3 4.7 15 30 11 3.3 6.6 3.0 18 42 23 2.9 6.8 3.7 33 72 3.1 6.7 25 5.522 47 4.8 7.6 30 72 4.9 6.7 52 4.9 16 3.5 16 32 3.5 5.2 18 48 2.9 4.5 34 3.2 53 b Lifetime and year prevalence rates of CSA Lifetime and year prevalence A minor did things to me that I would consider sexual abuse by adult to look at/touch his/her private Forced parts or he/she tried to do this me by a minor to look at/touch his/her private Forced parts or he/she tried to do this me Adult had sex with me A minor did things to me that I would consider sexual abuse 17 3.7 22 3.6 39 3.6 12 2.6 12 2.0 24 2.2 Adult had sex with me Forced by adult to look at/touch his/her private Forced parts or he/she tried to do this me by a minor to look at/touch his/her private Forced parts or he/she tried to do this me Type of maltreatmentType Intra familial Lifetime prevalence prevalence Year Extra familial TOTAL 102 22.3 128 20.8 230 21.5 77 16.8 93 15.1 170 15.9 Item: ‘Adult had sex with me’ at extra familial level is only included for adolescents aged 12 to 15 years. alpha = .005. Table 3.2 Table a b Overall N = 451 Girls N = 250 13.9 18 7.2 46 10.2 Boys a N = 201 Overall N = 441 Girls N = 267

56 Boys N = 174 Overall N = 180 Girls N = 98 12–13 years 14–15 years 16–17 years Boys N = 82 n%n %n %n%n %n %n%n %n % %n %n%n %n %n%n %n n%n 3 3.7 3 3.1 6 3.3 19 10.9 23 8.6 42 9.5 15 7.5 22 8.8 37 8.2 Year prevalence rates of CSA: intrafamilial vs. extrafamilial and offender (minor vs. adult) rates of CSA: intrafamilial vs. extrafamilial and offender prevalence Year b MinorAdultTotalMinor 0 1Adult 1 0.0 2 1.2 1Total 1.2 3 2.4 1 1 1.2 0 3.7 2 1.0Minor 1 1.0 1 0.0 3 1.2 2.0 1 2 1.0 1 3.1 0 4 0.6 1.1 2 0.6 6 0.0 2.2 10 1.1 20 3.3 1 7 5.7 15 11.5 14 26 28 15 0.6 4.0 8.6 8.0 14.9 10.5 5.6 16 28 15 24 40 48 10.5 25 6.0 8.6 9.0 15.0 10.9 43 5.7 23 66 18 38 31 9.8 5.2 15.0 6.7 8.6 8 15.4 25 33 16 44 24 4.0 20 12.4 21.9 7.5 8.0 9.6 15 10.0 32 47 22 55 30 6.0 28 12.8 18.8 12.2 12.0 8.8 57 23 91 50 38 12.6 5.1 20.2 11.1 8.4 Adult Total 4 4.9 3 3.1 7 3.9 27 15.5 29 10.9 56 12.7 34 16.9 35 14.0 69 15.3 Type of maltreatment Type Offender Intrafamilial Extrafamilial Item: ‘Adult had sex with me’ at extra familial level is only included for adolescents aged 12 to 15 years. alpha = .005. Table 3.3 Table a b Intrafamilial vs. extrafamilial and offender (minor vs. adult) 16

14

12

10

8 Boys 6 Girls 4

2

0 12–13 12–13 12–13 12–13 14–15 14–15 14–15 14–15 16–17 16–17 16–17 16–17 IF IF EF EF IF IF EF EF IF IF EF EF minor adult minor adult minor adult minor adult minor adult minor adult

Figure 3.1 Year prevalence rates of CSA: intrafamilial (IF) vs. extrafamilial (EF) and and offender (minor vs. aduls) in %. Chapter 3

Three largest ethnic groups 18 16 14 12 57 10 Child sexual abuse in Suriname 8 Boys 6 Girls 4 2 0 Indo CIndo CIndo CIndo C Afro S Afro S Afro S Afro S Javan Javan Javan Javan IF IF EF EF IF IF EF EF IF IF EF EF minor adult minor adult minor adult minor adult minor adult minor adult

Figure 3.2 Year prevalence rates of CSA: three largest ethnic groups in %. IF: intrafamilial; EF: extrafamilial; Indo C: Indo Caribbean; Afro S: Afro Surinamese; Javan: Javanese.

DISCUSSION

The main objective of this study was to assess the lifetime and year prevalence of child sexual abuse (CSA) in Suriname, and to gain deeper insight in these prevalence rates (age, ethnicity, extrafamilial vs. intrafamilial, offender (minor vs. adult) and specific unwanted sexual experiences). We found differences between rates of CSA, with girls reporting significantly more sexual abuse by a minor within the family both lifetime (5.5%) and Overall N = 110 Girls N = 54 Boys N = 56 7.79.6 3 2 5.4 3.6 2 2 3.7 3.7 5 4 4.5 3.6 13.6 6 10.7 0 0.0 6 5.5 13.0 5 8.9 2 3.7 7 6.4 a a a a Overall N = 266 Girls N = 324

58 Boys N = 211 Overall N = 113 Girls N = 143 Indo Caribbean Surinamese Afro Javanese Boys n %n %n % n %n %n %n %n %n % %n %n %n %n %n % n %n %n n N = 123 12 9.8 1 0.7 13 4.9 13 11.5 29 13.7 42 Year prevalence rates of CSA: three largest ethnic groups largest rates of CSA: three prevalence Year b Adult 7Total 5.7 0Minor 5 0.0Adult 4.1 7 0 2.6 8 0.0 8 6.5 5 7.1 5 1.9 23 3.5 18 10.9 13 15.9 31 4.9 26 12.3 13 44 11.5 30 14.2 43 13.3 4 7.1 3 5.6 7 6.4 Minor 4 3.3 5 3.5 9 3.4 7 6.2 18 8.5 25 Total 12 9.8 1 0.7 13 4.9 24 21.2 43 20.4 67 20.7 8 14.3 2 3.7 10 9.1 Extrafamilial Type of maltreatment Type Intrafamilial Item: ‘Adult had sex with me’ at extra familial level is only included for adolescents aged 12 to 15 years. alpha = .005. Table 3.4 Table a b year (3.6%) prevalence than boys, and boys reporting significantly more experiences of being touched or forced by a minor to look at/touch the others private parts outside the family both lifetime (11.6%) and year (8.3%) prevalence than girls. A significant portion of CSA thus constitutes peer-to-peer sexual victimization. Furthermore, an increased risk of CSA (year prevalence) was found as adolescence progresses. The present study supports previous findings elsewhere of adolescence as a period of increased risk of CSA for both genders and the significant proportion of abuse within the peer context (Black, Heyman, & Smith Slep, 2001; Davies & Jones, 2013; Finkelhor, Ormrod, Turner, & Hamby, 2005, Finkelhor, Shattuck, Turner, & Hamby, 2014; Finkelhor, Turner, Ormrod, & Hamby, 2009; Finkelhor, Turner, Shattuck, & Hamby, 2013; Kloppen, Haugland, Svedin, Mæhle, & Breivik, 2016; Radford, Corral, Bradley, & Fisher, 2013). An extensive study in the UK showed two-thirds of the victims of contact abuse reported a boyfriend or girlfriend as the offender (Radford, Corral, Bradley, & Fisher, 2013). The present study showed high prevalence rates for both boys and girls. This confirms earlier Caribbean data suggesting boys and girls report similar levels of CSA (World Bank, 2003). The Chapter 3 high year prevalence rates of CSA for Caribbean boys stand out in comparison to other non-Caribbean countries (Jones, 2013). Afro Surinamese adolescents proved to be most at risk for being a victim of CSA as compared to adolescents from other ethnicities. It should be noted that there have been studies that suggest some ethnic groups are more 59 likely to disclose abuse than others, but this has yet to be confirmed (Fontes & Plummer, Child sexual abuse in Suriname 2010). Earlier research in the field of sexual behavior of Afro Surinamese adolescents in the interior of Suriname showed that boys generally start sexual activity earlier than girls and that the frequency of sexual contacts of boys is much higher than that of girls (Terborg, 2002; Guicherit & Bakboord, 2008). Like in other Caribbean countries, many researchers express the opinion that the onset of sexual activity in Suriname is occurring at a young age (UNICEF, 2010; Heemskerk, 2013). In some villages in the rural interior there is mention of sexual initiation at the age of nine (Ministry of Health Suriname, 2012). Early sexual initiation and sexual risk-taking amongst adolescents is associated with sexual and physical abuse in early childhood (Heemskerk, 2013).

CSA as it affects boys has received little attention in the literature. Most victimized children are girls, although the extent of CSA of boys has been largely overlooked and evidence indicates that the abuse of boys in the Caribbean region is an increasing problem (Jones, 2013). The present study confirms this concern. CSA is prevalent in most cultures and is considered a taboo subject in all of them (Fontes & Plummer, 2010; Preston, 2016). Reasons why boys may shy away from disclosure of CSA include homophobia (fears of being labelled homosexual), fear of retaliation, stigmatization or isolation because of the belief that boys are rarely victimized, the fear of becoming an abuser, not feeling masculine, and loss of self-worth (Alaggia & Millington, 2008; Bakboord, 2004; Finkelhor, 2009; Holmes & Offen, 1996; Valente, 2005; Watkins, & Bentovim, 1992). Other reasons why victims in Suriname in general may not disclose CSA are cultural barriers (e.g., reluctance of traditional and closed communities to involve outsiders in matters that are perceived to fall under the authority of local leaders; Arends, 2016), the acceptance of violence (e.g., corporal punishment of children; Van der Kooij et al., 2017; Van der Kooij et al., submitted), or the absence of police stations or emergency rooms to report a case (e.g., in the interior districts). In addition, frontline workers (such as teachers, nurses or social workers) who could potentially identify and report cases of CSA may not have received the necessary training on early identification and subsequent counselling and treatment of victims (Arends, 2016). This probably results in underreporting of the incidents and an underestimation of the true scope of the problem (Haile, Kebeta, & Kassie, 2013). The fact that several studies showed that boys are affected just as often as girls (Brown et al., 2009; Madu & Peltzer, 2001; Singh, Yiing, & Nurani, 1996) may indicate that previous research designs and methods might not have been adequately constructed to identify male victims or that boys face cultural and social barriers in reporting CSA that are different from girls. In general, higher levels 60 of reporting of CSA are found when study questions are framed around behaviorally specific acts and are carried out in environments that promote honesty, safety, and privacy (Veenema, Thornton, & Corley, 2014). The forced sexual acts boys experience, differ greatly from those girls experience, and include fellatio, being fondled, and anal sex (Ross et al., 2005). Boys are also more likely to be subjected to forced penetration (Aded, Dalcin, & Cavalcanti, 2007). Additionally, people may view it as more socially acceptable for boys to be involved in sexual acts than girls. Because of that, CSA involving boys might not be considered as serious a crime (Veenema, Thornton, & Corley, 2014).

Rates of past year experiences of intrafamilial CSA did not decline when adolescents became older, highlighting how important it is for professionals to remain alert to the continued risks of adolescents of experiencing victimization at home, at school, the peer group and in the community. This is in line with the UNCRC’s ‘Concluding Observations’ on the implementation of the Convention on the Rights of the Child in 2016 (United Nations Committee on the Rights of the Child, 2016, Concluding Observations, Suriname, para. 21). Reduced parental control as well as increased sexual experimentation might heighten the risk of unwanted or forced sexual experiences (Priebe & Svedin, 2008). In Suriname many households (16%) are poor in terms of material deprivation or on the edge of becoming poor (53%), particularly in the interior (Brokopondo and Sipaliwini, see Sobhie et al., 2016). To organize sufficient income parents frequently have more than one job, meaning that they are often out-of-home and have reduced parental control and time to spend with their children. Furthermore, many children grow up in reconstituted families (World Factbook, 2017), increasing the chance of intrafamilial CSA. Adolescents in our study may have underreported intrafamilial CSA, as those still living at home might be reluctant to disclose such information (see also Priebe & Svedin, 2008).

Our study corroborates the concern of the UNCRC about CSA, the lack of shelters for child victims and information on investigations of CSA cases in Suriname (United Nations Committee on the Rights of the Child, 2016, Concluding Observations, Suriname, para. 21). The Committee urged Suriname to ensure the development of appropriate legislation, policies, and services for prevention and recovery in the field of CSA. As of February 2017, Suriname has not implemented any special programs that address the issue of CSA. Recently, one evidence-based parenting program to prevent child maltreatment has been implemented and evaluated (Van der Kooij, Bipat, Boer, Lindauer,

& Graafsma, 2017). Chapter 3

Strengths and limitations Our study enhanced disclosure by using an anonymous self-reporting instrument 61 administered outside of the home (Olsson et al., 2000; Veenema, Thornton, & Corley, Child sexual abuse in Suriname 2014). It also included peer-to-peer sexual victimization. The investigation of CSA was conducted through questionnaires that consisted of questions about specific behavior since multiple studies show higher reporting rates when this approach is taken (Veenema, Thornton, & Corley, 2014).

Our study is not without limitations. First, it relied upon children’s self-reported victimization and did not include any independent verification. Second, the data were collected solely from adolescents in school, and the children who may be also at risk of being exposed to CSA (e.g., drop-outs and children not sent to school) were therefore not included. Third, it is likely that the lack of absolute confidentially in the classroom setting could have influenced children’s willingness to report some (more shameful) experiences of maltreatment. Fourth, an individual’s culture and lived experience highly influence one’s perception of sexuality and sexual violence. Consequently, statements and questions that include subjective terms such as ‘abuse’ could be confusing because of differences in how study participants may define them. Using descriptive situations to describe CSA such as ‘being forced into sex against your will’ instead of ‘abuse’ promotes reporting and disclosure (Jewkes, Levin, Mbananga, & Bradshaw, 2002). However, the definition of CSA in our study was left open (‘a minor did things to me that I would consider sexual abuse’). Leaving the definition of these terms open to interpretation by the adolescent may have resulted in some false positive and false negative responses. Fifth, for financial and logistic reasons, it was not possible to collect this amount of data in one year. Therefore, we combined the data collected in 2008 and 2012–2013. We are aware that, for this reason, the rates might not provide a fully representative picture of the year prevalence of CSA in Suriname. Given the survey design, definitional issues, and sample characteristics, caution should be taken in generalizing our results to a different time period and different age groups.

Conclusion

Noting the detrimental and lasting impact of CSA it may be concluded that CSA is a major health problem in Suriname. Peers seem to constitute a significant portion of the offenders in adolescence. Our findings also show there is a substantial gap between known, substantiated cases of CSA, as reported to the police, and rates for the year prevalence of CSA reported in this research. The wide gap between police records and self-reported cases indicate that CSA in Suriname, especially as it pertains to boys, is still a taboo influenced by strong gender-based beliefs and expectations. Keeping the 62 high rates of CSA in mind, the government of Suriname might seriously consider the suggestions of the CRC and develop a number of measures in order to reduce CSA, e.g., establish mechanisms, procedures and guidelines to ensure mandatory reporting of CSA, conduct awareness-raising and education programs, ensure that all professionals working with and for children are provided with the necessary training and supervision, upgrade the existing shelter and open additional shelters for child victims of CSA and ensure the development of programs and policies for the prevention, recovery and social reintegration of child victims. REFERENCES

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Perceptions of corporal punishment among Creole and Maroon professionals and community members in Suriname

Inger W. van der Kooij Josta Nieuwendam Gerben Moerman Frits Boer Ramón J.L. Lindauer Jaipaul L. Roopnarine Tobi L.G. Graafsma

Child Abuse Review, 2017 ABSTRACT

Child discipline is a vital part of child rearing in all cultures. The need for child discipline is generally recognised, but considerable debate exists regarding the best methods. Corporal punishment (CP) is a dominant practice in Caribbean cultures. This qualitative study investigated community perceptions of the function, legality and boundaries of CP in child-rearing practices in Suriname, in which CP is defined as hitting a child on their buttocks or extremities using an open hand. Twelve focus group discussions were conducted with adolescent and adult community members from Creole and Maroon backgrounds, as well as with professionals working with children. ATLAS.ti version 7, a qualitative data package, was used to conduct the analyses. This study showed how violent forms of disciplining children are widely accepted and practiced in Suriname. CP is considered a necessary and respected form of disciplining children, particularly by parents. Participants know about the existence of the Convention on the Rights of the Child that has been ratified in Suriname, but there is a lack of knowledge about its content. Developing appropriate policy responses to violence towards children requires understanding of the perception and use of CP. Such knowledge is needed to tackle the invisibility and social acceptance of violence in child discipline. 68 INTRODUCTION

The United Nations Convention on the Rights of the Child requires nations to protect children against all forms of physical or mental violence while they are in the care of parents and others (Article 19). The United Nations Committee on the Rights of the Child (CRC) has underlined that corporal punishment (CP) as a form of violence is incompatible with this Convention (General Comment No. 13, CRC). Unfortunately, in various countries violence towards children – physical and mental – is socially and legally accepted in a variety of contexts (Stoltenborgh et al., 2015; UNICEF, 2016).

Child discipline is an integral and vital part of child rearing in all cultures. It can be thought of as the group of deliberate actions designed to teach children self-restraint and self-control resulting in acceptable behaviour for the specific sociocultural context in which a child is raised (Papalia et al., 2006). Perceptions of CP differ within and between countries and cultures (Lynch & Onyango, 2013; Nadan et al., 2015; Raman & Hodes, 2012). Whether CP is helpful or harmful to children continues to be the source Chapter 4 of considerable debate among both researchers and the public. The terms CP, ‘physical punishment’, and ‘spanking’ are largely synonymous. The majority of the studies use the term physical punishment, which is defined by Gershoff and Grogan-Kaylor (2016, p. 1) as ‘noninjurious, open-handed hitting with the intention of modifying child behavior’. 69 In their recent meta-analysis, however, they focused on the most common form of Perceptions of corporal punishment among Creole and Maroon physical punishment which is known as spanking, and which they defined as ‘hitting a child on their buttocks or extremities using an open hand’ (Gershoff & Grogan-Kaylor, 2016, p. 1). Harsher methods of physical punishment have been shown to be more strongly associated with negative child outcomes than ordinary spanking (Ferguson, 2013; Larzelere & Kuhn, 2005). Overall, in the same recent meta-analysis no evidence was found that spanking is associated with improved child behaviour but rather that spanking is associated with an increased risk of several detrimental outcomes (Ferguson, 2013; Gershoff & Grogan-Kaylor, 2016; Larzelere & Kuhn, 2005). There is increasing recognition of the importance of eliciting children’s and adolescents’ views about their own experiences (Breen et al., 2015). This is particularly important in the case of CP, as discrepancies have been found in how children and parents define CP (Dobbs & Duncan, 2004; Dobbs, 2007).

In the Caribbean, CP is a dominant practice (Smith, 2016). Suriname is one of two Caribbean countries geographically located in South America. Currently, three large ethnic groups are represented in Suriname, all of which have their own cultural characteristics (World Factbook, 2016). The largest of those is the Afro Surinamese group, the inhabitants of Suriname of Sub-Saharan African ancestry. This group can be divided into two subgroups – the Creoles and the Maroons – of which the Creoles are the mixed-race descendants of African slaves and Europeans, and the Maroons the runaway slaves who formed independent settlements together in the interior of the country (Eersel, 1984). Since its commitment to the implementation of the CRC in 1993, the Government of the Republic of Suriname has planned, executed, and evaluated programmes to set and improve the basic conditions for its implementation (United Nations Convention on the Rights of the Child. Committee on the Rights of the Child. Consideration of reports submitted by States parties under article 44 of the Convention. Third and fourth periodic report of States parties due in 2010: Suriname (CRC/C/SUR/3-4), 4 May 2015). CP, however, is still legal within the households and in schools. While the Surinamese Government recently stated that it accepts recommendations to prohibit CP in schools, there is as yet no formal prohibition to this end in legislation (UNICEF, 2016). Only in some 50 countries around the world (situation November 2016) CP is prohibited by law in all settings, including at home – no Caribbean country is among them yet.

CP is widely practised in Suriname. In our previous work (Van der Kooij et al., 2015), we reported that around 35 per cent of all adolescents and young adults in Suriname were subjected to CP, a rate comparable to that in other countries in the Caribbean (UNICEF, 70 2006, 2010; Global Movement for Children (GMfC), Latin America & Caribbean Division, Workgroup on Violence (2009). According to UNICEF (2014), this rate is considerably higher among younger ages. More than 80 per cent of the Surinamese children between the ages of 2 and 14 years were reported to have experienced violent physical discipline in the month prior to the interview. Suriname is no exception in the region: Barrow and Ince (2008) concluded that CP of children, including those below age five, is the norm in homes and communities across the entire Caribbean. So we may well assume that about four out of five children are subjected to some form of violent discipline at home. Interestingly, although CP is widely practised across the country, only 17 per cent of the Surinamese caregivers acknowledged that CP is a necessary child-rearing tool (UNICEF, 2010). This raises the question of whether these caregivers are aware that CP violates children’s rights.

This qualitative study aimed to explore community perceptions of CP as a method of disciplining children and personal experiences with CP in Suriname in further detail by conducting focus group discussions (FGDs) with adult caretakers, adolescents and professionals from Creole and Maroon backgrounds who resided in the studied community in Suriname. More specifically, the study aimed to address several issues: Is CP inherently thought of as a form of abuse in Suriname? If not, where does maltreatment start? Why and when do adults use CP? The data presented in this report are among the few resources available to help develop a more complete understanding of the nature of violent disciplinary practices in Suriname and their boundaries with maltreatment.

METHOD

Studied area

The study was conducted in three of 10 districts in Suriname with most inhabitants of Maroon and/or Creole ancestry: Paramaribo, the capital, in which almost half of the population of the country lives; and two rural districts, Brokopondo and Marowijne.

Participants

The study sample, divided in twelve focus groups, included 16 Maroon and/or Creole

Surinamese mothers (mean age = 41.2 years, SD = 9.2, age range: 29–55 years), 13 Chapter 4 fathers (mean age = 36.7 years, SD = 10.0, age range: 23–55 years), 20 adolescents (mean age = 14.9 years, SD = 1.3, age range: 12–18 years) and 18 professionals (male: 20%, mean age = 42.7 years, SD = 9.4, age range between: 27–57 years, most of whom were schoolteachers and social workers). Each focus group contained three to 71 eight participants (mean = 6). The focus group discussions all took place in March 2013. Perceptions of corporal punishment among Creole and Maroon

Focus Group Guide

A Focus Group Guide was developed (by TLGG, IWvdK, JN and GM) to ensure that each group included the same topics and similar questions. This guide included a series of questions about the prevalence of CP in Suriname (“Do you think that hitting is common in your district/country?” “If so, why do you think it is common in Suriname?” “What are mediating factors for CP?”), differences between CP and maltreatment (“What is the border between acceptable and not-acceptable treatment of children on a physical level?”), perceptions of CP (“Are parents allowed to hit their children?” “If yes, in what kind of situations?” “What is acceptable? When are you going too far?” “What is a lot? Once, once a week, a month?” “What if a child does not listen?”), own personal experiences (“Have you been hit (as a child)?”), and help available in Suriname (“What kind of help for children of parents is available in the country?”). In our study, CP was defined as hitting a child on their buttocks or extremities using an open hand. PROCEDURE

Sampling of the participants

One of the researchers (JN) organised a meeting with the district commissioners (rural areas) and school teachers (Paramaribo) to discuss the study objectives, the type of informants needed and ethical matters. Sampling of participants (caregivers, adolescents and professionals; largely equally distributed across groups in terms of socio-demographic characteristics) was performed by the tribal leaders (village heads) of the districts. Professionals were selected from the public sectors (e.g., teachers, government officials). Participant inclusion/exclusion criteria were established upfront.

Importantly, in establishing discussion groups, we tried to make sure that participants would feel comfortable sharing ideas with each other, by (1) establishing groups within a small age range (to avoid younger people feeling intimidated by older participants; (2) creating discussion groups of participants without large ‘power’ discrepancies (to avoid participants not being willing to make candid remarks with superiors present) and (3) avoiding cliques (influential school peers). The tribal leaders and schoolteachers used these criteria as a basis to screen potential applicants. All participants were contacted by the tribal leaders or schoolteachers and briefed about the study aims before being asked 72 to participate in a group discussion. All potential participants who were approached and could make the time for the focus group discussions agreed to participate. To avoid any potential inhibition of expressing certain views in the company of the opposite gender, for the parents/caregivers homogeneous discussion groups were created. Since professionals were mainly asked about their (general) perceptions of CP in their institution in Suriname, and the adolescents were already familiar with each other, they were both placed in mixed-gender groups.

Data collection

All focus group discussions took place in schools, except for one, which was conducted at the home of one of the participants. Each focus group began with several standardised questions meant to help bring up the different forms of CP. The two moderators (IWvdK, a female child psychologist from the Netherlands, and JN, a female social anthropologist from Suriname) followed a standard focus group procedure (consent process, introduction, explanation of the process, logistics, ground rules, ask for questions, turn on the tape recorder, start focus group discussion). After this procedure, both moderators loosely followed an interview guide (Focus Group Guide), which they modified and interspersed with probes according to the flow of conversation. In a typical group, the participants sat together in a horseshoe position and responded to questions posed by the group moderator. All focus groups were audiotaped. Participants were divided into four different groups, i.e. adolescents (12–18 years, mixed), males (fathers), females (mothers) and professionals (mixed). The discussions lasted between 45 minutes to one hour and 15 minutes. For the discussions with adolescents, an example vignette of an abused child – which was deliberately chosen for a description of an extreme form of CP – was used to serve as discussion starter and encouragement for participants to share their ideas about their own memories and/or experiences.

Analysis

The discussions were transcribed verbatim. Original statements were sometimes given in Sranan Tongo, as this is the everyday language in the country. The research team (JN) translated these discussion quotes into Dutch, the country’s official language. The twelve focus group transcripts were coded and analyzed using ATLAS.ti (version 7.5.4). Chapter 4 At the end of the group sessions, IWvdK wrote memos regarding initial thoughts on the interpretation of content and process. These memos served as the basis for a preliminary list of qualitative codes. To develop this list IWvdK used initial coding, as suggested by Charmaz (2014), but with a more exploratory and descriptive objective. The initial coding 73 phase was followed by focused coding in order to reduce the complexity and bring more Perceptions of corporal punishment among Creole and Maroon focus to the analysis. The focused coding was especially aimed at highlighting recurring statements, themes and ideas shared within the groups. IWvdK and GM used a constant comparison strategy (Charmaz, 2014) to refine these focused codes into categories that were applicable to all data. Both researchers have put a strong emphasis on looking for deviant cases and nuances in the data, in order to allow for qualitative complexity, rather than simplicity. In order to achieve saturation of the categories (Strauss & Corbin, 1998), IWvdK used these final categories to link the most salient themes and shared perceptions to their necessary conditions, consequences, contexts and contradictory uses. The result of these different iterative coding procedures and the collaborative interpretation of the categories led to the various conceptualizations of CP, as discussed below.

Ethical issues

The study received ethical approval from the Ministry of Education and the Ministry of Regional Development. In addition, permission was obtained from different community authority levels in the rural districts in Suriname. Participants were informed about the study aims and procedures by letter and in person. Consent forms for the focus group participants were completed in advance by all those willing to participate. Before each focus group, the purpose of the study and issues of confidentiality were discussed with the participants.

RESULTS

No gender differences were observed between parents, and parents and professionals (mixed-gender) did not differ in their perceptions regarding the use of CP towards their children. For this reason, results were combined into one ‘adult’ group.

Is CP inherently a form of abuse?

Adults Most adults, parents and professionals, agreed that CP was not inherently a form of child abuse. To most adults, parents have the right to discipline a child using CP. However, CP was considered abusive in two circumstances. First, CP was thought of as a form of maltreatment in case of physical injuries and psychological harm visible to observers:

“About physical abuse I would say: if bruises appear. Giving the child a 74 little slap is not abuse. Wantonly flogging is not allowed. There should be no scars. You can tell it is abuse if someone has bruises and scars.”

“You can punish a child with a stick or with your hands. Punishment without visible injury is not abuse.”

One parent remarked that injuries are not always visible to outsiders:

“Sometimes you give a slap without injuries on the outside, but then on the inside… A little slap is allowed, but if it is causing internal injuries, it is called abuse.”

Second, in all of the focus groups, adults qualified their statements in support of CP by adding that when such punishment is carried out in a fit of irritation and anger instead of a conscious disciplinary practice it becomes maltreatment:

“If I take my anger out at him, what do I do? A parent needs a house full of patience, because if you punish when you are angry, it becomes abuse.” Adolescents Adolescents generally agreed with adults in that caretakers have the right to use CP. However, just like adults, adolescents felt that CP could become abuse in several circumstances, i.e. (1) when blood flows, (2) when it hurts, or (3) when it causes sadness. They hinted at impulsive CP when stating that CP (4) carried out “for no acceptable reason” is a form of maltreatment. “Physical child maltreatment means that someone hurts you, without a reason”. Adolescents agreed that parents are allowed to give the child a slap or a punch without becoming abusive when children are not behaving well. In other words, there has to be an understandable ‘educational’ goal. According to the adolescents questioned, beating a child with a stick is allowed, “but not too often”. Similar to statements of the adults, adolescents agreed that beating with a stick turns into abuse when blood flows. However, while almost every adolescent reported that they had been beaten by their parents with bruises or scars as a result, they stated this did not feel like abuse if they thought they deserved it. “It can happen accidentally”, one child said, “When parents beat too hard”. But if a parent caused bruises on purpose, or Chapter 4 had beaten the child “black and blue”, the punishment was thought of as maltreatment.

Adults and adolescents showed similar responses to whether CP is abuse or not. They both see CP as abuse when physical injuries emerge (‘when blood flows’). Furthermore, by saying ‘without a reason’, adolescents seem to allude to a similar perspective among 75 adults: CP is abuse when it is carried out in a fit of anger and frustration. Perceptions of corporal punishment among Creole and Maroon

CP: why should it or should it not be used?

Adults Most adults, parents and professionals, stated that CP should not be allowed in schools and other institutions. They perceived the use of CP at home to be an ‘inalienable right’ of parents – but of parents only.

“Corporal punishment… A teacher should not use it. That does not say it does not happen. A toddler hit me and I hit back in a reflex. I physically punish my own children if the situation gets out of hand. A little slap, I do that occasionally, but I stop before blood flows.”

In all focus groups, CP was said to be a common phenomenon that, for most, was a relatively normal and necessary tool in the correction and education of children. Adults hoped that CP would help to teach their children right from wrong, keeping them on the right path. A major justification was the conviction of parents that CP is an effective means to that end, in particular when nothing else seems to work. In their justification, some adults referred to their own personal history. One adult mentioned he deserved it and it did him good. “If they would not have hit me at school, I would still be a toddler”. However, opinions about the acceptability and usefulness of CP varied. Some adults believed that CP should be followed by an explanation of the motive. “When you punish the child or give the child a little slap, the child should always know exactly why that happened.” … “Hey, that I slapped you means that I am angry with you, not that I do not love you!” Overall, it seems that CP was thought of as acceptable if the motives are clearly explained to the child.

Some adults reported that their mind-sets about the acceptability and usefulness of CP changed over time:

“I am a mother of eight children. I have given them any type of punish- ment. I was still immature. Now I am not anymore. Now I will never do that again.”

Another adult mentioned:

“In my work I am really not allowed to hit children. I was taught not to hit children. I had to be taught not to hit my children, because I was used 76 to doing that…” Furthermore, some adults mentioned the emotional and physical consequences of CP for the child. “The child gets traumatized. Sometimes children talk about headaches, pressure on their nose, suddenly nose bleedings or pain in the ear”. “To slap a child’s ears… It is bad for the eardrums”. Consequences of CP for the parents themselves were also mentioned: “A slap to the ears happens easily but is dangerous. Then you have to go to the doctor on-and-off”. One mother mentioned the fear of being seen as an abusive mother:

“My daughter literally has a thin skin. When I give her one slap when she is doing something wrong, you can immediately see it. Others will think: this mother has maltreated her child.”

One father said: “Pupils know the teacher is not allowed to use violence. The child knows that and can call the children helpline”. For some, their own experiences in the past seemed reason to avoid repetition: “My father maltreated me too. I always said I would never hit my own children. And I never did”.

There were adults who felt that children should never be hit. They considered CP a form of aggression that did not teach anything good. On the contrary, they believed it scares children and harms a child’s personality: “You have to remember: the sadness you feel when you hit the child, the child feels this as well. That is why you do not hit your children. You talk with children.”

Some of the adults, when probing for detrimental consequences, said they experienced regret after using CP. They voiced concern that CP could cause harm to children when they reached adolescence. “It can cause injuries and psychological trauma. Children will sometimes hide from others, in which case it shows that they are maltreated”. Some adults emphasized that they preferred using positive interactions, explanations and non-physical forms of discipline rather than CP. As one parent said: “You have to talk in a friendly way. You should ask him what he wants and make sure he is calm and quiet”.

Adults mentioned that the decision to use CP is influenced by various socio-cultural contexts. In certain social circumstances (single parent families, large families, poverty) adults perceived CP to be normative and almost inescapable:

“If you have one child or you have two children. But I have 10 children. Chapter 4 I am 34 years old. My eldest son is 15 years old. If I do not stand up, he is going to walk all over me, you know?” One adult mentioned the link between the lack of social services and educational 77

support and CP: Perceptions of corporal punishment among Creole and Maroon

“For example, that girl gets pregnant. Then you have to go to the Ministry of Social Affairs, the requirements which a girl has to fulfil… They don’t help you. You have to raise your children using force.”

Adults were aware of the changing views in favour of approaching and communicating with children:

“Little boys and girls nowadays are really rude. Because of the European law children feel powerful. They tell their parents that they are not allowed to beat them.”

In particular, in the rural areas (Brokopondo and Marowijne), adults spoke about rights of children as something that they were not accustomed to:

“So, people have written down the rights of the child, isn’t it? But there is never a day set aside to discuss the duties of the child. People talk about the rights of the child all the time, but you never hear anything about their duties.” Adults expressed the fear that when they do not apply CP their children might end up on the street. They worry that children’s rights have a harmful influence on their behaviour:

“Picture that at a certain point in time, you are not even allowed to speak to your children. You cannot even shout to them … And at a certain moment, these children will end up on the street.”

Adults agreed that CP is more or less accepted. The introduction of the CRC however brings new perceptions of CP and the dignity of the child. In fact, respect now has to come from two sites (both adult and child), which is in contrast to the common perceptions that children have to respect adults. ‘In the best interest of the child’ and the ratification of the CRC is something that causes fear and conflict in parents. For example, they fear that children may take over power or no longer accept the authority of parents. Most parents do not know the CRC, and those who do are more or less ambivalent and perceive the convention as something ‘Western’.

Adolescents For some adolescents it was difficult to talk in a group about their perceptions of CP. To lower the threshold to speak about CP, in two out of the three adolescent focus 78 group discussions first an example vignette of an abused boy was read out loud (See Supplement 4.1). One adolescent mentioned that this case was abuse, not in the first place because of CP, but because of the fact that this boy had to work as a child. Other adolescents mentioned that this was abuse because the father hit the child and because fathers cannot force children to work for them. One adolescent said: ‘I think that children should not be beaten’. When the moderator mentioned that children sometimes make a parent very angry, this same adolescent opted for a non-violent punishment, such as chores that the child could carry out.

Some other adolescents stated that hitting a child is sometimes justifiable: “They are allowed to hit you, when you deserved it”. One adolescent stated that his father hits him indiscriminately, e.g., in case of bad grades or when he does not want to rake the garden. He added that he hopes to avoid hitting his own children, when grown up. “Not like this, this is bad”, in which he referred to a lack of reason for the severe punishment.

Most adolescents remarked that hitting does not help the child to listen better and that talking to a child is the best option. “Spanking does not help, you’d better talk. You have to talk a lot with a child. Perhaps something is bothering the child”. Adolescents often mentioned reasons why parents disciplined children physically. “Sometimes when your parents don’t have enough money or when they have too much stress, they are going to hit you”. They tended to understand and forgive the parent’s anger and frustration. However, all adolescents indicated a preference for a non-violent approach: they wanted to be heard, and to be talked to rather than being beaten:

“Well, you should talk to the child. Maybe something is bothering the parent and he or she does not know how to get out. And you do not know if there is anything wrong with the child. So you have to talk to him, because you do not know what is going on.”

The issue addressed here seems to involve the desire of adolescents for their caretakers to first listen to a child in order to examine what is going on. Adolescents acknowledged that both parents and children could have problems. They all emphasized that CP “without a reason” should not be allowed:

“Well, if your parents spoke too much to you and you did not listen. Then they are allowed to give you a strong beating. But they are not allowed Chapter 4 to maltreat you.”

DISCUSSION

Through the use of focus group discussions with community representatives in three 79 Perceptions of corporal punishment among Creole and Maroon districts of Suriname, we explored perceptions around the use of CP. Most participants in this study, adults and adolescents, believed that using some form of CP at times is a necessary and respected form of disciplining children. Adults believed that CP was both useful and essential in certain situations, particularly when children were ‘bad mannered’ or would not respond to forms of discipline other than CP. They emphasized that they use CP in the best interests of the child, and thus, not with the intention to damage the child. Participants mentioned both internal and external factors supporting the use of CP. Internal factors included parents’ own experiences with CP as a child, perceived normativeness of CP within their communities, and their own ideas of CP as an effective way of discipline. External factors included poor and stressful circumstances, as for example single parent families. Participants did consider the lawfulness of the behaviour, but were primarily interested in the intentions of the caretakers when using physical discipline. If these were interpreted ‘in the best interest of the child’, and not just expressions of anger and frustration, CP was not considered maltreatment.

Most adults understood that CP has the potential of being psychologically and physically harmful. However, perceived benefits, such as compliance of children, seemed to take the upper hand. Parents did express the wish to be able to discipline their children in non-violent ways, but lacked the skills to do so. The CRC and its ratification changes the relations between generations for many communities, as most people still believe in the usefulness of CP. In their perception, ‘in the best interest of the child’ would result in a society in which children have too much rights and will become too powerful. We found no urban/rural distinction in viewpoints regarding these matters.

Consistent across all focus groups was the idea that CP should be allowed as a ‘last resort’ in keeping children on a path toward responsible citizenship and behaviour, and preventing them from getting involved in dangerous activities and unhealthy lifestyles (see also Roopnarine et al., 2014). Unfortunately, these motives are in conflict with the growing body of evidence suggesting that CP is associated with risk for increased aggressive behaviour (see for example Mills, 2013; UNICEF, 2014) and that other, non- violent ‘positive parenting’ methods of disciplining children exist that assist caretakers to teach children self-control and acceptable behaviour (Pickering & Sanders, 2016). This study confirmed some findings from other Caribbean countries, such as research from Jamaica (CP as a result of a loss of parental control; Brown & Johnson, 2008) and Barbados (the endorsement of CP by parents and adolescents; Anderson & Payne, 1994). In addition, our findings are in line with research findings of 34 low- and middle- income countries, which showed that still large proportions of children are subjected 80 to CP even if their mothers/primary caregivers did not consider this method necessary (Cappa & Kahn, 2011).

Limitations

While we have made every attempt to provide an accurate and balanced report of this study, there are a number of potential limitations. First of all, the findings reported only represent the views of the Creole and Maroon participants in this study and should not be seen as representing all Creole and Maroon inhabitants of Suriname. At this moment, a qualitative study among Indo Caribbean inhabitants of Suriname is being conducted to examine the viewpoints within this population. Second, the data on children’s views were solely collected within schools, which may have excluded children most at risk for being exposed to violence (e.g., drop-outs and children not sent to school). Third, the focus group that was conducted at the home of a respondent seemed to result in more openness of the participants compared to the focus groups carried out at school. Schools as official educational institutions might lead to socially desirable responses that fit with perceived school policy on child rearing, as well as responses that fit with what the researchers might want to hear. Fourth, the researcher present at the focus groups was from Dutch descent (white) and unknown to the participants before the focus groups started. It is possible that the participants would have responded differently if this researcher had been native or an acquaintance. While the Surinamese moderator and Dutch researcher both did not notice any restraint or discomfort, the historical background of Suriname as a colony of the Netherlands might have influenced people’s statements during the focus groups. In a study dealing with a sensitive topic like this, the moderators took efforts to establish relationships with their group participants in order to delve deeply into the subject matter. Furthermore, the moderators’ own perceptions of CP might have influenced their attitude, body language, tone, etc. This might have biased the results. Fifth, we should be aware of the possibility of underreporting of CP. Arguably, it is difficult for children to criticize their own parents and to put themselves in the victim role (by labelling what they have experienced as child abuse), which might have biased the findings.

Strengths

Focus group discussions provide certain advantages that other qualitative data-gathering Chapter 4 techniques do not have. As a way of collecting qualitative data, focus group discussions are particularly well suited to explore cultural issues, because participants have the opportunity to elaborate on the norms and values underlying cultural practices, establish their own categories, and place emphases where they wish. Interactions between focus 81 group members can lead to the introduction and discussion of different aspects of a Perceptions of corporal punishment among Creole and Maroon topic. Focus group discussions are an efficient way to gather opinions from groups of people over a short period of time (Stewart & Shamdasani, 2014). Moreover, participants often find focus group discussions less threatening than individual interviews addressing sensitive topics (Farquhar & Das, 1999). Some specific strengths of this study should be mentioned as well. First, this is the first qualitative study to address the practice of CP in Suriname. Second, the research team was familiar with the environment as well as with the socio-political structures. The multi-professional and non-professional composition of the focus groups gave richness and wide perspective to the findings. Third, the focus groups were designed in such a way as to enhance participants’ comfort with the situation and openness in responding to the questions – e.g., initial questions in the interview were non-threatening in nature, gradually leading to more sensitive questions, including their own experiences of discipline in childhood and eventually the use of CP with their own children. In regard to future research, the focus group topics can be accommodated in a more quantitative set-up. Conclusion

The study shows that, under certain circumstances, CP is accepted and applied in Suriname, despite growing knowledge of its harmful consequences. Both adults and adolescents consider CP a necessary and respected form of disciplining children at times. CP is not considered maltreatment as long it is interpreted as ‘in the best interest of the child’. In general, it is thought of as a form of child disciplining when nothing else works.

The data presented in this study are among the few resources available to develop a more complete understanding of the nature of child discipline in Suriname. Our findings can help to guide efforts to prevent violent discipline and encourage positive parenting. In general, child maltreatment prevention studies concluded that parent education programmes show promise in reducing the risk factors for child maltreatment and for actually preventing child maltreatment (Barlow, 2014; Chen & Chan, 2016). Unfortunately, there is a lack of available evidence-based parenting programmes in Suriname (Van der Kooij, Bipat, Boer, Lindauer, & Graafsma, 2017). Developing appropriate policy responses to the issue of violence towards children requires an understanding of what motivates caregivers to choose among different ways to discipline children. Such information may be helpful when developing and implementing laws, policies, regulations and services 82 for prevention and response to violence towards children in general. REFERENCES

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schappelijke Informatie. [Eersel, H. (2002). Language and people in the Surinamese society. Chapter 4 Paramaribo: Foundation Scientific Information]. Farquhar, C., & Das, R. (1999). Are focus groups suitable for ‘sensitive’ topics? In R. S. Barbour & J. Kitzinger (Eds.), Developing Focus Group Research (pp. 47-63). Sage: London. Ferguson, C. J. (2013). Spanking, corporal punishment and negative long- term outcomes: A meta- analytic review of longitudinal studies. Clinical Psychology Review, 33, 196-208. Gershoff, E. T., & Grogan-Kaylor, A. (2016). Spanking and child outcomes: Old Controversies and 83 New Meta-Analyses. Journal of Family Psychology. Perceptions of corporal punishment among Creole and Maroon Global Movement for Children (GMfC), Latin America & Caribbean Division, Workgroup on Violence (2009). Mapping the Caribbean for follow up to the UN SG’s Study on Violence Against Children. SMC Research Foundation: Aruba. Kooij, I. W. van der, Nieuwendam, J., Bipat, S., Boer, F., Lindauer, R. J. L., & Graafsma, T. L. G. (2015). A national study on the prevalence of child abuse and neglect in Suriname. Child Abuse & Neglect, 47, 153-161. Kooij, I. W. van der, Bipat, S., Boer, F., Lindauer, R. J. L., & Graafsma, T. L. G. (2017). Implementation and evaluation of a parenting program to prevent child maltreatment in Suriname. American Journal of Orthopsychiatry. In press. Larzelere, R. E., & Kuhn, B. R. (2005). Comparing child outcomes of physical punishment and alternative disciplinary tactics: A meta- analysis. Clinical Child and Family Psychology Review, 8, 1-37. Lynch, M. A., & Onyango, P. (2013). Understanding Child Abuse and Neglect Across Cultures: Reflections from Kenya and the UK. In C. H. Kempe, A 50 Year Legacy to the Field of Child Abuse and Neglect (pp. 247-256). Springer Netherlands. Mills, R., Scott, J., Alati, R., O’Callaghan, M., Najman, J. M., & Strathearn, L. (2013). Child maltreatment and adolescent mental health problems in a large birth cohort. Child Abuse & Neglect, 37(5), 292-302. Nadan, Y., Spilsbury, J. C., & Korbin, J. E. (2015). Culture and context in understanding child maltreatment: contributions of intersectionality and neighborhood-based research. Child Abuse & Neglect, 41, 40-48. Papalia, D. E., Olds, S. W., & Feldman, R. D. (2006). A Child’s World. Infancy through Adolescence (10th ed.). New York: Mc Graw-Hill. Pickering, J. A., & Sanders, M. R. (2016). Reducing Child Maltreatment by Making Parenting Programs Available to All Parents A Case Example Using the Triple P-Positive Parenting Program. Trauma, Violence, & Abuse, 17(4), 398-407. Raman, S., & Hodes, D. (2012). Cultural issues in child maltreatment. Journal of Paediatric Child Health, 48(1), 30-37. Roopnarine, J. L., Krishnakumar, A., Narine, L., Logie, C., & Lape, M. (2014). Relationships between parenting practices and preschoolers’ social skills in African, Indo, and Mixed-ethnic families in Trinidad and Tobago: The mediating role of ethnic socialization. Journal of Cross-Cultural Psychology, 45, 362-380. Smith, D. E. (2016). Corporal punishment of children in the Jamaican context. International Journal of Child, Youth and Family Studies, 7(1), 27-44. Stewart, D. W., & Shamdasani, P. N. (2014). Focus groups: Theory and practice (Vol. 20). Sage Publications. Stoltenborgh, M., Bakermans-Kranenburg, M. J., Alink, L. R., & IJzendoorn, M. H. (2015). The Preva- lence of Child Maltreatment across the Globe: Review of a Series of Meta-Analyses. Child Abuse Review, 24(1), 37-50. Strauss, A. L., & Corbin, J. M. (1998). Basics of qualitative research: Techniques and Procedures for Developing Grounded Theory. London: Sage. UNICEF. (2006). Multiple Indicator Cluster Survey-3, Suriname. Monitoring the situation of children and women. UNICEF. Retrieved from: http://www.childinfo.org/files/MICS3_Suriname_ FinalReport_2006_En.pdf (accessed November 2016). UNICEF. (2010). Multiple Indicator Cluster Survey-4, Suriname. Monitoring the situation of children and women. UNICEF. Retrieved from: http://www.childinfo.org/files/MICS4_Suriname_ FinalReport_Eng.pdf (accessed November 2016). UNICEF. (2014). Hidden in plain sight. Retrieved from: http://files.unicef.org/publications/files/ Hidden_in_plain_sight_statistical_analysis_EN_3_Sept_2014.pdf (accessed November 2016). UNICEF. (2016). End Corporal Punishment Now. Retrieved from: http://www.endcorporalpunishment. org/assets/pdfs/states-reports/Suriname.pdf (accessed November 2016). 84 World Factbook. (2016). Retrieved from: https://www.cia.gov/library/publications/the-world- factbook/geos/ns.html (accessed November 2016). SUPPLEMENT 4.1 VIGNETTE

The eight-year old Timbai lives with his father, mother, grandmother, sister, brother and newborn sister in the city (Paramaribo). Father is a woodworker (Tembe) and has his workshop at home. Mother works as a cleaner. Grandmother is old. She does not work anymore. Timbai and his sister are going to school. Timbai has to help his father when his father is busy. If he does not do so, he is being kicked and beaten by his father. Sometimes father throws him to the ground or hits him on his back with a piece of wood. Timbai does not participate in swimming, because he is ashamed of his bruises. Chapter 4

85 Perceptions of corporal punishment among Creole and Maroon 86 5

Perceptions of adolescents and caregivers of corporal punishment: a qualitative study among Indo Caribbean in Suriname

Inger W. van der Kooij Rita K. Chotoe-Sanchit Gerben Moerman Ramón J.L. Lindauer Jaipaul L. Roopnarine Tobi L.G. Graafsma

Violence & Victims, state of final acceptance ABSTRACT

While the protection of children from all forms of violence is a fundamental right guaranteed by the Convention on the Rights of the Child, violence remains a part of life for children around the globe. Corporal punishment is a form of violence and a dominant practice as a method of corrective parenting in the Caribbean. While researchers are starting to ask children directly about their experiences of violence, there is limited research on children’s perspectives of the function, legality and boundaries of corporal punishment, particularly in low-income and middle-income countries. This study begins to address this gap by reporting on 12 focus groups that were conducted with adolescents (aged 12 to 18 years) and caregivers of Indo Caribbean background in Suriname. The aim is to explore adolescents’ and caregivers’ shared perspectives about the prevalence of corporal punishment in Suriname, responses to and feelings about its use as a discipline strategy and perspectives of the rationales for and against corporal punishment, and their views on banning it. Analyses were done using ATLAS.ti version 1.0.50, a qualitative data package. Corporal punishment showed to be an everyday experience in children’s lives in Suriname. There was no clear consensus regarding adolescents’ and caregivers’ perspectives on the parental use of corporal punishment. Many participants hesitated to support efforts to prohibit corporal punishment legally. 88 Messages arising from this study could usefully inform the development of a public information campaign on safe and effective discipline of children in Suriname. INTRODUCTION

The protection of children from all forms of violence is a fundamental right guaranteed by the Convention on the Rights of the Child. Yet violence remains a part of life for children around the globe – regardless of their economic and social circumstances, culture, religion, or ethnicity – with both immediate and long-term consequences (Finkelhor, Turner, Shattuck, & Hamby, 2013; Vachon, Krueger, Rogosch, & Cicchetti, 2015). One of the challenges facing preventative efforts that aim to decrease children’s exposure to violence is the use of corporal punishment as a discipline method (Gershoff, 2010; Gershoff, Purtell, & Holas, 2015; Holden, Brown, Baldwin, & Caderao, 2014; UNICEF, 2014; UNICEF, 2016). The terms ‘corporal punishment’, ‘physical punishment’, and ‘spanking’ are largely synonymous. The majority of the studies define corporal punishment as non-injurious, open-handed hitting with the intention of modifying child behaviour (Gershoff & Grogan-Kaylor, 2016). Parents who rely on corporal punishment are at greater risk for physical child abuse than parents who do not rely on corporal punishment (Fréchette, Zoratti, & Romano, 2015; Meinck, Cluver, Boyes, & Mhlongo, Chapter 5 2015; Zolotor, Theodore, Runyan, Chang, & Laskey, 2011).

Corporal punishment continues to be prevalent in many countries around the world. A report (UNICEF, 2010) on corporal punishment in 35 low- and middle-income countries 89 notes that more than 80% of the Surinamese children between the ages of 2 and 14 Perceptions of corporal punishment among Indo Caribbean reported experiencing corporal punishment in the month prior to the interview. In a national prevalence study on child abuse and neglect (Van der Kooij et al., 2015), +/- 35% of all adolescents and young adults in Suriname reported that they had been subjected to corporal punishment in the year prior to the interview (corporal punishment was measured as physical assault within the family, including excessive corporal punishment) - a rate comparable to those of other countries in the Caribbean (Global Movement for Children, 2009; UNICEF, 2006; 2010). Cultural beliefs about the necessity and usefulness of corporal punishment and norms in favour of violence can contribute to the use of corporal punishment as a discipline method (Lansford et al., 2015). From the earliest writings on Caribbean childrearing, harsh and authoritarian types of discipline have been described as commonplace; ‘beatings’ (with hand, belt or instrument) are in fact defended as essential tools of the responsible parent throughout the Caribbean (Arnold, 1982; Clarke, 1999; Leo-Rhynie, 1997; Payne, 1989; Smith, 2016). Despite Suriname’s commitment to the implementation of the Convention on the Rights of the Child in 1993, corporal punishment is still legal within households and schools (situation November 2016; UNICEF, 2016). Suriname shows some of the highest suicide rates in the world for girls and the second-highest rate for boys (Kõlves & De Leo, 2014), even for very young children (Graafsma, Westra, & Kerkhof, 2016). Trauma and abuse are risk factors for suicide on the community level. In this context, the estimates of prevalence of corporal punishment and other forms of violence against children in Suriname are worrying (Martin, Dykxhoorn, Afifi, & Colman, 2016; Ministry of Health, Suriname, 2016).

Most studies on corporal punishment have focused on the perspectives and beliefs of parents, and thus little is known about how children and adolescents perceive their parents’ use of corporal punishment on them (Vittrup & Holden, 2010). There is increasing recognition of the importance of eliciting childrens’ and adolescents’ views about their experiences (Breen, Daniels, & Tomlinson, 2015). This is particularly important in the case of corporal punishment, as discrepancies have been found in how children and parents define corporal punishment. Studies where researchers investigate corporal punishment solely from the parents’ point of view lead to an incomplete picture, as children and parents often interpret events differently (Vittrup & Holden, 2010; Breen, Daniels, & Tomlinson, 2015). Discrepancies have been found in how children and parents define spanking with parents defining it as ‘a gentle tap or a loving smack’, whereas children defined it as a ‘hard hit’ or a ‘very hard hit’ (Dobbs & Duncan, 2004, p. 376). In order to get a more complete picture of the context and experiences of discipline, it is important to understand children’s perspectives. A recent study on perceptions of 90 corporal punishment among Creole and Maroon adolescents, caregivers and professionals in Suriname showed that a majority of parents approve of and use corporal punishment under certain circumstances, despite growing knowledge of its harmful consequences. Adolescents and caregivers were primarily interested in the intentions of caregivers when using corporal punishment. If these were interpreted as ‘in the best interest of the child’, and not merely expressions of anger and frustration, neither the adolescents nor the caregivers considered corporal punishment maltreatment. However, all adolescents preferred other methods of discipline, such as reasoning or withdrawing privileges. Some caregivers did express the wish to be able to discipline their children in non-violent ways but suggested that they lacked the skills to do so (Van der Kooij et al., 2017). Other researchers have found variations in harsh methods of disciplining children also among Caribbean ethnic groups. African and mixed-ethnic Caribbean caregivers were more likely to use harsher forms of discipline compared to Indo Caribbean caregivers (Roopnarine, Jin, & Krishnakumar, 2014; Roopnarine, Krishnakumar, Narine, Logie, & Lape, 2014).

There is a lack of research from low- and middle-income countries on perspectives of corporal punishment. The present study begins to address this gap by reporting on 12 focus groups that were conducted with adolescents (aged 12 to 18 years) and caregivers of Indo Caribbean background in Suriname. The aim of present study is to explore adolescents’ and caregivers’ shared perspectives of the prevalence of corporal punishment in Suriname, responses to and feelings about its use as a discipline strategy and perspectives of the rationales for and against corporal punishment, and their views on banning it. Findings are expected to contribute to an improved cultural-ecological understanding of the use of corporal punishment with the potential to inform family and community-based practices in Suriname.

METHOD

Study setting

Suriname’s multi-ethnic population of around 540,000 inhabitants consists of people of Afro Surinamese, Indo Caribbean, Javanese, and mixed-ethnic ancestry. There are also smaller numbers of individuals of European, Chinese, and Brazilian ancestry. Around 27.4% (180,000 inhabitants) of the population is from Indo Caribbean background Chapter 5 (General Bureau Statistics Suriname, 2016). People of Indo Caribbean ancestry were brought as indentured servants to supplement the shortage of labour on the English and Dutch plantation system following the abolition of slavery (Roopnarine, 2013). Suriname’s capital, Paramaribo, houses almost half of the country’s population. New Nickerie, the capital of the rural district Nickerie, is the second largest city in the country, while Wanica 91 Perceptions of corporal punishment among Indo Caribbean and Saramacca are more rural in nature. Suriname is considered part of the Caribbean, as it shares a common socio-historical experience with and maintains geo-political ties to other Caribbean countries, as well as Guyana and Belize. The study was conducted in four of Suriname’s 10 districts (Paramaribo, Nickerie, Wanica, and Saramacca) with most inhabitants of Indo Caribbean ancestry.

Study design and sampling

12 focus groups were conducted with 32 mothers, (age range: 34–59 years), 18 fathers (age range: 30–56 years), and 46 adolescents (age range: 12–19 years) of Indo Caribbean background, living in Paramaribo, Nickerie, Wanica, and Saramacca. These four districts were chosen because of the highest concentration of inhabitants of Indo Caribbean background. Each focus group contained 2 to 14 participants (mean = 5.7). Because the schoolteachers were responsible for collecting the sample, they only did register the participants that actually were able to participate in the focus groups. Each focus group lasted between 45 and 75 minutes, with an average of 53 minutes. Four primary schools were selected as sample sites. This selection was made because these schools are relatively large and thus serve children from different areas of the districts. The schoolteachers of the schools consecutively performed sampling of participants, largely equally distributed across groups in terms of socio-demographic characteristics. Participant inclusion/exclusion criteria were established upfront. Importantly, in establishing discussion groups, we tried to make sure that participants would feel comfortable sharing ideas with each other, by (1) creating focus groups without large ‘power’ discrepancies (to avoid participants not being willing to make candid remarks with superiors present); (2) establishing focus groups within a small age range (to avoid younger people feeling intimidated by older participants); and (3) avoiding cliques (dominated by influential school peers, for example). The schoolteachers used these criteria as a basis to screen potential applicants and thus were responsible for collection the sample. The participating mothers and fathers were not the parents/caretakers of the participating adolescents. All participants were contacted by the schoolteachers and briefed about the study’s aims before being asked to participate in a group discussion. Individuals who were approached and could devote time for the focus groups agreed to participate. There is evidence that males and females interact differently in mixed-sex as opposed to same-sex groups, and this has prompted some to suggest that focus group sessions should be homogenous in terms of gender (Stewart & Shamdasani, 92 2014). However, this assumes a focus on content only rather than process (Hollander, 2004). A shared history can facilitate openness by offering validation via the sharing of experience (Frith, 2000). To minimize disruption, focus groups with adolescents consisted of children from the same class. It was determined that mixed-sex groups of adolescents would work best because the boys and girls were already familiar with each other from being in the same class at school. To minimize potential inhibition of expressing certain views in the company of the opposite sex, homogeneous focus groups were created for caregivers.

Data analysis and validation

All interviews were audiotaped with permission. They were then transcribed verbatim by IWvdK (a Dutch female child psychologist). RCS (the moderator, a female Indo Caribbean woman, retired social worker, schoolteacher, and inspector of education with extensive experience in working with children and adults and leading groups) translated words given in Sarnami (daily language of the Indo Caribbean in Suriname) into Dutch (the formal language of the country). At the end of each focus group, memos (reflexive notes about the focus group) regarding initial thoughts on the interpretation of content and process were attached to the transcripts. Before being analysed, all transcripts were reviewed by another member of the research team (TG: professor in clinical child and youth psychology in Suriname). The twelve focus group transcripts were coded and analysed using ATLAS.ti (MAC version 1.0.50). The analysis started by re-reading the transcripts with annotations in relation to the study’s aim and research questions. The specific questions were: (1) “Do you think that corporal punishment is common in your district/country and why do you think it is (not) common in your district/Suriname?” (2) “What do you think about the use of corporal punishment?” and (3) “What do you know/ think about the law regarding corporal punishment?” and “What do you think about prohibition of corporal punishment at home and at school?” (see Focus Group Guide, Supplement 5.1). The text was then divided, coded into the different themes that were set upfront in the Focus Group Guide, list based on Van der Kooij et al. (2017). The final themes after different iterations were: (1) adolescents’ and caregivers’ perspectives of the prevalence of corporal punishment in Suriname, (2) responses to and feelings about its use as a discipline strategy and perspectives of the rationales for and against corporal punishment, and (3) their views on banning it. The theming of the data was Chapter 5 predominantly descriptive and the codes were mainly used to organize the data. Our focus groups are especially used to understand public opinion in its social setting. The idea here is that, rather than sampling individual opinions, which notoriously change in interview situations, one would gather a group of individuals, expose them to a particular 93 question, and see what kind of consensus evolved within the social dynamic. In this way, Perceptions of corporal punishment among Indo Caribbean our focus groups are about to uncover or create a shared perspective, rather than to pay serious attention to individual differences (Stewart & Shamdasani, 2015). We make use of the ‘emic’ viewpoint. Emic viewpoints come from citizens who have an ‘insider’ perspective on what is going on in their community (Gaber & Gaber, 2010; Raymond et al., 2010). No names are mentioned in order to protect the identity of the participants. The results of the process are presented below (Findings of the focus group discussions).

Ethical issues

Suriname does not have its own Institutional Review Board (IRB). Therefore, the National Assembly (the parliament, representing the legislative branch of government in Suriname) reviewed the research protocol and granted permission to conduct the study. Permission to conduct research on school children was also granted by the Ministry of Education, the Ministry of Regional Development, and all principals from the schools the children attended. Additionally, permission was obtained from different community figures in the rural districts in Suriname. Participants were informed about the study’s aims and procedures by letter. All participants completed consent/assent forms in advance. To make sure participants understood the information in the consent/assent form, the purpose of the study and confidentiality were discussed before each focus group.

Data collection

All focus groups were conducted in April 2016 and took place in a classroom during school hours at the children’s schools, eliminating the need for the children to travel to the study setting. Caretakers were not present during focus groups of the children. All participants were given the choice of participating in whichever language they felt comfortable (Dutch or Sarnami). They also had the opportunity to start the focus group in one language and continue the conversation in the other if they preferred. Prior to starting the focus groups, IWvdK provided the other moderator (RCS) with further information about qualitative data collection techniques, talking with children and caregivers about such a sensitive subject, the importance of a moderator’s non- judgmental attitude, and the ‘Focus Group Guide’. IWvdK was present during all focus groups. She adopted a less active role in the group and was not the primary moderator. Rather, her role was to observe the group dynamic, monitor the contributions of children to ensure that all respondents got a chance to contribute to the discussion, and seek clarification on specific issues where necessary according to the aims of the focus group 94 discussions. The moderator (RCS) followed a standard focus group procedure (consent/ assent process, introduction, explanation of the process, logistics, ground rules, ask for questions, turn on the tape recorder, start focus group discussion; see Ethical issues). Each focus group began with several standardized questions meant to stimulate discussions on the different forms of corporal punishment. After this procedure, both moderators loosely followed the ‘Focus Group Guide’, which they modified and interspersed with probes according to the flow of the conversation. This guide was developed (by TLGG, IWvdK, JN and GM) to ensure that each group included the same topics and similar questions. The following issues were discussed: (1) prevalence of corporal punishment in Suriname and its districts, (2) the use of corporal punishment as a discipline strategy, and (3) law and children’s rights. Questions were open-ended, leaving room for other areas to be explored that had not been included in the Focus Group Guide. It is important to note that the focus groups did not proceed through a rigid sequencing of question- and-answer exchanges. Thus, while participants’ stories and ideas not directly related to the topic sometimes dominated the sessions, each of the topic areas outlined above was addressed within each of the focus groups (see Focus Group Guide, Supplement 5.1). In a typical group, the participants sat together in a semicircle. A vignette of a physically abused child was used to serve as a discussion starter or as encouragement for participants to share their ideas about similar events (see Vignette, Supplement 5.2). After each data collection day, RCS and IWvdK met to discuss the focus groups and the emerging themes.

FINDINGS OF THE FOCUS GROUP DISCUSSIONS

The following issues related to corporal punishment were discussed: (1) the prevalence of corporal punishment in Suriname and in its different districts, (2) adolescents’ and caregivers’ perspectives and feelings about the use of corporal punishment as a discipline strategy, and their perspectives on the rationales for and against corporal punishment, (3) and their views on banning it. Participants spoke about the severity of the physical injury that results from corporal punishment; whether the parent’s conduct is normative; the proportionality of the conduct in relation to the child’s transgression; the manner in which the punishment is administered, which includes consideration of the location of the child’s injuries and whether any objects were used; chronicity, meaning the frequency Chapter 5 of the corporal punishment; and transparency and consistency, or whether the child knows the rules that will result in punishment and whether the parent administers those rules non-arbitrarily (Coleman, Dodge, & Campbell, 2010). All of the participants chose to have the focus groups conducted in Dutch. Nonetheless, some caregivers continued 95 parts of the focus group conversations in Sarnami. Perceptions of corporal punishment among Indo Caribbean

Corporal punishment in daily life

Corporal punishment emerged as an everyday experience in the adolescent’s lives. They were either the victims of corporal punishment at home or in the family, or they witnessed the use of corporal punishment with siblings at home or with other family members, peers at school or close neighbours. Caregivers differed in their opinions regarding the prevalence of corporal punishment in Suriname.

Adolescents All of the adolescents said ‘yes’ to the question: Is corporal punishment common in your district and/or country? One boy responded as follows to the question “Are Indo Caribbean children beaten less or more than children from other ethnicities?”

Boy: “I have visited Atjoni (a Maroon village), the village. I saw that all, or almost, even that little ones, they are just beaten flat. So...” Moderator: “Okay, and in general, what do you think?” [Silence] Boy: “Boi...” Moderator: “Does it happen in your neighbourhood?” [Silence] Moderator: “It is a difficult question...” Boy: “Yes very much! In fact, everyone is beaten.”

Adolescents’ stories involved their own experiences of being physically punished at home. They said their caregivers had hit them, if not now then when they were younger. Other adolescents reported that they had never been hit. Confusion was showed in trying to make meaning of their parent’s actions and their own views about corporal punishment, with some adolescents expressing strong negative feelings toward the adult who hit them. One girl told her classmates for the first time about her experiences at home: “I was beaten by my mother. Yes, and my sister. With a belt, with cooking spoons, hand, a ring on my lips…” Another girl said:

“Miss, I had beaten my sister. Then my father had made a fire, like a campfire. There we were, all, my mother was inside. There I was, and my sister was crying. Then my father stood up, he took wood from the fire, and he put it onto my leg. It was bad.”

Some adolescents spoke about their family members’ experiences or experiences in the neighbourhood. As the same boy described: “I see that people in the neighbourhood often beat their children. With a hand, stick, a broom. Whatever they can find.” One 96 girl mentioned:

“The neighbours next to me hit their children every day. And, you see it and ... I think it’s just bad because you should not beat a child. And one of those friends of my brother told us that his caregivers are beating him. He showed his back, bruises... And his father is the perpetrator, most of the time. You can hear it, they just cry all the time and they have to work very hard, day and night they have to work, they try hard enough, and they are still beaten, and verbally abused.”

Other adolescents mentioned the newspaper, television, and Social Media as sources of their knowledge about the prevalence of corporal punishment in their district and/ or country. Most of them experienced or witnessed corporal punishment at primary school, but said that corporal punishment in schools is now prohibited and happens only accidentally. For example, one girl said: “At nursery school, with an iron straightedge on my legs” and one boy mentioned: “At nursery school, my mouth was taped.” Caregivers were described as using objects such as planks (small pieces of wood) and belts in administering corporal punishment. The adolescents mentioned the specific names caregivers and teachers give the objects they used in corporal punishment. In response to questions about why caregivers might slap or smack a child, adolescents’ views centred on child behaviours that involved disobeying (“If you’re naughty”; “If you are using bad words”), ignoring the requests of a parent (“Because children do not listen to their caregivers, that’s why”), the fact that parents do not love their children (“If they do not love you, they’re going to hit you, miss”), strict parents (“When you have strict parents”), bad grades (“When you come home with bad grades”), and parental anger, loss of control or frustration (“If he is irritated or angry sometimes”). The shared perception was that the use of corporal punishment with children is decreasing, as they get older. In their eyes, older children do obey more. As one boy said: “I am wiser now.” The general view was that most adolescents are not beaten anymore, because they are older now.

Caregivers Caregivers differed with respect to the prevalence of corporal punishment in their district and/or country. Some caregivers said that corporal punishment is still happening; they Chapter 5 have heard it from neighbours or family members, saw it on television, or do use corporal punishment as a discipline method themselves. In this light, one mother stated: “Almost all families that I know in the area, are beating their children sometimes.” Another mother said: “I’ll do it though, sometimes, at least. Sometimes I think it is necessary.” 97

But the dominant view was that corporal punishment does not happen often anymore: Perceptions of corporal punishment among Indo Caribbean corporal punishment is something that occurred at the time they themselves were children. One mother explained this development: “Today, before you hit your child, you should think twice. If you have beaten him or her, what are the consequences? Because the children call 123 (Child Protection Helpline) if something happens to them.” Their own negative experiences with corporal punishment in their childhood was mentioned as a reason why they do not use corporal punishment as a parenting principle themselves. For example, one mother stated: “But I say, I do it differently with my family. I do not want my children to be beaten and crying and hatred and envy against me, as a mother.” Others said they do not have an idea about the prevalence of corporal punishment in their district and/or country. For example, one father said: “We have a family, a small family in Suriname. We also have friends of course. But what they do at home there? I don’t know.” Some were not aware of the fact that corporal punishment is still common in Suriname, as one mother said: “I thought earlier, until I heard those stories of yours, I thought it had decreased substantially. Because in my environment, my friends... So I did not… I am actually shocked. So you see, that you live in one area and do not know it still exists.” All caregivers rejected the use of an object in administering corporal punishment, except for one father who said he uses a belt to make his children obey: “If they (three children) are busy with their cell, or what, or they do stupid things.” Moderator: “Yes.” Father: “Then I am allowed to hit.” Moderator: “So if they are busy with their cellular, with their mobile.” Father: “And they do not make their classes on time.” Moderator: “Yes.” Father: “Yes. Or they have to sleep or something, 21h or 22h or so, and they go to sleep at 0h, I’ll get that belt.”

In summary, corporal punishment is a key experience in most adolescents’ lives. All adolescents mentioned corporal punishment is common in their district and country. They also mentioned the use of objects for corporal punishment. Caregivers differed in their opinions regarding the prevalence of corporal punishment. The dominant view among caretakers was that was that corporal punishment is not common anymore in Suriname, but some said it is still happening and some said they sometimes use corporal punishment. All caregivers, except for one father, reject the use of objects.

Motives in favour of corporal punishment

There was no clear consensus regarding adolescents’ and caregivers’ perspectives on 98 the parental use of corporal punishment. While participants generally accepted the use of corporal punishment as a parental right, the endorsement of corporal punishment was clearly contextually dependent. Mild corporal punishment was only acceptable for more serious transgressions.

Adolescents Corporal punishment was described by the adolescents as slapping or smacking children in response to misbehaviour. The dominant view was that a ‘light tap’ should be allowed for younger children, but slapping in the face was condemned at any time. A key argument expressed in favour of corporal punishment was its potential effectiveness with regard to controlling behaviour. More specifically, some adolescents emphasized that by slapping a child by way of punishment, caregivers are better able to correct more serious behaviours and set boundaries so that children would not repeat misbehaviours. In their eyes, younger children, in particular, have to learn the difference between good and bad. For example, one boy said: “A little spanking, for your own sake. Because if you did something wrong, you just know… Shouting and a few taps, and... You have to improve yourself and learn from your mistakes…” Some adolescents mentioned an age range for using corporal punishment from around 5 to 12 years. They stated: “Because children become more independent” or “Because your brains are not well developed in your childhood.” They tended to identify with parents when considering corporal punishment for younger children (‘corporal punishment helps to teach differences between good and bad behaviour’) but not for adolescents.

Adolescents presented specified prescriptions with regard to the exact situations in which caregivers are allowed to use corporal punishment as a form of discipline. They mentioned the frequency (“not too often”; “not every day”) and intensity (“not too hard”) of the administration of such punishment and the severity of the misdeed (“not without a good reason”) that elicited corporal punishment as a response. In the views of the adolescents, corporal punishment was acceptable in the context of behaviours that put the health of the child at risk. Also, if caregivers warned their children several times without the child obeying, they are allowed to use corporal punishment, “then you deserved it”, one girl added. One boy mentioned the acceptability of corporal punishment with reference to school results: “If someone gets bad grades and caregivers do nothing, then that child comes home with more bad grades.” Adolescents expressed understanding and forgiveness for their caregivers’ use of corporal punishment. Two Chapter 5 girls said: “I was young, now I am older. I do think that he was wrong, but I’ve forgiven him” and “They did not do it on purpose.” Most adolescents seemed to understand that parents and other caregivers were prone to using corporal punishment when frustrated or stressed. 99 Perceptions of corporal punishment among Indo Caribbean Caregivers Corporal punishment is only used by caregivers in order to force their children to obey, in particular when talking does not seem to produce the wanted effect. In this light, one father said: “Sometimes talking does not help either, then a tap is needed.” One mother explained: “I think ... a little tap is not abuse.” One mother brought up the definition of smacking. She said:

“Hitting, it’s really about defining hitting. Hitting can happen in a very gruesome manner. Hitting can also be just a slap. A tap. But in itself, I think, it’s no harm, it could happen, it does happen. Almost all families that I know in the area beat their children sometimes.”

The dominant view was that a tap is more useful for younger children than for the older ones. Where to stop using corporal punishment, however, was undecided. For example, one mother said: “Children are formed from their 0th to 16th, you will still ‘form’ them, so my thing, to me the limit, I think, at most, up to 13/14 years, I say yes. A tap is allowed.” In this light, one father stated: “If the child is above 11 years, then he has a good mind, so then, if you let him sit and talk, and he should be able to understand, ‘hey, this is not good, that is not good’.” Another father said: “Beating is not going to help for older children.” However, one mother mentioned she sometimes hits her 26-year-old son: “Sometimes I still hit him when he talks rude to me.”

The general view was that a little tap has the function to not only make the child obey, but also sets the hierarchical difference between child and parent. For example, one mother said: “Actually, it’s more to exert a little authority to the child, right? By saying: ‘Hey, I am the parent, right? You will not do what you want to do at this time.” Some caregivers mentioned their own experiences as a child and explained how corporal punishment helped them to develop. For example, another mother said: “Because I was naughty, huh? I was not listening. And then I got a beating and then you think: ‘if I’m going to do it again I’m going to get it again’, so I think... It has corrected me.”

In terms of effectiveness, some adolescents and most caregivers acknowledged that corporal punishment, specifically a light tap or slap, was often effective in correcting or challenging perceived misbehaviours. Contexts in which corporal punishment was acceptable according to the views of adolescents and caregivers were described with reference to behaviours that put the health of the child at risk. Both adolescents and caregivers acknowledged that corporal punishment is used more in contexts where 100 no alternative strategy seems available. Overall, adolescents displayed insight into the reasons why parents might adopt corporal punishment as a discipline strategy. Adolescents considered that caregivers tend to use corporal punishment as a last resort, especially when children were repeatedly defiant, or when caregivers were feeling out of control or frustrated. This was also a dominant view among caregivers, although some caregivers said they used corporal punishment to emphasize their authority. In general, corporal punishment was considered to be more acceptable and effective when used with younger rather than older children.

Motives against corporal punishment

Participants were asked about their motives against corporal punishment. Rationales against corporal punishment among adolescents and caregivers centred on the potential for causing distress and pain to a child and aggressive behaviour later in life, the damage to the parent–child relationship, and the lack of constructive or instructional value inherent in the corrective strategy. Adolescents Despite discussion of motives favouring the use of corporal punishment, almost all adolescents expressed their widespread disapproval of the use of corporal punishment by caregivers and gave detailed explanations and qualifications when voicing their opinions on this topic. A clear distinction was drawn between giving a child a smack or a light tap and a slap causing pain, an injury or leaving a mark on the child. The latter form of punishment was deemed unacceptable by adolescents and seen as abusive. They were all clear that a slap is a hard hit that hurts both physically and emotionally. In this light, one boy stated: “A smack may not cause pain, only for a moment.” One girl said: “When I walk around, I see some people, they are sad for no reason, and I think they are bullied or something’s happened to them… Sometimes I see they’re sad, when I ask them what happened, they cannot answer, but I can see from their facial expression that something is wrong.”

A motive, expressed by all adolescents, against the use of corporal punishment was the potential for causing injury and pain to a child. For example, one girl said: “Teacher, it Chapter 5 is wrong to hit a child. It could therefore… his inside; his spine may also be damaged. And... that... he may also be in the hospital, so the child can have a lot of pain. And especially for a small child it is not good to hit.” Overall, the adolescents were of the view that slapping and using corporal punishment had the effect of making children feel 101 bad in some way. They listed a range of responses to such punishment, all conveying Perceptions of corporal punishment among Indo Caribbean negative effects. Related to their concerns about causing physical pain and injury, the view that corporal punishment also had the potential to cause emotional distress and the risk of suicide was also expressed. For example, one girl said: “He could have sorrow. Some commit suicide. And... uh... a child can get, he can get a lot of pain. He or she... and... and it’s not good to hit a child. So it’s not... The child is also going to think: ‘why am I being beaten?’” A dominant view was that corporal punishment could result in anti-social behaviours and aggressive responses in later life. Two boys said: “Perhaps later he is going to treat his son the same” and “They’re going to be brutal, nasty.”

Some adolescents presumed that corporal punishment was not effective as a discipline strategy as it did not deter children from repeating what was considered to be misbehaviour. As one boy stated: “If you’re going to hit... The child is going to be stubborn. A child will be even more stubborn.” Another boy said: “Actually, if you’re going to hit, you achieve nothing.” One key argument against corporal punishment was the notion that corporal punishment does not strengthen communication between parent and child but results in the opposite: damage to the relationship between a child and the parent(s) or caregiver. For example, one girl stated: “The child does not love the person who has beaten that child. He is going to be afraid of that person” and one boy said: “For example, if you are 15 years old and your father beats you, and if you are older, you go tell him ‘you are the one who has beaten me’” ... “If he (father) has done something wrong, then you are going to say, ‘yes, that’s good for you. You’ve done the same to me’” … “If you are a kid then you do forget everything, but if you are older, then you will not easily forget anymore.”

All adolescents consider talking with children or other discipline strategies (e.g., withdrawal of privileges) to be better corrective options. Corporal punishment stemming from parental frustration was seen as inherently dangerous. One girl said this about a stressed parent: “Miss, if you (the parent) too much... uh... think about that thing which has happened before, miss, you do not know what you’re doing, miss, you uh... just hit and maybe that child can even have an accident.”

Adolescents were also aware of the possibility that being exposed to corporal punishment might, in turn, encourage children to adopt similar practices with their own children. One boy said about the young boy in the case vignette: “Perhaps later he is going to treat his son the same.”

102 Caregivers The general view was that corporal punishment, defined by them as a hard hit – and not just a tap –, is bad, mostly because of the negative physical and emotional consequences for the child. For example, one father said: “No bruises should arise, because then you talk about abuse.” In this light, a mother stated: “No blood may come.” and another mother said: “They (children) prefer talking louder instead of being beaten. Isn’t it? If you have hit them they feel different, so broken, then they are sad for a few hours more.”

All caregivers spoke about the risk of suicide: “Sometimes when you beat them, they may commit suicide.” A mother said: “I have read about suicide in Suriname. And we had a girl at school last year. The girl was 16 year. She had been beaten that much, that she took pesticide.”

Their own experiences as an important rationale against corporal punishment were mentioned, like the father who was abused as a child by his teacher because of his learning problems:

“If I see someone suppresses his/her child to learn, or hit the child or do something like that, or punishes the child, it is very bad, because that child will never unlearn. You need to talk with the child. By talking you correct something rather than by hitting. Because that child is going to get in his/her head: ‘if I make a mistake again, my mother is going to give me a spanking...’ It is not good. That’s why I never hit my kids, they get everything from me, they are spoiled, everything, but they listen to me.”

Another father mentioned: “But I think my mother, uh... Who simply reacted so frustrated because she was not in a good situation.” Moderator: “Okay.” Father: “Yes, if you did something wrong. So looking back now that I am an adult, I think: ‘it was not necessary.’” Moderator: “It was not necessary.” Father: “It was just unnecessary, but she was frustrated, so she had to express it. And I think she has expressed it that way.” Moderator: “Okay.” Father: “Because if you look at the reason for spanking, I think, it was not necessary.” Some caregivers stated it is hard to define when corporal punishment becomes abuse. For example, one father said: “It is unclear, because you know what, gentlemen? At the beginning, a tap, today it is a small tap, but the next day it becomes a little harder, in two weeks it will be so bad. Three taps. When? When we are talking about abuse? That is unclear.” Chapter 5

Caregivers mentioned children’s rights. Some therefore are afraid of using corporal punishment because their children will call the police or the Child Protection Helpline. One father said: “Nowadays you can not beat a child with a belt. They just call the 103 police, those children are so far already.” Perceptions of corporal punishment among Indo Caribbean

In short, both adolescents and caregivers drew a clear distinction between giving a child a light tap or slap and inflicting more severe corporal punishment, resulting in a mark on the child’s skin or causing some injury. This latter form of corporal punishment was indisputably considered to be unacceptable. Both adolescents and caregivers mentioned that the use of corporal punishment in response to child misbehaviour has the result of making children feel bad in some way. They expressed widespread disapproval of the use of corporal punishment by parents because of the potential to cause serious physical injury or emotional distress to a child and damage to the parent-child relationship. An argument expressed by adolescents was that corporal punishment did not promote parent-child communication and therefore children were less likely to learn from the disciplinary encounter. All participants mentioned the increased risk of suicide after corporal punishment. For some caregivers, this was one of the reasons to abandon the use of corporal punishment. Should corporal punishment be banned?

Participants were asked whether they would agree with the idea of banning corporal punishment in the home. While many participants hesitated to support efforts to prohibit corporal punishment legally, a number of them argued that such a ban could have helped in protecting children from parents who used corporal punishment excessively. Caregivers mentioned the lack of alternative parenting principles and the importance of the implementation of parenting programs before banning corporal punishment.

Adolescents Arguments expressed against banning corporal punishment were the complexity involved in terms of assessing the severity of the corporal punishment and the reluctance of children to report the behaviour of their caregivers to other adults or authorities in cases where corporal punishment was severe. As one girl said: “It’s not, it’s not going to happen (banning corporal punishment). No one is going to know if my mother is beating me. Nobody will know.” Another girl said: “It’s a bit of... for example, by her example, they (the police) go to your home, they go to hear things and stuff, and then you think: ‘what have I done? Rather I had not call the police.’” The dominant view was that abuse should be banned, but corporal punishment – in terms of a mild tap – can 104 remain. A key issue emphasized by adolescents when reflecting on the possibility of banning corporal punishment in the home was the clear distinction they drew between banning corporal punishment in the home and banning corporal punishment in schools. They felt that corporal punishment in schools should be prohibited. Some adolescents expressed the view that parents had ‘the right’ to punish their children physically because they carried responsibility for the child. A relevant part of this argument was the sense that adolescents trusted their parents not to abuse the power they had over them in terms of administering corporal punishment. For example, one boy said: “Parents are allowed to hit you, but teachers are not. They raise you, from small to big. They take care of you, and they do everything for you. She is just a teacher. She is an outsider.”

Caregivers Among caregivers, opinions were mixed regarding banning corporal punishment. Some caregivers were of the opinion that corporal punishment should be banned:

“Why not? Times are changing. I think, now caregivers need to go a little bit with the kids. We are not in the old times anymore; we are not in the seventies. Social Media has now become a very big impact on children. Anyway, so times are changing, the caregivers are going to think a little bit and want to cooperate. And the new generation.... They go, that is... 10 steps ahead. They are going to think differently and they will have a different way of parenting.”

Others were of the opinion that caregivers should make their own decisions on whether to use corporal punishment and that prohibiting corporal punishment undermines good parenting. For example, one father said: “It works against parenting, huh? Because if you have certain rules in certain families and a child now suddenly comes with all those rights, you know what, they think: ‘I’m going to do what I want, dad can not beat me’”. Most caregivers spoke about what kind of corporal punishment exactly should be banned and expressed some doubts. As one mother said: “If I hit him a little bit, he should not report me, uh... You have got a problem. It depends. Of course it has positive aspects, sure, I agree, but what is written in the law? What have you defined?”

A dominant view was that the use of corporal punishment is a consequence of a lack of a set of parenting skills. They felt that prohibiting corporal punishment alone is not a Chapter 5 good policy. Providing help to caregivers in developing good educational skills should be prioritized. One father said:

“But I think that law, before this law comes… Before this law comes, I think, personally, then such an institute, by school, or by caregivers, if the 105

direction of the school says: that parent is beating his/her children, then Perceptions of corporal punishment among Indo Caribbean the institute should talk to caregivers first, like, what is happening, why is it happening, etc. … To define a law. It is done quickly, but in practice... Do you understand what I mean? … Parenting is difficult. … And yes. … There are no guidelines how it should or should not be done.”

Almost all caregivers agreed that corporal punishment at school should be prohibited. However, one mother said: “My son goes to school. I have said to his teacher: ‘if he does not listen, if he is stubborn, or just does something reckless, you are allowed to hit him’. I said that as his parent.” Another mother said: “Yes, but there must be a limit to where the teacher can beat, a little hit, a little hit is allowed, but not a broken ear, or a black eye, or a pulled out nail”.

To summarize, the majority of adolescents did not feel that law should prohibit corporal punishment at home but that it should be at school. They made reference to the right of caregivers to use corporal punishment with children and pointed to the complexity of implementing a ban on corporal punishment in the home. However, some adolescents did favour the legal prohibition of corporal punishment by caregivers, pointing out that such prohibition would protect children whose caregivers used corporal punishment excessively or severely. The views of caregivers were consistent with those of the adolescents. They noticed the difficulty of parenting and the lack of educational alternatives to corporal punishment. Providing educational help to caregivers should precede the banning of corporal punishment, in particular at home.

DISCUSSION

Little is known about perspectives of corporal punishment in low- and middle-income countries. The present study addressed this gap by reporting on 12 focus groups that were conducted with adolescents (aged 12 to 18 years) and caregivers of Indo Caribbean background in Suriname. By using a focus group methodology it aimed to explore adolescents’ and caregivers’ shared perspectives of the prevalence of corporal punishment in Suriname, responses to and feelings about its use as a discipline strategy and perspectives of the rationales for and against corporal punishment, and their views on banning it. Because children are the major recipients of discipline, including corporal punishment, it is important to add their voices to the debate. The study showed that corporal punishment is a key experience in most adolescents’ lives. The prevalence of 106 corporal punishment is consistent with global findings (Hillis, Mercy, Amobi, & Kress, 2016), findings from Suriname (Van der Kooij et al., 2015), and from countries in the Caribbean (UNICEF, 2010). Many of the adolescents reported having been hit with objects when they were younger, consistent with a recent conducted prevalence study of child maltreatment and a qualitative study about experiences and perspectives of corporal punishment among people from Creole and Maroon background in Suriname (Van der Kooij et al., 2015; Van der Kooij et al., 2017).

Beliefs about the necessity and appropriateness of corporal punishment play an important role in determining whether any resulting injury is perceived as maltreatment (Gracia & Herrero, 2008). Some adolescents in this study did express their views about whether they believed that corporal punishment was necessary, and many did underline a sense of responsibility for having been beaten, the result of them having done something wrong or in the very least as their own fault. This may reflect that, despite them not liking being beaten, they see it as necessary or appropriate similar to views reported in previous studies (Breen, Daniels, & Tomlinson, 2015; Simons & Wurtele, 2010). There was consensus that despite negative responses to corporal punishment, parents had the right to use this strategy in selective and appropriate circumstances. Significantly, adolescents assigned the right of corporal punishment exclusively to their parents. ‘Reasonable corporal punishment’ was only acceptable for more serious transgressions. However, it is found to be hard to distinguish between ‘reasonable corporal punishment’ and maltreatment (Coleman, Dodge, & Campbell, 2010). Furthermore, in a recent meta-analysis no evidence was found that spanking is associated with improved child behaviour and rather found spanking to be associated with increased risk of several detrimental outcomes (Ferguson, 2013; Gershoff & Grogan-Kaylor, 2016; Larzelere & Kuhn, 2005). Negative consequences of corporal punishment were expressed in terms of the physical and psychological distress that it inflicted upon a child, the serious implications for the quality of child-parent relationships, the lack of constructive or instructional value inherent in the corrective strategy, the potential to generate increased anti-social behaviours and aggressive responses in later life. These findings are consistent with a large body of research emphasizing the potentially damaging effects of corporal punishment mentioned by children themselves (Breen, Daniels, & Tomlinson, 2015; Kish & Newcombe, 2015). Much research has documented the lack of constructive learning inherent in corporal punishment (Gershoff & Grogan-Kaylor, 2016; Smith, Chapter 5 2016). Some children did report physical injury as a result of corporal punishment, and they did report what might be described as emotional injury. The sadness and anxiety that they experienced when exposed to corporal punishment at home and at school, as reported in others studies (Dobbs, 2007; Sanapo & Nakamura, 2011), often led to 107 children in the study avoiding asking others for help. Children’s attachment relationships Perceptions of corporal punishment among Indo Caribbean are key protective factors for positive outcomes in adverse contexts (Masten, 2011). Damage to the parent–child relationship is a well-established outcome of exposure to corporal punishment (Gershoff, 2002), and our data showed how this impacts on how adolescents make use of potential resources. This is in line with earlier qualitative research conducted in South Africa (Breen, Daniels, & Tomlinson, 2015). Adolescents’ views on the possibility of banning corporal punishment at home reflected a substantial degree of ambivalence. While many adolescents hesitated to support efforts to prohibit corporal punishment legally, a number of them argued that such a ban could have helped in protecting children from parents who used corporal punishment excessively. A minority of adolescents was unequivocally in favour of banning corporal punishment at home and rationales in support of this action centred on the argument that corporal punishment causes injury to a child. Many adolescents expressed some reluctance to ban corporal punishment. These views were primarily associated with the difficulties of monitoring parental behaviours in the home (borders between acceptable and non- acceptable forms of corporal punishment) and the fear that parents could be imprisoned for using corporal punishment. The abovementioned could be a result of ‘all-or-nothing’ thinking, a mark of adolescence (e.g., “I studied and I failed the test, so I guess studying is a waste of time”; Fisher & Frey, 2015). They tended to identify with parents when considering corporal punishment for younger children, even when they might have been subjected to (severe) corporal punishment during their childhood. Considering that spanking rates peak around ages two till four (Straus & Stewart, 1999; Vittrup, Holden, & Buck, 2006), with a slow decrease as children age (Giles-Sims et al., 1995), it was expected that adolescents would report being spanked more when they were young. The adolescents did indeed report being spanked less frequently than before, and they also expressed the view that corporal punishment is both more effective and acceptable when used with younger children.

Despite high prevalence rates of corporal punishment in Suriname (Van der Kooij et al., 2015) most caregivers were of the opinion that corporal punishment is not very common anymore. Their approval of corporal punishment was rooted in beliefs linking the use of corporal punishment with positive or neutral outcomes such as: ‘I was spanked in my childhood and look where I am today’, and that corporal punishment is believed to be effective when talking does not have the desired result. Here, corporal punishment seems to be a last resort in forcing children to comply. Also linked to approval were beliefs about the state of society: today’s generation is worse off than previous ones 108 and children have too much power. This finding is congruent with an extended content analysis on beliefs and ideologies linked with approval of corporal punishment, showing that reasons for approval of the use of corporal punishment are linked with beliefs of positive outcomes (‘I was spanked and I am okay’), that spanking improves child behaviour, that spanking is more effective than other forms of discipline and that spanking is not abuse (Taylor et. al, 2016). Furthermore, caregivers also use corporal punishment to assert their authority. They seemed to be afraid to relinquish control over their children for fear that their children might take over power in the parent-child relationship. These findings fit with a recent study amongst Creole and Maroon people in Suriname (Van der Kooij et al., 2017). Most parents appeared to have little knowledge of developmental psychology. Surprisingly, they tended to use corporal punishment for younger children despite the fact that children show more resistance during their adolescence. This raises the question: do they observe that corporal punishment does not work anymore or that corporal punishment possibly should be more severe to have the same effect? Some caregivers mentioned the right of teachers to hit their pupils, as long as they provided permission for teachers to do so. They related corporal punishment to a lack of non-violent parenting skills, and that the development and implementation of supportive parenting programs should precede the banning of corporal punishment in all circumstances. This is in agreement with findings regarding the lack of available evidence-based parenting programs in Suriname (Van der Kooij, Bipat, Boer, Lindauer, & Graafsma, 2017) and is consistent with recommendations of the UN Children’s Rights Committee (Convention on the Rights of the Child, see General Comment 13). Caregivers’ motives for condemning corporal punishment also centred on the potential of corporal punishment to cause a child distress and pain and the lack of constructive or instructional value inherent in the corrective strategy. Another argument offered by caregivers to reject corporal punishment was the fear that children might call the Child Protection Helpline or the police. This is in line with earlier research, showing that whereas parents talked candidly about the use of severe corporal punishment earlier on, perpetrators now are more aware of public disapproval towards violence in childrearing (Komen, 2003). They also mentioned the increased risk of suicide, consistent with a growing body of research showing some of the highest suicide rates in the world for girls and the second-highest rate for boys in Suriname (Kõlves & De Leo, 2014). Chapter 5 Strengths and limitations

First of all, caution should be exercised in extrapolating the findings of the study to all Indo Caribbean families in Suriname because of the diversity that exists in this ethnic group across regions in socio demographic characteristics. Second, some issues related 109 to the use of focus groups (specifically regarding a sensitive topic as corporal punishment) Perceptions of corporal punishment among Indo Caribbean should be mentioned. Within the context of focus groups, some participants may have felt intimidated and/or may have been reluctant to express their true opinions. There might have been a process in each group in which participants tried to check what others thought and then re-evaluate their own opinions about corporal punishment. We therefore should be aware of the possibility of the underreporting of corporal punishment. Arguably, it is difficult for children to disapprove of their own parents or caregivers. Furthermore, it might have been difficult for adolescents to put themselves in the victim role. These issues might have influenced the findings. Third, confidentiality among participants in focus groups can never be fully guaranteed since disclosures are shared with all group members. Although informed assent/consent were discussed extensively, and participants were made aware of the limits to confidentiality (see Ethical Issues), it is not clear to what degree this may have affected participants’ responses. In a small, cohesive community such as Suriname, community members will remember when the groups were conducted, will probably know who participated, and will be concerned about what the process will reveal about their community. Focus group participants may be concerned that their voice will be recognized if sessions are audiotaped. This concern may be present regardless of the topic discussed (Teufel & Shone, 2010). This might have influences participant’s responses. The results are generalized and do not include quotes that allow direct association between a specific statement and a particular participant. The research team determined which direct quotes were suitable for public dissemination, that is, if a statement could have made by many community members or if everyone will know who said it. Fourth, selection bias might have been present before the focus groups were constructed. Schoolteachers might have selected children who were or were not subjected to corporal punishment in their eyes, as child characteristics of those subjected to corporal punishment are substantially different from characteristics of those not punished (Morris & Gibson, 2011). Fifth, our choice of moderator had pros and cons. As an older woman, she was more likely to have been seen as a grandmother figure than a parental authority figure or teacher, and therefore facilitated trust. In spite of training and experience in interviewing children and adolescents, she came across at times as judgmental. Both moderators’ own perceptions of corporal punishment might have unknowingly influenced their attitude (body language, word choice, tone, etc.). This might have biased the results, as well. Sixth, the data on adolescents’ views were solely collected within schools, possibly excluding children also at risk for being exposed to violence (e.g., drop-outs and children not sent to school).

110 A recommendation for future research would be to use a ‘mixed methods’ approach. Individual interviews can give more depth and detail on the topics that appear in the focus groups.

Implications for interventions

The data presented in this study are among the few resources available to develop a more complete understanding of the nature of child discipline in Suriname. Messages arising from this study could inform the development of a public information campaign on safe and effective discipline of children in Suriname. Participants’ views, especially adolescents’ views, on these issues could be incorporated into existing parenting programs that seek to provide support for parents. Dissemination of these findings might heighten parents’ awareness of their children’s perspectives on discipline and punishment. A possible avenue for intervention would be to discuss findings of studies such as this one in the community, to explain and demonstrate alternative disciplinary strategies and to secure cooperation and provide support in using them. Discipline practices are generally part of a cultural system, and as such, they are difficult to change. Earlier research showed that myths about harmlessness and effectiveness and necessity of corporal punishment were identified, and that these types of myths were found to be predictive of intension to use corporal punishment. Changing those myths might lead to a reduction of the parental use of corporal punishment (Kish & Newcombe, 2015). Even though a discipline method may be culturally based, this does not mean that it is not harmful to the child and should be permitted.

Conclusion

There is a lack of good quality data on the prevalence of corporal punishment in Suriname. This knowledge gaps weaken efforts to develop interventions to address this form of violence against children. This study shows that, under certain circumstances, corporal punishment is accepted and applied in Suriname, despite growing knowledge of its harmful consequences. The implementation of the Convention on the Rights of the Child seems to play an important role in discussions and probably has accelerated the discussion about corporal punishment in Suriname. Keeping the high rates of corporal punishment and the high suicide percentages in Suriname in mind, the government of

Suriname might seriously consider the suggestions of the Convention on the Rights of Chapter 5 the Child and develop a number of measures in order to reduce corporal punishment, e.g., amend its legislation to explicitly prohibit corporal punishment in all settings and strengthen and expand its efforts, through awareness-raising programs and campaigns, to promote positive, non-violent and participatory forms of child-rearing and discipline as 111 an alternative to corporal punishment; as well as expand parenting education programs, Perceptions of corporal punishment among Indo Caribbean and training for professionals working with and for children. REFERENCES

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1. Prevalence of corporal punishment in Suriname and its districts (“Do you think that corporal punishment is common in your district/country and why do you think it is (not) common in your district/Suriname?”; “What are mediating factors for corporal punishment?”; “Do you think corporal punishment is still happening at schools?”)

2. Perceptions of the functions of corporal punishment (“What do you think about the use of corporal punishment”; “What is acceptable? When is one going too far?”; “What is a lot? Once, once a week, a month?”; “What if a child does not listen?”; “Are teachers allowed to hit children when they do not listen?”)

3. Law and children’s rights (“What do you know/think about the law regarding corporal punishment?”; “What do you think about prohibition of corporal punishment at home and at school?”) Chapter 5 SUPPLEMENT 5.2 VIGNETTE

The following case vignette was read out loud as a starter or during the focus group discussions: 115

The eight-year old Kishan lives with his father, mother, grandmother, Perceptions of corporal punishment among Indo Caribbean sister, brother and newborn sister in the city (Paramaribo). Father is a woodworker and has his workshop at home. Mother works as a cleaner. Grandmother is old. She does not work anymore. Kishan and his sister go to school. Kishan has to help his father when his father is busy. If he does not do so, he is kicked and beaten by his father. Sometimes father throws him to the ground or hits him on his back with a piece of wood. Kishan does not participate in swimming, because he is ashamed of his bruises. 116 6

Implementation and evaluation of a parenting program to prevent child maltreatment in Suriname

Inger W. van der Kooij Shandra Bipat Frits Boer Ramón J.L. Lindauer Tobi L.G. Graafsma

American Journal of Orthopsychiatry, 2017 ABSTRACT

The prevention of child maltreatment has become a global health concern because child maltreatment is a violation of children’s rights. Across the world a variety of parenting programs have been developed to address this problem. However, no such parenting programs currently exists in Suriname. This pilot study aimed to implement a parenting program (‘Lobi Mi Pikin’; LMP) in Suriname and to evaluate its effects on corporal punishment (CP) and child behavioral problems. Parents/caregivers (N = 70) of children (aged 3–12 years) with externalizing behavioral problems participated in a protocolled parenting program. The child’s behavioral problems and parenting style of the parent/caregiver were assessed using the Strengths and Difficulties Questionnaire and Parental Behavior Scale, pre-treatment and post-treatment. Five-week follow-up measures revealed significant positive effects of LMP on all outcome measures. Follow- up comparisons demonstrated (a) a large reduction of total child difficulties and conduct problems, (b) a moderate reduction of hyperactivity and emotional problems, (c) a moderate to large increase in the self-reported positive behavior of the parent, and (d) a small decrease in the use of CP. This study provides preliminary evidence that LMP may be an effective model of parent training in Suriname. Moreover, it can help guide efforts to reduce the use of CP and encourage positive parenting, thereby preventing 118 child maltreatment. INTRODUCTION

The prevention of child maltreatment has become a global health concern because child maltreatment is a violation of children’s rights (Finkelhor & Tucker, 2015). Its impact is profound, long lasting (often lifelong), and has enormous social and economic costs (D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012; Fang et al., 2015; Gilbert, 2009; Mueller et al., 2010). Poor parenting is a critical risk factor for child maltreatment (Munro, Taylor, & Bradbury-Jones, 2014). That is, children are more likely to be maltreated if parents perceive them as ‘difficult’, have insufficient knowledge of child development, have poor parent-child relationships, have high levels of stress and depression or believe that corporal punishment (CP) is useful (Crosson-Tower, 2004; Hansen, Sedlar, & Warner- Rogers, 1999; Murphy et al., 2014; Poole, Seal, & Taylor, 2014; Stith et al., 2009).

According to Belsky, parenting is a multi-determined set of behaviors that are influenced by a broad range of factors, including the parent’s developmental history and personality, characteristics of the child, and contextual sources of stress and support (Belsky, 1984). Chapter 6 Parenting should thus be considered a complex and dynamic repertoire of behaviors, which are embedded in an ecological network consisting of the family context (e.g., the marital relationship, family financial stress), characteristics of the parent (e.g., personality), characteristics of the child (e.g., temperament) and the social context (e.g., ethnicity/ 119 culture, community characteristics; Kotchick & Forehand, 2002; Okagaki & Luster, 2005). Implementation and evaluation of a parenting program These factors, along with educational and socialization goals, may result in particular parenting styles, some of which are well described by Baumrind (e.g., 1971).

The use of CP to correct misbehavior is a widespread practice, yet its effectiveness and even its appropriateness are shrouded in debate (Gershoff & Grogan-Kaylor, 2016). CP is sometimes considered an attractive option for parents to discipline the child, not least because of its prompt (although perhaps not enduring) result of immediate compliance (Gershoff, 2002; Larzelere & Kuhn, 2005). In particular in situations of great psychosocial stress (e.g., households in poverty, or with a drug/alcohol abusing parent) frustration and agitation may result in violence towards the child (see also Roopnarine et al., 1995). Arguably, non-violent forms of conflict-resolution and discipline take more effort without the guarantee of ‘immediate success’. However, meta-analyses provide evidence that CP is largely ineffective and harmful. It is associated with a lower quality of the parent-child relationship, lower levels of moral internalization and mental health in childhood and adulthood, as well as higher levels of cognitive impairment (academic impairment, suicidality, and attitudes about spanking), aggression in childhood and adulthood, antisocial behavior in childhood and adulthood, risk of being a victim of physical abuse, and risk of abusing one’s own child or spouse as an adult. Furthermore, harsher methods of CP are more strongly associated with negative child outcomes than ordinary spanking (Ferguson, 2013; Gershoff, 2002; Gershoff et al., 2016; Larzelere & Kuhn, 2005; Paolucci & Violato, 2004).

Societies, communities, and families differ in their views on the acceptability of the use of violence in conflict resolution and in helping children conform to the wishes of parents. Sometimes religious motives (‘save the rod and spoil the child’) are used in rationalizing these practices. In many communities it was, and often still is, accepted that husbands use physical and psychological violence towards their spouses, as well as towards their children. In Suriname, more than 80% of parents report using corporal punishment (CP; UNICEF, 2006; UNICEF, 2010). Suriname is no exception in the Caribbean region: a cross-national regional study involving 34 countries found that a majority of mothers in Jamaica, Belize, Trinidad and Tobago and Guyana uses CP on children between 2 and 12 years of age (Cappa & Kahn, 2011). In our previous national prevalence study on child abuse and neglect (van der Kooij et al., 2015), we reported that 35% of all adolescents and young adults in Suriname had been subjected to CP in the year prior to the interview (CP, including excessive CP, was measured as physical assault within the family).

120 Since the ratification of the Convention on the Rights of the Child (CRC) in 1999 (Convention on the Rights of the Child, 2000) many Surinamese parents have been in conflict. The principle of the CRC states that a child should be protected from ‘all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child’ (article 19(1)). What used to be considered necessary (i.e., corporal punishment) and therefore common practice is now morally abnormal and abusive (for an overview on international reactions to the introduction of the CRC, see Doek, 2009).

Influenced by growing scientific knowledge about the importance of the parent-child relationship and knowledge about the detrimental effects of child maltreatment on the development of the child, a variety of parenting programs have been developed that focus on helping parents develop non-violent ways of parenting. A parenting program is a structured process of education and training intended to enhance the parenting skills of participants (Bunting, 2004). Parenting programs designed to prevent child maltreatment typically aim to do so by trying to improve parents’ child rearing skills, encouraging positive child management strategies and increasing parents’ knowledge of child development (Mikton & Butchart, 2009). In general, child maltreatment prevention studies concluded that parent education programs show promise in reducing the risk factors for child maltreatment and for actually preventing child maltreatment (Barlow, 2014; Chen & Chan, 2016). However, research on their effectiveness in low-income countries is limited (Knerr, Gardner, & Cluver, 2013). Most programs stem from a foundation rooted in Western developmental psychology and Western educational values and aspirations. These do not necessarily correspond to rearing goals and values in developing and non-western cultures, or with longstanding local styles of parenting (Baumrind, 1971; Berry, 2016; Roe, 2012).

Therefore, one of the key issues to consider when implementing a parenting program in non-western or developing countries is the modification of the program to fit the local cultural situation (Baumann et al., 2015; Mejia, Calam, & Sanders, 2012). Not adapting a program to the local context, education goals and language is likely to compromise both engagement and outcomes (Lau, 2006). Socialization practices may be different from those in Western and – in terms of the Human Development Index (United

Nations Development Programme, 2011) – more developed countries. This certainly Chapter 6 poses a challenge to the development of parenting programs in the Caribbean: the vast region consists of many cultural groups and ethnicities that speak many different languages. Suriname’s population (570,000 inhabitants) is composed of three relatively large ethnic groups: the Creoles (persons of mixed African and European heritage), 121 the descendants of escaped African slaves known as Maroons, and the descendants of Implementation and evaluation of a parenting program Indian and Javanese contract workers (World Factbook, 2016). In Suriname, the official language (and thus the language of the former oppressor) is Dutch, but the widely and informal spoken language in the country is Sranan Tongo, a mix of Dutch, English and several other languages.

Parenting programs are available in the country, but conducted on a small scale. Thus far no other evidence-based programs have been implemented, adapted, and evaluated. A recent study on CP among Creoles and Maroons conducted in Suriname showed that both adults and adolescents believed that using some form of CP is at times a necessary and a respected form of child discipline. Those who received of CP agreed on the necessity or acceptability of CP when this was ‘in the best interest of the child’ and did not consider CP as a form of violence or maltreatment in that case. Parents expressed the wish to be able to discipline their children in non-violent ways, but also reported that they lacked the skills to do so (Van der Kooij et al., 2017). In recent years, governmental and non-governmental organizations have implemented many different activities to meet the expressed needs of parents for support in the upbringing of their children. This study aimed to implement a tailored parenting program (Lobi Mi Pikin [LMP], meaning “I love my child” in the Sranan Tongo language) in Suriname. It evaluates Lobi Mi Pikin’s effects on positive parenting and the use of CP and child behavioral problems. To the best of our knowledge, this is the first study to address the scientific evaluation of a parenting program in Suriname.

METHOD

Participants

In total, 72 parents/caregivers of children with (mild) externalizing behavioral problems signed up for the parenting program ‘Lobi Mi Pikin’ (LMP). All parents lived in and around Paramaribo, the capital of Suriname. Two parents/caregivers discontinued the program due to time constraints. Of 70 parents/caregivers that followed LMP, 59 (27–56 years old, M = 39.81, SD = 7.00) completed at least two measures (one before and one after intervention) about themselves and their children (3 till 14 years old, boys: 67.8%, M = 7.12 years, SD = 2.89). In total, 11 parents were excluded from analyses because they did not complete a measurement after intervention (Time 2 and Time 3). Ten LMP courses have been conducted, with an average of five participants per group 122 (M = 5.4, SD = 2.90). Data collection took place from November 2012 till November 2014. Demographic variables are shown in Table 6.1.

Instruments

Child behavior problems The Strengths and Difficulties Questionnaire (SDQ) is a screening inventory comprising 25 items, which ask parents about pro-social and difficult behavior in children aged 3 to 16 years (Goodman, 1997; Dutch translation by Van Widenfelt, Goedhart, Treffers, & Goodman, 2003). The questionnaire consists of five subscales (Emotional Problems; Conduct Problems; Hyperactivity; Peer Problems; and Pro-social behavior), each including five items that are rated on a three-point Likert scale (0 = not true; 1 = a little bit true; 2 = very true). A Total Difficulties Score (maximum total score = 40) is derived from the combined scores of the first four scales, with higher scores indicating more difficulties. A score of 14 or above is considered in the ‘abnormal’ range. The subscales have a mean internal consistency reliability coefficient of 0.71, mean test–retest reliability co-efficient over six months of 0.62, and strong criterion validity for predicting psychological disorders (Goodman, Meltzer, & Bailey, 1998; Goodman, 2001; Muris & Van den Berg, 2003). Table 6.1 Demographics of the participants

N = 59

n%

Parent/caregiver Mother 47 79.7 Father 5 8.5 Other family member (female) 5 8.5 Other 2 3.4

Ethnicity Indo Caribbean 4 6.8 Javanese 8 13.6 Afro Surinamese 20 33.9 Mix 25 42.4 Missing 2 3.4

Education Lower vocational and extensive education 8 13.6

Secondary 23 39.0 Chapter 6 Senior general secondary and pre-university 8 13.6 Higher vocational and university 20 33.9

Children Boys 40 67.8 Girls 19 32.2 123 Implementation and evaluation of a parenting program

Parenting behavior The Parental Behavior Scale-short version (PBS, Van Leeuwen & Vermulst, 2004; Van Leeuwen & Vermulst, 2010) was used to measure parenting behavior. The PBS comprises five subscales: Positive Parenting (8 items), Discipline (4 items), Corporal Punishment (5 items), Material Rewarding (3 items), and Rules (5 items; maximum total score: 75). All items are formulated as statements about concrete parenting behavior in everyday life towards one specific child; for example, “I give my child a slap when he/she has done something that was not allowed”. The frequencies of these behaviors are rated on a five-point Likert scale (1 = (almost) never, 2 = little, 3 = sometimes, 4 = often, and 5 = (almost) always). Internal reliability was acceptable to good for all subscales. Confirmative factor analyses supported structural validity (Lambrechts, Van Leeuwen, Boonen, Maes, & Noens, 2011). Socio demographics Questions regarding socio-demographic characteristics of the children and their parents/ caregivers were embedded in the abovementioned questionnaires (i.e. date of birth, parents’/caregivers’ relation to child, ethnicity and highest level of education of parent/ caregiver).

Procedure

The study received ethical approval from the Ministry of Education in Suriname and was conducted from November 2012 to November 2014. Recruitment was facilitated through advertisement in local newspapers, newsletters, a local television network, radio and the Internet. One of the employees of the Medical Parenting Bureau in Paramaribo (MOB; a governmental center offering psychosocial and educational help) and one of the facilitators conducted the consent/sign-up procedure by telephone. All parents with children between 3 to 12 years of age having externalizing behavioral problems were accepted for LMP, providing that these externalizing behavioral problems were not too complex. The complexity was assessed by telephone by one of the facilitators. All parents were included in the study, irrespectively of the pre-treatment SDQ scores of their children. There were no exclusion criteria. Those who agreed completed a consent 124 form and the set of standardized assessment measures. All sessions took place at the MOB or at the University of Suriname’s Institute for Graduate Studies and Research (IGSR), both in Paramaribo. All participants were compensated for their participation (LMP, measurements, follow-up).

Study design

Assessments were conducted prior to the start of the parenting program (Time 1), immediately after program delivery (Time 2), and at five-weeks’ follow-up (Time 3). Only one parent per family participated in the study. Participants who completed Time 1 (pre-intervention), the intervention (LMP) and Time 2 (post-intervention) and/or Time 3 (post-intervention) were included in the study (see Figure 6.1).

Training

Lobi Mi Pikin (LMP; De Gijsel & Spanjaard, 2012) is a groupbased training intervention for parents of children from 3 to 12 years of age with (mild) externalizing behavioral problems. It is the revised and culturally adapted version of ‘Parenting Course of Medical Parenting Bureau’, a course given in the past at the Medical Parenting Bureau that was (QUROOPHQW 1 

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developed out of the two Dutch parenting courses ‘3x Growth’ (Dangel & Polster, 1984; Theunissen & Haspels, 2007) and ‘Parenting & So’ (Janssen, Blokland, & Ligtermoet, 2006). LMP uses a combination of principles from these two parenting programs, i.e. the competence model and the social learning theory. Core features of the competence model include a focus on parenting qualities and the parent–child relationship and a functional approach emphasizing behaviors and skills in everyday performance. The social learning theory assumes that learning is a cognitive process that takes place in a social context and that it can occur through observation or direct instruction. In addition, learning also takes place through the experience of reward and punishment. Combining positive attention with good ‘example’ behavior of the parent/caregiver is considered essential for good parenting. Parents/caregivers are also taught to set limits on their child’s undesirable behavior without using corporal punishment.

Parents practice each intervention extensively with each other during the course before they carry out the intervention at home. The group sessions provide abundant opportunities for practice (e.g., modeling, role plays, followed up with direct feedback and experiential exercises). Self-initiated change involves a complex but difficult to define interplay of cognitive, behavioral and affective processes; these changes include the capacity to plan and anticipate, regulate one’s own emotions, solve problems and collaborate when necessary with others (e.g., partners, teachers, and grandparents) involved in the care or education of children. It also involves a set of planned actions; the execution of the plan; a review of whether the plan worked; and if necessary, further tailoring of the plan until the goal is attained (Moffitt et al., 2011; Sanders & Mazzucchelli, 2013).

LMP therefore involves teaching techniques of positive and negative reinforcement 126 to parents, helping them to focus on their child’s positive behavior (by praising and rewarding the desired behavior), and helping them to introduce limit-setting and ‘timeout’ consequences for the child’s negative behavior. Parents are also taught how to model appropriate behavior. Group facilitators and leaders have the opportunity to model key parenting skills in each session, whilst parents imitate and practice the new skills through role play and homework assignments. The cognitive component of LMP focuses on problematic thinking patterns in parents that have been associated with conduct problems in their children. For instance, typical cognitive distortions include globalized ‘all or nothing’ thinking in which one minor setback may trigger a negative automatic thought (e.g., ‘I am a bad parent’) thereby leading to feelings of stress, hopelessness, low self-esteem, a perceived inability to cope with the situation and learned helplessness (Seligman, 1990). Thus, LMP aims at helping parents to learn how to reframe distorted cognitions or misattributions and to coach them in the use of problem-solving and anger management techniques. An outline of the topics LMP covered over the five weeks is shown in Table 6.2. Table 6.2 Outline of ‘Lobi Mi Pikin’

Session Content

Session 1 Introduction to course Developmental stages of children Important parenting skills

Session 2 Attention Praise Reward

Session 3 Prohibit Instruct

Session 4 Time out

Session 5 Appropriate punishments Evaluation

Session 6 Sharing experiences (Follow-up) Chapter 6

Program facilitators All facilitators had a professional background in health or education and were experienced 127 in delivering parenting programs (e.g., Parenting Course of Medical Parenting Bureau) Implementation and evaluation of a parenting program in The Netherlands and Suriname. Each program was delivered by two facilitators. Prior to program implementation all facilitators followed an intensive training course for LMP that was delivered by one of the program authors. The training also included a topic regarding potential biases during evaluation, as the facilitators were also the assessors. Facilitators completed adherence checklists at the end of each group session and also attended small group supervision sessions with other facilitators after each session.

Cultural adaptation

All facilitators were already experienced in delivering the original ‘Parenting Course of Medical Parenting Bureau’, a program that was used to gather pilot/feasibility data for LMP. Observations of the facilitators and evaluations of the parents were both used in the adaptation process. First, some language issues were addressed. LMP uses a mixture of the original language of the Dutch program and Sranan Tongo. Some important changes were made. Surinamese parents who participated in the original course thought that the word ‘ignore’ meant ignoring the child completely. For this reason, the name of the sub-intervention ‘ignore’ was changed to ‘unresponsiveness to undesirable conduct’. Furthermore, some Dutch words were translated into Sranan Tongo. Names of persons in example scenarios were changed to recognizable Surinamese names, and information in the manual was made detailed and sufficiently colloquial to be understood by largely illiterate parents/caregivers. Second, all exemplary situations were adapted to the Surinamese culture. Furthermore, one of the main strategies was modified after LMP had already been started. After two full LMP programs (consisting of four sessions) it became clear that in the fourth – and last – meeting too much information was conveyed at one time. The ‘time out’ intervention in this specific session raised many questions, because most were not familiar with this strategy. Instructions regarding this intervention were extended and refined according to the guidelines of Parent Child Interaction Therapy (PCIT; Eyberg, Nelson, & Boggs, 2008). Based on observations of the facilitators it was decided by the facilitators and research team to add a fifth meeting for parents to receive feedback on practicing the ‘time out’ intervention and to leave room for other questions. We had to keep in mind that time management is not as strict as in more developed countries, many participants do have more than one job, and that transportation facilities are limited and irregular. This means that participation in the study may have taken a lot of effort. All participants received a fee (25USD) after completing the tasks in the study. In addition, handout materials were provided. 128 Consent procedure

Participants were informed about the study’s aims and procedures by letter and in vivo. Consent forms for the participants were completed prior to the first session. To ensure that participants understood the information in the consent form, these topics were communicated verbally, i.e. (1) participation (“You have the right to withdraw at any time”); (2) the purpose of the study (“We would like to see if LMP can help making parenting more easy and fun”; “We would like to see if LMP effects the behavior of the children”; “We would like to write and publish an article about this”); (3) procedures; (4) risks/discomfort for participant; (5) time schedule; (6) personal contact in case of questions/remarks; and (7) confidentiality (“We will not associate your name with anything you say in the sessions”; “We will ask participants to respect each other’s confidentiality, here and outside the sessions”).

Analysis

Data were analyzed with SPSS Statistics 19 (Chicago, IL, USA). Prior to analyses all variables were examined for accuracy of data entry, missing values and presence of outliers. Descriptive statistics (percentages, means, frequencies and standard deviations) were computed for demographic variables. Inspection of the distribution of scores on the continuous dependent variables showed that the scores were reasonably normally distributed. One-way repeated measures analyses of variance (ANOVA) were used to examine change over time (Time 1 pre-intervention to Time 2 post-intervention and Time 3 at five weeks’ follow-up) on (parent and child) standardized measures (PBS and SDQ). A p value of less than .05 was considered significant. Partial eta-squared (tekentje toevoegen), a measure of effect size for use in ANOVAs, was used. Effect sizes of .02, .13 and .26 were considered small, medium, and large, respectively (Pierce, Block, & Aguinis, 2004).

RESULTS

Within group outcomes

Means, standard deviations, and main effects for time are displayed in Table 6.3. For Chapter 6 a graph of change scores over time on both measures, see Figure 6.2 and Figure 6.3.

SDQ Post-intervention scores on the SDQ indicated that, compared to the start of the program, parents reported that their child displayed significantly less hyperactivity, F(1.91, 80.17) 129

= 7.47, p = 0.001, and fewer conduct problems, F(1.87, 78.69) = 22.19, p = 0.000, and Implementation and evaluation of a parenting program emotional problems, F(1.91, 80.17) = 7.47, p = 0.001, after the program. Furthermore, the Total Difficulties scale score reduced significantly, F(1.90, 79.93) = 30.39, p = 0.000.

Children were classified as clinically improved if they moved from the clinical ranges to the non-clinical range on the SDQ Total Difficulties scale. Of the 31 (52.5%) children who scored in the clinical range at Time 1, this number decreased to 20 children (34.5%) at Time 2 and further decreased to 13 children (28.9%) remaining in the clinical range at Time 3.

PBS Post-intervention scores on the PBS indicate that, compared to the start of the program, parents tended to show more positive parenting toward their children, F(1.78, 76.52) = 14.15, p = 0.000. Furthermore, their use of (noncorporal) discipline was higher, F(1.89, 81.46) = 5.10, p = 0.009, and their use of violent parenting practices (corporal punishment) was significantly reduced, F(1.71, 73.40) = 5.25, p = 0.010, after the program.

PBS 2  culties Questionnaire, Prosocial Behavior; Prosocial Rules. Time 2 = 1 missing. Rules. Time R PRO Strengths and Diffi Strengths SDQ Peer Problems and Peer Problems Material Rewarding and Material Rewarding PEER MR analysis of variance; ANOVA Conduct Problems, Conduct Problems,

130 Corporal Punishment, Time 3 N = 45 CON CP Discipline, D Hyperactivity, Hyperactivity, Time 2 N = 58 HYPER Positive Parenting, Positive Parenting, PP Time 1 N = 59 Emotional Symptoms, EMOT culties, Repeated measures ANOVA time effect LMP time effect ANOVA Repeated measures TDEMOTHYPERCONPEERPRO 15.00 2.50 5.24 6.18 2.27PP 4.07 2.90D 3.33 11.97CP 1.91 2.28 7.38 4.67MR 1.96 6.14R 1.84 2.66 2.04 2.61 10.71 2.90 38.39 1.51 2.09 7.86 56.19 4.20 11.20 5.61 65.85 2.05 52.71 1.60 2.49 8.95 F (1.90, 79.77) = 31.73 1.70 43.17 10.00 2.49 2.51 F (1.91, 80.17) = 7.73 51.78 11.19 59.76 10.27 F (1.93, 81.18) = 10.72 2.14 63.50 7.91 10.75 56.64 1.80 p = 0.000 F (1.87, 78.69) = 22.19 44.20 8.67 9.61 2.00 F (1.94, 81.36) = 4.43 p = 0.001 53.95 10.01 p = 0.000 10.99 59.91 0.43 F (1.76, 74.00) = 2.04 62.36 11.18 58.93 F (1.78, 76.52) = 14.15 p = 0.000 0.16 8.90 0.20 9.83 p = 0.016 55.31 8.74 F (1.89, 81.46) = 5.10 p = 0.143 0.35 F (1.71, 73.40) = 5.25 p = 0.000 10.66 F (1.83, 78.76) = 4.88 0.10 F (1.88, 80.88) = 4.33 0.05 0.25 p = 0.009 p = 0.010 p = 0.012 p = 0.018 0.11 0.11 0.10 0.09 Total Diffi Total Scale M SD M SD M SD ANOVA Partial SDQ PBS Parent Behavior Scale-short version, Parent Table 6.3 Table Note. Data in Times 1–3 are means, with standard deviations in parentheses. deviations in parentheses. means, with standard 1–3 are Note. Data in Times TD 40

35

30 TD 25 EMOT

20 HYPER CON 15 PEER 10 PRO 5

0 Time 1Time 2Time 3

Figure 6.2 Strengths and Diffi culties Questionnaire: pre- and post-intervention scores. TD, Total Diffi culties; EMOT, Emotional Problems; HYPER, Hyperactivity; CON, Conduct Problems;

PEER, Peer Problems; PRO, Pro-Social Behavior. Chapter 6

75 70 131

65 Implementation and evaluation of a parenting program PP 60 D 55 HP 50 MR

45 R

40

35 Time 1Time 2Time 3

Figure 6.3 Parenting Behavior Scale - short version: pre- and post-intervention scores. PP, Positive Parenting; D, Discipline; CP, Corporal Punishment; MR, Material Rewarding; R, Rules.

Parents/caregivers were classified as clinically improved if they moved from the clinical ranges to the non-clinical range on the PBS scale Corporal Punishment. Of the 30 parents/ caregivers (50.8%) who scored in the clinical range at Time 1, this number decreased to 23 parents/caregivers (39.7%) at Time 2 and further decreased to 18 parents/caregivers (40.0%) remaining in the clinical range at Time 3. DISCUSSION

The aim of this study was to implement and evaluate the parenting program ‘Lobi Mi Pikin’ (LMP), a program aimed at supporting parents in the use of non-violent forms of parenting, thereby reducing the risk of child maltreatment, in Suriname. The findings of the study provide encouraging results for parents who attended the program and their children. After completing the program, parents showed more positive behavior towards their child(ren). They displayed a greater ability to discipline their children by using rules instead of corporal punishment (CP). Parents also reported fewer conduct and emotional problems and hyperactivity in their children. The results of our study are broadly consistent with comparable international parenting programs. Systematic reviews, meta-analyses, and benchmarking studies provide evidence that parenting programs derived from social learning theory produce changes in parent behavior, child behavior, and parent adjustment (Lee, Horvath, & Hunsley, 2013; Michelson, Davenport, Dretzke, Barlow, & Day, 2013; Proctor & Brestan-Knight, 2016; Sanders, Kirby, Tellegen, & Day, 2014a; Sanders, Kirby, Tellegen, & Day, 2014b). Still, some parents found it difficult to let go old habits and ideas regarding the use of CP. This in line with earlier research, which revealed that adults who were physically punished as children are more likely to accept and enforce CP on their own children, indicating the cyclical nature of 132 CP in families (Bell & Romano, 2012).

There are several hypotheses about why the positive changes in the parents and their children occurred. First, when considering intervention and behavior change that occur in the family context, it is necessary to keep in mind the ‘non-independence’ of the data. Parents and children are mutually influential in their emotions and behaviors. This is implied in a parent-directed treatment such as LMP, where the parent is necessarily the mediator of change in the behavior of the child. Intervening to change the way of parenting changes the patterns of responsivity and sensitivity in the parent-child relationship, leading to improvements in child behavior (Forgatch & DeGarmo, 1999; Gardner, Hutchings, Bywater, & Whitaker, 2010; Masten & Schaffer, 2006; Shaffer, Lindhiem, Kolko, & Trentacosta, 2013). The increased self-regulation of the parents could also have caused a change in child behavior (Bridgett, Burt, Edwards, & Deater- Deckard, 2015). Family environments both contribute to and are affected by children’s problems (Grusec, 2011). Children flourish when their parents and other caregivers provide a safe, stimulating environment that encourages exploration and mastery (Lee, 2010). Second, increased parental social support and confidence may have resulted from sharing problems within a group context (Barlow & Stewart-Brown, 2001; Patterson, Mockford, & Stewart-Brown, 2005). Third, and most likely, the positive changes that occurred may have resulted from a combination of all abovementioned factors. It is likely that increased knowledge of child development, improved parenting skills, a change in attitude towards behavioral problems, but also the expertise and professionalism of the program facilitators may all have led to more positive parenting and decreased behavioral problems of the child (Wyatt Kaminski, Valle, Filene, & Boyle, 2008).

Limitations

Although first results show that LMP resulted in positive effects in terms of changed behaviors on both parenting and child behavior, some limitations regarding the study should be mentioned. First, although a randomized controlled trial (RCT) is the most rigorous scientific method and ‘gold standard’ for evaluating the effectiveness of health care interventions, our study used a non-experimental design (pre- and posttest comparison of the intervention group). This choice was made because of logistic restrictions (Hanley, Chambers, & Haslam, 2016). A second limitation of this study is the reliance on parents’ self-reports as the only source of data. There is the possibility of Chapter 6 overestimation of the desired behavior of their children at Time 2 and 3, because they wished to see it. It is possible that parents judged their own behavior as being more positive and less violent (for example based on a social desirability tendency or the wish to do ‘better’). Earlier research showed that parents might be biased toward reporting 133 benefits of the program (Shaw, 2006). Future research could evaluate the validity and Implementation and evaluation of a parenting program reliability of the self-report measure by comparing the parents’ responses to ratings provided by independent observers, and to self-reports on other well-established measures (Al-Hassan & Lansford, 2011). Third, while highly unlikely, it may be that this study – conducted by not fully independent researchers – may have led to more positive results. There might be a chance of ‘allegiance bias’, that is, the possibility that improvement is effected by a placebo effect, based on a therapeutic optimism of the program facilitators (Cuypers & Cristea, 2016). There could also be a ‘high fidelity view’, that is, facilitators trained by intervention developers know the characteristics and theoretical background of the intervention very well - they know better than anyone how to implement them as precisely as possible. However, interventions are carried out less precisely in daily practice, resulting in less favorable results. This could have affected generalization (Beelmann & Lösel, 2006; Gorman & Conde, 2007). To minimize these tendencies, all facilitators were informed and trained from the start regarding this topic. Strengths

Some clear strengths of the study should also be acknowledged. The current feasibility study was the first to address an evaluation of a protocolled parenting program in Suriname. We evaluated what ingredients worked for the parents (study design, amount of sessions, formation of groups, etc.) and what caused parents to be willing to participate in the program. The parenting program was initiated and implemented by senior local practitioners and researchers with understanding of cultural traditions and background of the participants. At the last session and at five-weeks’ follow-up, all participants evaluated LMP positively and could identify ways that LMP had changed them and their practices. Although parents initially tended to blame their children for their parenting problems and although they were not used to sharing such problems ‘in public’, they soon candidly shared their ‘shortcomings’ and questions in parenting a particular child. Research showed that when parenting programs are restricted to a small minority of vulnerable parents with established serious problems (a common approach used in targeting parenting interventions), such programs can be viewed as something for struggling or ‘failed’ parents with difficult children (Sanders, 2012). To normalize parental engagement, and to increase openness toward participating in the program, we normalized the process of seeking help for children with behavioral and 134 emotional problems by focusing on the positive outcomes and other evidence-based interventions throughout the world. A recent meta-analysis (Gardner, Montgomery, & Knerr, 2015) suggested that parenting programs appear to be at least as effective when they are applied in cultures other than the country where they were first developed. The basic psychological principles (e.g., parent-child relationship building through play and positive attention, child behavior change through social learning) of a parenting course such as LMP are universal across cultures (O’Connor, Matias, Futh, Tantam, & Scott, 2013). Furthermore, the principles of LMP do not only ‘fit’ the principles of the CRC (respectful treatment of children, parenting goals, supporting parents in raising questions and learning to renounce violence), they also ‘fit’ local customs and wishes in Suriname, such as requirements for non-violent strategies and understanding and respect for longstanding habits (Van der Kooij et al., 2017). Our program adherenced to the imported manual and training methods with some adaptations for Suriname. Many adults in Suriname have great difficulty discussing parenting problems, especially in the presence of other parents (and families) because such might be a sign of failure as a parent. The facilitators were all well aware that their attitude regarding this matter might be an important determinant of the atmosphere in the group. Abovementioned qualities probably contributed to the continued success of LMP. Implications and recommendations for policy and future research

Although this study showed that LMP has a positive impact on a range of outcomes, the availability is limited and many parents do not receive the support they need. Given the high emotional, relational, social and economic costs associated with ineffective parenting, the implementation of policies supporting LMP, aimed at the development of positive parenting, should be prioritized. Furthermore, programs for Surinamese parents of adolescents (12 years and older) – for whom different types of Social Media play a substantial role – should be developed and evaluated as well. Further research should also aim to explore the factors that affect parenting program attendance, as well as responsiveness to the intervention. Conducting a follow-up is important for establishing the validity of the program. Prolonging the period before the follow-up assessment to six months would help to further test the sustainability of treatment effects observed following LMP. Furthermore, a ‘refresher’ after a few months would be useful for parents. Although fathers and surrogate fathers have been identified as important figures in combating poverty – addressing the lost developmental potential of young children, improving the Chapter 6 nutritional status and safety of children, and reducing experiences with violence during the early childhood years (Cabrera & Tamis-LeMonda, 2013; Lamb, 2010; Shwalb, Shwalb, & Lamb, 2013) – the limited number of studies within the Caribbean region has largely focused on mothers and children’s behavioral difficulties. Further research should focus 135 on how fathers contribute to developmental outcomes in difficult circumstances and Implementation and evaluation of a parenting program harsh, conflict-ridden family environments (Roopnarine, 2013; Roopnarine & Hossain, 2013; Samms-Vaughan, 2005). It could also be valuable to consider gathering data from children/adolescents whose parents have attended parent training in evaluating such programs. Evaluations of second (objective) informants should be included. The possibility of using an RCT can be considered when it would be logistically possible in Suriname. To make the social-emotional outcomes more visible, future research would be strengthened through the inclusion of qualitative data (Tinajero, Cohen, & Ametorwo, 2016).

At this moment, the government in Suriname is involved in developing strategies addressing child maltreatment, within the framework of a multidisciplinary child mental health approach, targeting all violence against children (UNICEF 2006; 2010). Every approach to change degrading and humiliating practices like CP needs requires efforts from several fronts, for example international and national policy; legislation; public health; psycho-education; evidence based parenting programs; and awareness of the costs in terms of loss of health, schooling and productivity. The Convention on the Rights of the Child produces sound General Comments, offering a range of valuable suggestions and strategies helping to address CP. Conclusion

This study provides preliminary evidence that the parenting program LMP in Suriname may be an effective form of parent training. Parenting is a challenging and complex life task and LMP may be seen as a useful resource for supporting parents in their vital parental tasks. Investment in reducing violence towards children in Suriname – in particular very small children, who are most vulnerable and most at risk for child maltreatment – needs much more attention. Cultural traditions do not change overnight, however; years of inspired effort of many kinds are necessary to make the world safer for children.

136 REFERENCES

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Use of a screening tool for posttraumatic stress disorder in children in Suriname

Inger W. van der Kooij Eva Verlinden Carien D.E. de Jonge Susanne de Kruijf Shandra Bipat Frits Boer Ramón J.L. Lindauer Tobi L.G. Graafsma

Academic Journal of Suriname 2013, 4, 347-352 ABSTRACT

The use of validated instruments on Post Traumatic Stress Disorder (PTSD) concerning children in Suriname is scarce. Worldwide, the Children’s Revised Impact of Event Scale (CRIES-13) is one of the most used instruments to screen for PTSD in children. Current study investigated the use of this tool in Suriname. In three group homes in Paramaribo and a welfare institute, two schools, and two group homes in Nickerie, 65 children filled out the CRIES-13. All these children had been exposed to one or more Adverse Childhood Experiences during their lives. In Nickerie, where there was the possibility to include participation of parents, the Anxiety Disorders Interview Schedule for DSM-IV - Child and Parent Version (ADIS-C/P) was administered to 26 children and their parents to assess PTSD. The CRIES-13 showed to have good face validity. Besides, it demonstrated good internal consistency (0.75) and high test-retest reliability (.80). Furthermore, the CRIES-13 correlated well with the ADIS-C/P. A cut-off score of 30 emerged as the one striking the best balance between sensitivity (.91) and specificity (.73). The CRIES-13 was shown to be a reliable and valid instrument to screen for PTSD in children in Suriname. This will allow the detection of children who are in need of professional help, and therefore offer treatment in an early stage in order to prevent 144 chronic symptoms. INTRODUCTION

Worldwide, children are exposed to Adverse Experiences (e.g., disasters, violence, and neglect). One of the possible consequences of experiencing such events is developing a Post Traumatic Stress Disorder (PTSD). PTSD in children and adolescents can impair psychosocial functioning and increase the children’s risk of developing comorbid disorders, such as mood disorders, behavioral disorders, and anxiety disorders (Bolton et al., 2000; De Bellis & Van Dillen, 2005; Kearney at al., 2010; Schnurr et al., 2002). Research on PTSD in developing countries is scarce. While individuals in developing countries are thought to be at elevated risk of being exposed to adverse experiences, only 6% of PTSD prevalence studies are conducted in these areas. Although international studies show that symptoms of posttraumatic stress are comparable across cultures, languages, racial/ethnic groups and geographic areas, differences in violence, disasters, cultures, social structures, and coping behaviors may influence the prevalence and course of PTSD among people of different countries (e.g., Cardozo et al., 2000; De Jong et al., 2001; De Girolamo & McFarlane, 1996; Rosner et al., 2003). It is therefore not likely that Chapter 7 research in developed countries can be generalized to developing countries.

Situation-bound risk factors, such as poverty, inadequate housing, single-parent fami- lies, substance abuse problems, and lower levels of education are more common in 145 developing countries. These factors may increase the risk of developing PTSD (Bernal & Use of a screening tool for PTSD in children in Suriname Saez-Santiago, 2006). Not surprisingly, substantially higher rates of PTSD are observed in those countries (Cardoza et al., 2000; De Jong et al., 2001; Scholte et al., 2004). Another important factor that may place children from developing countries at higher risk of developing PTSD is stress as a consequence of immigration and culture-related intergenerational conflicts (Dutton et al., 2000).

Presumably higher rates of PTSD in developing countries require research into symptoms and the exact prevalence, and therefore reliable and valid instruments that can elicit children’s reports of their psychological adjustment (Giannopoulou et al., 2006). To assess symptoms after experiencing adverse and uprooting events, the Children’s Revised Impact of Event Scale (CRIES-13; Children and War Foundation, 1998; Olff, 2005) is one of the most widely used selfreport measures within the trauma literature (Perrin et al., 2005). The CRIES-13 is an adaptation of the Impact of Event Scale (IES; Horowitz et al., 1979), which was originally designed for adults. Its revision is a short questionnaire developed for children aged eight years and older, who might be at risk for PTSD (Horowitz et al., 1979; Giannopoulou et al., 2006). The CRIES-13 has been used to screen very large samples of at-risk children who experienced a wide range of adverse events in their childhood (Perrin et al., 2005). One of the developing countries that merit more research on the measures of PTSD among children is Suriname. The population consists of around 540,000 people, of whom approximately 200,000 are children. More than half of this population lives in the capital, Paramaribo. The citizens are mainly of Asian, Indo Caribbean, Indigenous, African Surinamese, Javanese, Chinese, and Dutch descent (General Office of Statistics, Census Office, 2011). Approximately 70% of the population lives below the poverty line (IndexMundi, 2012). In Suriname, research on PTSD in children is scarce. To provide solid health care in this country, proper instruments are necessary in the process of early detection of symptoms. Early detection is important in order to prevent chronic symptoms developing and to offer treatment in an early stage. Furthermore, recognition by the environment (social support) has shown to be important in decreasing the risk of developing PTSD (Olff, 2012).

This study intends to investigate the use of a short screening tool (CRIES-13; Children and War Foundation, 1998; Olff, 2005) to detect PTSD in children living in Suriname. No study so far has been focused on tools to examine symptoms of posttraumatic stress in children in Suriname.

146 METHODS Participants

The study population consisted of a sample of 65 children and adolescents (27 male, 41.5%) aged between 8 and 16 years old (M = 11.48, SD = 2.31), all exposed to one or more adverse event(s) during their lives, mainly abuse and/or neglect. One part of the study (N = 39) took place in three group homes in different parts of Paramaribo, the capital of Suriname. The other part of the study (N = 26) took place in the welfare institute WiN Group, two group homes, and two schools in Nickerie, a small city in the Northwestern part of Suriname. All participants experienced at least one adverse experience in their past. The adverse experience(s) were categorized as a single external event (type I) or a long-standing series of such events (repeated exposure, type II; Terr, 2003). In this population, 12 children had been exposed to a single adverse event, and 53 children had been exposed to longstanding series of such events. In Paramaribo, participants were recruited between March and July 2011. Data in Nickerie were collected in July and August 2009. Instruments

The Children’s Revised Impact of Event Scale-13 The Children’s Revised Impact of Event Scale (Children and War Foundation, 1998; Dutch translation by Olff, 2005) is a short questionnaire to screen children aged eight years and older for PTSD. Respondents rate the frequency with which they have experienced each of the 13 items during the past week, using a four-point Likert-like scale (0 = none, 1 = rarely, 3 = sometimes, and 5 = often). Scores are acquired for four intrusion items, four avoidance items, and five hyperarousal items (Giannopoulou et al., 2006). Validity data from two samples of children showed that 75–83% of the children were correctly classified as having PTSD after completing the CRIES-13, in which a cut-off score of 30 or higher on the total score was indicative of probable PTSD. The CRIES-13 has been used to screen very large samples of at-risk children who experienced a wide range of adverse events in their childhood (Perrin et al., 2005). The Dutch translation of the CRIES-13 (Olff, 2005) is currently being validated in the Netherlands (Verlinden et al., unpublished data). Chapter 7

The Anxiety Disorders Interview Schedule for DSM-IV The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Version (ADIS- C/P; Silverman and Albano, 1996; Dutch translation by Siebelink & Treffers, 2001) is a 147

semi-structured interview for diagnosing anxiety and other related disorders in children Use of a screening tool for PTSD in children in Suriname and adolescents between the ages of 7 and 17 years. The ADIS-C/P is administered separately to children and their parent(s). Symptoms are rated by these two informants as either present (‘yes’), absent (‘no’) or ‘other’ (e.g., ‘sometimes’ or ‘don’t know’). In addition, impairment ratings of each diagnosis are considered. Diagnoses are derived based upon the child report (ADIS-C) and parent report (ADIS-P) separately. In addition, the interviews provide combined diagnoses based on child and parent reports. The ADIS-C/P appears to be a reliable instrument for deriving DSM-IV anxiety disorder symptoms and diagnosis in children. The current version shows to have excellent test- retest reliability (kappa values ranged from 0.61 to 1.00; Silverman et al., 2001).

Procedures

Permission was granted by the board of each group home (Paramaribo), the board of the welfare institute WiN Group, the boards of the different institutes where the study took place (Nickerie), and by the participating children and their parents/caretakers. All children were invited to participate. However, it was emphasized that the child was free not to participate. The anonymity of the screening was explained as well. Although the participants mastered the Dutch language, a list with definitions and explanations in Sranan Tongo matching the questionnaires was given to the caretaker, as Sranan Tongo is the everyday language in the country. Assessment in Paramaribo took place in three group homes. Because not everyone had the opportunity to go the welfare institute WiN Group, assessment in Nickerie took place in different settings, i.e. at the welfare institute WiN Group, at the schools of the children, and at the homes of the participants. Detailed instructions, including information about the study and the way of completing the questionnaire, were given by the researchers. The researcher was there to answer questions when necessary. In the group homes, the caretaker of the child was present as well. Depending on the reading level of the child, the researcher was allowed to provide help by reading every item out loud. In Nickerie, where there was the possibility to include parents in participation, the PTSD section of the ADIS-C/P was administered. A clinically trained psychologist interviewed both child and parent separately. The CRIES-13 and ADIS-C were completed in the same session.

Statistical analyses

Internal consistency was assessed by using Cronbach’s alpha. Spearman’s rank correlation coefficient was used to examine test-retest reliability and the extent to which the 148 CRIES-13 is measuring the same construct as the alternative measure of posttraumatic stress (ADIS-C/P). Furthermore, to examine the efficacy of the CRIES-13 as a measure to identify PTSD in children, sensitivity, specificity, positive/negative predictive value, and overall efficiency were calculated. All analyses were performed by using software SPASW Statistics 19 (Chicago, IL). A p-value < 0.05 was considered significant.

RESULTS

According to results of the ADIS-C/P, 11 out of 26 children (42.3%) are suffering from PTSD. Table 7.1 presents the demographic characteristics of the CRIES-13.

Face validity

In general, the CRIES-13 seemed to be a valid screening tool. All children seemed to understand the fixed instruction. However, some items may be ambiguous and misinterpreted by the children. Words and sentences such as ‘irritable’ and ‘waves of strong feelings’ often had to be explained by the researcher or parent/caretaker. In addition, the CRIES-13 sometimes seemed to be difficult for the younger children, especially questions that were negatively phrased, e.g., ‘Do you try not to think about it?’ Table 7.1 Demographic characteristics of the CRIES-13

Mean (SD) Scale N = 65 Range

Intrusion 9.8 (5.5) 0–20

Avoidance 10.6 (4.9) 0–20

Hyperarousal 11.4 (5.5) 0–23

Total 31.8 (11.7)1–59

Reliability

The total score of the CRIES-13 demonstrated good internal consistency. Spearman’s rank correlation coefficient showed high test-retest reliability for the total score. Table 7.2 shows the reliability of the CRIES-13. Chapter 7

Table 7.2 Reliability of the CRIES-13

Internal consistency Test-retest

Value 95% CI Value 95% CI 149 Use of a screening tool for PTSD in children in Suriname Intrusion 0.73 0.60–0.82 0.58 0.25–0.79*

Avoidance 0.46 0.21–0.65 0.68 0.40–0.84*

Hyperarousal 0.53 0.33–0.69 0.53 0.18–0.76*

Total 0.75 0.65–0.83 0.80 0.60–0.91*

*p < 0.01.

Concurrent validity

The extent to which the CRIES-13 measures the same construct as the ADIS-C/P was examined by using Spearman’s rank correlation coefficient. Correlations were higher for the child interview (ADIS-C) than for the parent interview (ADIS-P). Table 7.3 presents the concurrent validity of the CRIES-13.

Subsequently, total scores on the CRIES-13 were plotted against the presence or absence of a PTSD diagnosis to determine the best cut-off score. For this reason, the information from both child and parent interview were combined. A cut-off score of 30 emerged as the one striking the best balance between sensitivity and specificity. Results showed that Table 7.3 Concurrent validity of the CRIES-13

ADIS-C ADIS-P

Value 95% CI Value 95% CI

Intrusion 0.52 0.17–0.76* 0.48 0.11–0.73**

Avoidance 0.51 0.15–0.75* 0.32 0.00–0.63***

Hyperarousal 0.82 0.63–0.92* 0.57 0.23–0.78*

Total 0.78 0.56–0.90* 0.61 0.29–0.81*

* p < 0.01, ** p < 0.05, *** p = 0.11.

10 out of 11 children with PTSD according to the ADIS-C/P were correctly identified by the CRIES-13. Furthermore, 11 out of 15 children without PTSD according to the ADISC/P were correctly identified as not having PTSD by the CRIES-13. This translated into an overall efficiency rate of 81%. The high negative predictive value (.92) of the CRIES-13 indicates that if a child does not have a total score above the cut-off, it is unlikely that he or she has PTSD. Table 7.4 presents the predictive accuracy of the CRIES-13.

150 Table 7.4 Predictive accuracy of the CRIES-13

Value 95% CI

Sensitivity 0.91 0.62–0.98

Specificity 0.73 0.48–0.89

PPVa 0.71 0.45–0.88

NPVb 0.92 0.65–0.99

a PPV = Positive Predictive Value. b NPV = Negative Predictive Value.

DISCUSSION

This explorative study investigated the use of a short screening tool, i.e. the CRIES-13 (Children and War Foundation, 1998; Olff, 2005), to detect PTSD in children living in Suriname. In this research population, all children had been exposed to one or more adverse event(s) during their lives, mainly abuse and/or neglect. As the results of the ADIS-C/P show, a large percentage (42.3%) of these children suffer from PTSD. The current study does provide further support for the excellent psychometric properties of the CRIES-13. The screening tool was shown to have good face validity, good internal consistency, and high test-retest reliability for the total scale. It should be noted however, that values for the three subscales were lower than those reported by Smith et al. (2003). Furthermore, the CRIES-13 correlated well with the ADIS-C/P. A cut-off score of 30 emerged as the one striking the best balance between sensitivity and specificity. In other words, a score of 30 or higher indicates the presence of PTSD. This cut-off score is in line with the one reported by Perrin et al. (2005).

Strengths and limitations

The CRIES-13 is a short instrument. It consists of only 13 items and therefore is not time- consuming. The items can be scored easily, which makes the CRIES-13 a user-friendly tool. In Suriname, where research on this topic and the use of instruments to assess PTSD in children is scarce, a brief instrument is to be preferred over a time-consuming and demanding one, such as the ADIS. In the current study, the CRIES-13 appears to Chapter 7 have high sensitivity. In other words, the CRIES-13 does not exclude children with a PTSD diagnosis. Furthermore, a self-report of PTSD symptoms, rather than a measure that has to be administered to parents and/or teachers is important, because evidence indicates that these informants tend to underestimate children’s level of these symptoms 151 in comparison to children’s self-ratings (Earls et al., 1988; Yule & Williams, 1990). Use of a screening tool for PTSD in children in Suriname

To make the children in the group homes feel more at ease, their caretaker was present during assessment. We realize that this might have been of influence on the answers of these children. The misunderstanding of some items could be a result of the lower level of education of the children in this country (Multiple Indicator Cluster Survey-3, Suriname, 2006). Misunderstandings may also have been caused by some unfamiliarity with expressing feelings in the formal language (Dutch), while these are normally expressed in Sranan Tongo. Unfamiliarity in general with expressing emotions may be a determining factor as well. Parents and other caretakers might be low in sensitivity and responsivity, resulting in children not recognizing, verbalizing, and communicating their emotional states. We have no knowledge of empirical research in Suriname addressing this subject.

Recommendations

The CRIES-13 is a useful instrument to screen for PTSD in children and can be administered by professionals with medical and/or social education. It should be mentioned however, that one cannot make a clinical diagnosis based on the scores on the CRIES-13. If the CRIES-13 indicates the presence of PTSD, further clinical assessment is necessary in order to make a proper diagnosis. In this study, the CRIES-13 was administered in different settings in two relatively highly populated cities in Suriname. In continuing this study, the population may be widened, in particular through including settings that are located in the interior. In addition, further investigation in other settings, such as hospitals, mental health centres, and among general practitioners, is recommended. To eliminate factors that could yield difficulties, a fixed glossary with explanations in the local language is recommended, as well as the presence of a professional who can provide help at any time. The conversion of the negative items would probably make the questionnaire more accessible for young children as well.

Conclusions

In summary, our results indicate that the CRIES-13 may serve as a useful tool to screen for PTSD in children in Suriname. A tool in order to screen children for PTSD can detect children who are in need of professional support, and therefore assist in providing treatment at an early stage and help to prevent chronic health related symptoms. 152 REFERENCES

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154 Chapter 7

155 Use of a screening tool for PTSD in children in Suriname 156 8

Summary & general discussion SUMMARY

The aim of this thesis is to provide scientific knowledge on the current situation of child abuse and neglect in Suriname. It provides information on the (year) prevalence of child abuse and neglect in Suriname, with particular attention to sexual abuse of children. It also gives insight into perceptions of the use and function of corporal punishment among young people and parents/caregivers from different ethnic backgrounds. Furthermore, it pays attention to the prevention of child abuse through the implementation and evaluation of a parenting program. Finally, a tool that screens for posttraumatic stress disorder – one of the possible negative outcomes of child abuse – is examined in order to identify children at risk in an early stage after a (potential) traumatic event.

The current chapter provides a summary and discussion of the main findings of the previous chapters and will set out future directions for research and clinical practice.

INTRODUCTION

Chapter 1 starts off with the issue of child abuse. Child maltreatment, also referred to as child abuse and neglect, is defined by the World Health Organization as: “all forms of 158 physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that result in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power” (World Health Organization, 2017). The protection of children from all forms of violence is a fundamental right guaranteed by the United Nations Convention on the Rights of the Child (from here called: CRC). Yet violence remains a part of life for children around the globe – regardless of their economic and social circumstances, culture, religion, or ethnicity – with both immediate and long-term consequences. Factors identified to have a risk for child abuse include characteristics of the parents (e.g., substance abuse, mental health problems, early parenting) and child (e.g., disability, lower or retarded mental development), family circumstances (e.g., large families, limited parenting skills, intimate partner violence), and contextual factors (e.g., poverty, poor social network; Coulton, Crampton, Irwin, Spilsbury, & Korbin, 2007; Gilbert et al., 2009; MacKenzie, Kotch, & Lee, 2011; Sedlak et al., 2010). Prevalence rates are hard to assess, due to different methodologies, the lack of consensus of what constitutes child abuse and the hidden nature of child abuse. Data describing the prevalence of child abuse in all its forms are relatively less available in many low- and middle-income countries, such as Suriname. Estimates, however, show that 86% of children aged 2 till 14 years in Suriname are subjected to violence like (severe) corporal punishment during the month prior to the interview (UNICEF, 2010). Suriname is no exception in the Caribbean region: a cross-national regional study involving 34 countries found that a majority of mothers in Jamaica, Belize, Trinidad and Tobago and Guyana uses corporal punishment on children between 2 and 12 years of age (Cappa & Kahn, 2011). Since its commitment to the implementation of the CRC in 1993, the Government of the Republic of Suriname has planned, executed, and evaluated programmes to set and improve the basic conditions for its implementation. In 2016, however, the United Nations Committee on the Rights of the Child (UNCRC) expressed in her ‘Concluding Observations’ a serious concern about child abuse and neglect in Suriname, the lack of shelters for child victims and information on investigations of cases of child abuse and neglect. The Committee urged the State party to ensure the development of appropriate legislation, policies, and services for prevention and recovery (Committee on the Rights of the Child, 2016).

PREVALENCE OF CHILD ABUSE IN SURINAME Chapter 8 Chapter 2 provides the results of the national representative study of child abuse and neglect in Suriname. One thousand three hundred and ninety-one (1,391) adolescents and young adults of different ethnicities completed a questionnaire about child abuse. The study sample, obtained by random probability sampling, consisted of students (aged 159 12 through 22 years) from five districts in Suriname. Among the adolescents (aged 12 till Summary & general discussion 18 years), 57.1% were exposed to child abuse in the past year. To compare our data with the sentinel data (reports from professionals) of the National Incidence Study – 4 (NIS-4; Sedlak et al., 2010) and the Netherlands’ Prevalence Study of Maltreatment of Children and Youth (NPM-2010, Euser et al., 2013), a selection of items from the questionnaire was used. In total, 13 items were considered by reliable coders (NPM-2010) to match the definition of child abuse used by the NIS-4. The selection consisted of items assessing sexual and physical abuse and items assessing experienced conflicts between parents. When this definition of child abuse was applied, 36.8% of adolescents reported having experienced at least one form of abuse in the past year. The Netherlands’ Prevalence Study on Maltreatment of Children and Youth and the National Incidence Study – 4 reported that 34 in 1,000 children and 39.5 in 1,000 children had been abused during the past year, respectively. Compared to these results, the rates in Suriname are alarmingly high: more than 36% (a proportion of 368 in 1,000) of the adolescents reported having experienced at least one form of maltreatment during the past 12 months. Although most participants reported to have been exposed to violence by their parents, they might not feel they have been maltreated. The results, however, indicate (extremely) high prevalence rates of child abuse in Suriname. A national approach to child abuse and neglect is recommended, including the development of a national strategic plan, a national surveillance, and monitoring system, and changes to the state programmatic and policy response.

CHILD SEXUAL ABUSE IN SURINAME

Chapter 3 provides the results of our national prevalence study, with a focus on child sexual abuse (CSA). One thousand hundred and twenty (1,120) adolescents (aged 12 till 18 years) of different ethnicities completed a questionnaire about child abuse, including CSA. Present study showed high prevalence rates for both adolescent boys and girls in all stages of adolescence, with an increased risk of CSA (year prevalence) as adolescence progresses. More than 16% of all boys and 15% of all girls indicated that they had been exposed to some form of CSA in the past 12 months. Girls reported significantly more CSA by a minor inside the family than boys (year prevalence: 3.6% vs. 0.7%). Boys reported more experiences of being touched or forced by a minor outside the family to look at/touch his private parts than girls (year prevalence: 8.3% vs. 4.1%). A significant portion of CSA constitutes peer-to-peer sexual victimization. It was concluded that CSA is a major public health problem in Suriname. Further research 160 is needed. As the study relied upon children’s self-reported victimization and did not include any independent verification, a more objective, external evaluation is needed.

PERCEPTIONS OF CORPORAL PUNISHMENT AMONG CREOLE AND MAROON ADOLESCENTS, CAREGIVERS AND PROFESSIONALS

Chapter 4 describes perceptions of corporal punishment (CP) among adolescent and adult community members from Creole and Maroon background, as well as from professionals from Creole and Maroon background working with children. In total, twelve focus group discussions were conducted. Our study showed how violent forms of disciplining children are widely accepted and practiced in Suriname. Both caretakers and adolescents considered CP at times to be a necessary and respected form of disciplining children. It should be allowed as a ‘last resort’ in keeping children on a path toward responsible citizenship and behaviour, and preventing them from getting involved in dangerous activities and unhealthy lifestyles. Participants saw CP as abuse when physical injuries emerge (‘when blood flows’). Furthermore, by saying ‘without a reason’, adolescents seemed to allude to a similar perspective among adults: CP is abuse when it is carried out in a fit of anger and frustration. CP was not considered abuse as long it is interpreted as ‘in the best interest of the child’. In general, it was thought of as a form of child disciplining when nothing else – less painful, like inducing fear – works. Participants knew about the existence of the CRC and its ratification by Suriname, but there was a lack of knowledge about its content. Given the adverse effects of the use of CP, it is important that parents learn about the possible devastating consequences and that they are offered alternative (non-violent) ways of parenting. The wide availability of Internet could be exploited as a way of distributing information, in particular into less accessible areas.

PERCEPTIONS OF CORPORAL PUNISHMENT AMONG INDO CARIBBEAN ADOLESCENTS AND CAREGIVERS

In Chapter 5 a second qualitative study is described, in which 12 focus groups regarding

perceptions of corporal punishment (CP) are conducted with adolescents and caregivers Chapter 8 of Indo Caribbean background in Suriname. This study showed that CP is a key experience in the lives of most adolescents. There was no clear consensus regarding adolescents’ and caregivers’ perspectives on the parental use of CP. While participants generally accepted the use of CP as a parental right (though not a right of teachers however), the 161

endorsement of CP was clearly contextually dependent. Mild CP was only acceptable for Summary & general discussion more serious transgressions. Rationales against CP centered on the potential for causing distress and pain to a child and aggressive behaviour later in life, the damage to the parent-child relationship, and the lack of constructive or instructional value inherent in the corrective strategy. While many participants hesitated to support efforts to prohibit CP in all settings legally, a number of them argued that such a ban could have helped in protecting children from parents who used CP excessively. Caregivers mentioned the lack of alternative parenting principles and the importance of the implementation of parenting programs before banning CP. Messages arising from this study could usefully inform the development of a public information campaign on safe, non-violent but still effective ways to disciplining children in Suriname. As the UNCRC in her Concluding Observations emphasizes, there is a need to create child-friendly environments that protect children from violence. Parents should be supported in healthy child rearing through a variety of easy to access means. Attitudes, which perpetuate the tolerance and condoning of violence towards children, the regulation of the depiction of violence by mass media included, should be challenged. THE PARENTING PROGRAM ‘LOBI MI PIKIN’

Chapter 6 describes the study that aimed to implement a parenting program (‘Lobi Mi Pikin’; LMP) in Suriname as well as to evaluate its effects on corporal punishment (CP) and child behavioral problems. Parents/caregivers (N = 70) of children (aged 3 through 12 years) with externalizing behavioural problems participated in a protocolled parenting program. The child’s behavioural problems and parenting style of the parent/ caregiver were assessed using the Strengths and Difficulties Questionnaire (Goodman, 1997; Dutch translation by Van Widenfelt, Goedhart, Treffers, & Goodman, 2003) and Parental Behaviour Scale - short version (Van Leeuwen & Vermulst, 2004; Van Leeuwen & Vermulst, 2010), pre- and post-treatment. Five-weeks’ follow-up measures revealed significant positive effects of LMP on all outcome measures. Follow-up comparisons demonstrated a large reduction of (1) total child difficulties and (2) conduct problems, a moderate reduction of (3) hyperactivity and (4) emotional problems, a moderate to large increase in the (5) self-reported positive behaviour of the parent and a small decrease in the (6) use of CP. This study provides preliminary evidence that LMP may be an effective model of parent training in Suriname. Moreover, it can help guide efforts to reduce the use of CP and encourage positive parenting, thereby preventing child abuse. The major providers of early childhood experiences are parents. Supporting and 162 strengthening the family will increase the likelihood of optimal childhood experiences. Key principles of brain development, child development, and caregiving should be integrated into public education.

SCREENING FOR PTSD IN SURINAME

Chapter 7 describes the investigation of a screening tool for posttraumatic stress disorder (PTSD), the Children’s Revised Impact of Event Scale (CRIES-13; Children and War Foundation, 1998; Dutch translation by Olff, 2005). Experiencing child abuse has been linked to a variety of negative consequences, including PTSD. In different settings, 65 children filled out the CRIES-13. All these children had been exposed to one or more Adverse Childhood Experiences during their lives. The Anxiety Disorders Interview Schedule for DSM-IV - Child and Parent Version (ADIS-C/P; Silverman & Albano, 1996; Dutch translation by Siebelink & Treffers, 2001) was administered to 26 children and their parents to assess PTSD. The CRIES-13 was shown to be a reliable and valid instrument to screen for PTSD in children in Suriname, having good face validity, good internal consistency, and high test-retest reliability. Furthermore, the CRIES-13 correlated well with the ADIS-C/P. A cut-off score of 30 emerged as the one striking the best balance between sensitivity and specificity. We recommend instructing general practitioners and psychologists to use the instrument for children who might be at risk for PTSD in an early stage after a (potential) traumatic event and therefore offer treatment in order to prevent chronic symptoms.

GENERAL DISCUSSION

Suriname today

Suriname – fully independent since 1975 – is an upper middle-income country. The country was one of the Caribbean’s best performing economies over the last decade, largely due to its rich endowment in natural resources. The economy contraction has deepened in 2016, accompanied by currency depreciation and high rates of inflation. The economy is dominated by the mining industry, with exports of oil, gold, and alumina, making the economy highly vulnerable to mineral price volatility. Between 2012 and 2016 Chapter 8 the country lost 80% of her mining revenues, impoverished seriously and has recently (2016) asked the International Monetary Fund for help (Ministry of Finance, March 2017). Most of Suriname’s population and economic activities are located in low-lying coastal areas that are vulnerable to rising sea levels, heavy rainfall, and strong winds. Most recent percentages show that 16% of all inhabitants are ‘material poor’ and 53% 163 Summary & general discussion is at risk of being ‘material poor’ (Sobhie, De Abreu-Kisoensingh, & Dekkers, 2016). Present-day Suriname is the home to many cultures. Its population (570,000 inhabitants) is composed of three relatively large ethnic groups. Today the Indo Caribbean makes up the largest ethnic group in Suriname (27%). The second largest group are the Maroons (22%), descendants from the slaves that escaped into the interior and established their own free societies there. The third largest group are the Creoles (16%). This term refers to persons of African descent who may often show some admixture with other ethnic groups (Sobhie, De Abreu-Kisoensingh, & Dekkers, 2016). The official language (and the language of the former oppressor) is Dutch, but the widely and informal spoken language in the country is Sranan Tongo, a mix of Dutch, English and several other languages (World Factbook, 2017). Suriname shows a high rate of suicide in general, with the highest rates for girls and the second-highest rate for boys in the world (Kõlves & De Leo, 2014; Graafsma, Westra & Kerkhof, 2016). Trauma and abuse are found to be risk factors for suicide (Martin, Dykxhoorn, Afifi, & Colman, 2016). Also in this context, the high prevalence rates of child abuse and neglect in Suriname, as our thesis revealed, are worrying. Despite these high prevalence rates, child protection system and services in Suriname still are limited and ‘understaffed’ (Arends, 2016). Across Caribbean ethnic groups, parenting has been described as a mix of indulgence and warmth in combination with harsh treatment of children (Leo-Rhynie, 1997). This includes the use of corporal punishment (Cappa & Kahn, 2011). Obedience, compliance, and respect are expected of children (Evans & Davies, 1997; Wilson, Wilson, & Berkeley-Caines, 2003), and according to some accounts, there is little praise or reward directed at children (Leo-Rhynie, 1997; Roopnarine, Bynoe, & Singh, 2004). A recent study across four predominantly Black Caribbean nations, however, reported different results (Lipps et al., 2012). Lipps and colleagues surveyed parenting styles experienced by nearly 2,000 Caribbean adolescents and presented that authoritative parenting, referring to strict parental standards for behaviour intertwined with a high degree of parental warmth, was the most common. This apparent cohort difference in the favoured parenting style may reflect an evolution of parenting styles among Caribbean parents.

The use of corporal punishment in parenting

The Caribbean presents an exclusive case with respect to research on child rights and child rights issues. It has been suggested that the legacy of slavery and colonialism may help to explain the social and cultural traditions that have hindered acceptance of the child rights movement (UNICEF, 2006). The focus groups of our thesis showed a 164 widespread acceptance and use of corporal punishment (CP) as an appropriate form of disciplining and/or punishing children. Approval of CP among parents and caretakers was rooted in beliefs linking the use of CP with positive or neutral outcomes such as: ‘I was spanked in my childhood and look where I am today’, and that CP is believed to be effective when talking does not have the desired result. Also linked to approval were beliefs about the state of society: ‘today’s generation is worse off than previous ones and children have too much power’. This finding is congruent with an extended content analysis on beliefs and ideologies linked with approval of CP, showing that reasons for approval of the use of CP are linked with beliefs of positive outcomes (‘I was spanked and I am okay’), that spanking improves child behaviour, that spanking is more effective than other forms of discipline, and that spanking is not abuse (Taylor et. al, 2016). Some adolescents did express their views about whether they believed that CP was necessary, and many did underline a sense of responsibility for having been beaten, the result of them having done something wrong or in the very least as their own fault. This may reflect that, despite them not liking being beaten, they see it as necessary or appropriate similar to views reported in previous studies (Breen, Daniels, & Tomlinson, 2015; Simons & Wurtele, 2010). There was consensus that despite negative responses to CP, parents had the right to use this strategy in selective and appropriate circumstances. Significantly, adolescents assigned the right of CP exclusively to their parents. Earlier research (Kish & Newcombe, 2015) identified some myths about harmlessness and effectiveness and necessity of CP. It was shown that such myths were predictive of intention to use CP. Changing those myths might lead to a reduction of the parental use of CP.

To support parents in the use of non-violent forms of parenting, thereby reducing the risk of child abuse, a parenting program called ‘Lobi Mi Pikin’ was implemented. The findings of this study provide encouraging results for parents who attended the program and their children. After completing the program, parents reported more positive behaviour towards their child(ren). They displayed a greater ability to discipline their children by using rules instead of CP and also reported fewer behavioural problems in their children. Several hypotheses about why these changes in the relation between the parents and their children occurred can be mentioned. It is assumed that parents and children are mutually influential in their emotions and behaviours. Intervening to change the character of parenting effectively changes the behavioural contingencies and patterns of responsivity in the parent-child relationship, subsequently leading to Chapter 8 improvements in child behaviour (Forgatch & DeGarmo, 1999; Gardner, Hutchings, Bywater, & Whitaker, 2010; Masten & Schaffer, 2006). The increased self-regulation of the parents also may have caused a change in child behaviour. Children flourish when their parents and other caregivers provide a safe, predictable, and stimulating 165 environment that encourages exploration and mastery. Maternal sensitivity at each period Summary & general discussion of development appears to promote adaptive functioning (Bradley & Corwyn, 2013; Bridgett, Burt, Edwards, & Deater-Deckard, 2015; Lee, 2010). Furthermore, increased parental social support and confidence may have resulted from sharing problems within a group context (Barlow, 2001; Patterson, Mockford, & Stewart-Brown, 2005). Still, some of the parents participating in the parenting program found it difficult to let go habits and ideas regarding the use of CP. For them, prohibiting CP felt as a violation of a right. This finding fits with earlier research, which revealed that adults who were physically punished as children themselves are more likely to accept and enforce CP on their own children, indicating the cyclical nature of CP in families (Bell & Romano, 2012). Some caregivers expressed in the focus groups their wishes to discipline their children in another (non violent) way. They, however, lacked the skills to do so. The principles of LMP do not only ‘fit’ the principles of the CRC (respectful treatment of children, parenting goals, supporting parents in raising questions and learn to renounce violence), they also ‘fit’ local customs and wishes in Suriname, such as requirements for non-violent strategies and understanding and respect for longstanding habits. Internet could be a useful tool to reach parents in the interior, as no evidence based parenting programs are easily available here. Parenting programs like LMP could provide them with evidence-based tools to discipline their children in a non-violent way.

Until now, there is no justification for the use of CP by parents and others enshrined in law in Suriname, but legal provisions against violence are not interpreted as prohibiting all CP in childrearing. The fact that CP is not yet unlawful in Suriname is likely to be both a cause and effect of the attitude towards violence against children (End Corporal Punishment Now, 2017). While noting the progress in prohibiting CP in schools through a ministerial decree, in 2016 the Committee on the Rights of the Child reiterates its previous recommendations that the State party: (a) amend its legislation to explicitly prohibit CP in all settings, and (b) strengthen and expand its efforts, through awareness- raising programs and campaigns, to promote non-violent forms of child-rearing, as well as expand parenting education programs, and training for principals, teachers and other professionals working with and for children (Committee on the Rights of the Child, 2016). In our study, caregivers mentioned the lack of alternative parenting principles and the importance of the implementation of parenting programs before banning CP. Many adolescents also expressed some reluctance to ban CP. These views were primarily associated with the difficulties of monitoring parental behaviours in the home and the fear that parents could be imprisoned for using CP. Only a minority of adolescents was 166 indisputably in favour of banning CP at home. In other words, tensions between the ‘law’ (CRC) and ‘everyday reality’ have been found. As in 2017, the ‘everyday reality’ in Suriname lags behind the law, as the CRC considers all forms of CP as violence that should be rejected.

Sexual abuse of boys

Sexual abuse as it affects boys has received little attention in the literature. The most recent extensive meta-analysis on the prevalence of sexual abuse across the world showed an overall prevalence rate of 13%, with a rate for girls (18%) being more than twice that of boys (8%; Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). Our thesis, however, revealed unexpectedly high prevalence rates of sexual abuse for boys. The high year prevalence rates of sexual abuse for Caribbean boys stand out in comparison to other non-Caribbean countries (Jones, 2013). Several hypotheses about these high prevalence rates can be mentioned. Earlier research in the field of sexual behavior of Afro Surinamese adolescents in the interior of Suriname showed that boys generally start sexual activity earlier than girls and that the frequency of sexual contacts of boys is much higher than that of girls (Terborg, 2002; Guicherit & Bakboord, 2008). Like in other Caribbean countries, many researchers express the opinion that the onset of sexual activity in Suriname is occurring at a young age (UNICEF, 2012; Heemskerk, 2013). In some villages in the rural interior there is mention of sexual initiation at the age of nine (Ministry of Health Suriname, 2012). Early sexual initiation and sexual risk-taking amongst adolescents is associated with sexual and physical abuse in early childhood (Heemskerk, 2013). Words used in the questionnaire (‘forced’, ‘things that I would consider abuse’) showed the abusive character of (some of) these sexual experiences. Masculine gender expectations – even more prevalent in Caribbean countries such as Suriname – teach boys they cannot be victims (Gardner, 2011). This might be a reason boys do not speak out in daily life. Boys are supposed to be competitive, resilient, self-reliant, and independent, but certainly not emotionally needy. ‘Real’ men initiate sexual activity and want sex whenever it is offered, especially when women/girls behave seductive. For them, acknowledging victimization implies admitting they are weak, ‘no real man’ (Easton, Saltzman, & Willis, 2014; Gardner, 2011). Our study possibly enhanced disclosure by using an anonymous self-reporting instrument administered outside of the home. Other reasons why victims in Suriname in general may not disclose sexual abuse in daily life are cultural Chapter 8 barriers (e.g., reluctance of traditional and closed communities to involve outsiders in matters that are perceived to fall under the authority of local leaders; Arends, 2016), the acceptance of violence (e.g., corporal punishment of children), or the absence of police stations or emergency rooms to report a case (e.g., in the interior districts). In addition, 167 frontline workers (such as teachers, nurses or social workers) who could potentially identify Summary & general discussion and report cases of sexual abuse may not have received the necessary training on early identification and subsequent counselling and treatment of victims (Arends, 2016). The fact that several studies showed that boys are affected just as often as girls (in Africa and Malaysia; Brown et al., 2009; Madu & Peltzer, 2001; Singh, Yiing, & Nurani, 1996) may indicate that previous research designs and methods might not have been adequately constructed to identify male victims or that boys face cultural and social barriers in reporting sexual abuse that are different from girls. In general, higher levels of reporting of sexual abuse are found when study questions are framed around behaviourally specific acts and are carried out in environments that promote honesty, safety, and privacy (Veenema, Thornton, & Corley, 2014). Further (qualitative) research should focus on (perceptions of sexual abuse, masculinity and sexuality of) male victims in Suriname.

The right to be heard & age of consent

The right to be heard is a child rights principle as defined by the Convention on the Rights of the Child (CRC). According to Article 12 of the Convention, children have the right to express their views in all matters affecting them and their views have to be given due weight in accordance with the age and maturity of the child. As a general principle, the child’s right to be heard reflects the concept of children’s ‘agency’, viewing children not only as vulnerable persons in need of special protection, but also as informed decision makers, rights holders and active members of society (Committee on the Rights of the Child, 2009). Our thesis showed that the CRC and its ratification changes the relations between generations for many communities in Suriname, as most people still believe that children have to respect their parents and should fulfil their ‘duties’ instead of speaking out. In particular in the rural areas, caregivers in our focus groups spoke about rights of children as something that they were not accustomed to. They also expressed the fear that when they do not apply CP their children might end up on the street. They worry that children’s rights have a harmful influence on their behaviour. By only talking and listening to children, they are afraid to relinquish control over their children for fear that their children might take over power in the parent-child relationship.

The age of consent is the minimum age at which an individual is considered legally old enough to consent to participation in sexual activity. Individuals aged 15 years or younger in Suriname are not legally able to consent to sexual activity, and such activity may result in prosecution for statutory rape or the equivalent local law. Suriname statutory rape law is violated when an individual has consensual heterosexual sexual contact with a 168 person under age 16, or has consensual homosexual sexual contact with a person under age 18. Suriname does not have a close-in-age exemption. Close in age exemptions, commonly known as ‘Romeo and Juliet laws’ in the United States, are put in place to prevent the prosecution of individuals who engage in consensual sexual activity when both participants are significantly close in age to each other, and one or both partners are below the age of consent. Because there is no close-in-age exemption in Suriname, although this is rare, it is possible for two individuals both under the age of 16 who willingly engage in intercourse to both be prosecuted for statutory rape. Similarly, no protections are reserved for sexual relations in which one participant is a 15 year old and the second is a 16 or 17 year old (Age of Consent, 2017).

FUTURE RESEARCH

Although the studies in this thesis have provided new insights with regard to the current situation of child abuse and neglect in Suriname, they have also raised new questions. Several recommendations for future research are presented below.

First of all, our prevalence study (Chapter 2 and Chapter 3) relied upon children’s self- reported victimization only. As there could have been tendency biases, a more objective, external evaluation is needed. Furthermore, the influence and role of Social Media could be subject of further research. Qualitative research could focus on (perceptions of) sexual abuse of male victims. Furthermore, questions that include subjective terms such as ‘abuse’ should be replaced by descriptive situations, as those promote reporting and disclosure.

Second, a recommendation for future research regarding the focus groups (Chapter 4 and Chapter 5) would be to use a ‘mixed methods’ approach to further explore the issues. Furthermore, the use of individual interviews as an adjunct to focus groups may provide a forum for going beyond exploring perspectives on these issues. Participants’ views on these issues could be incorporated into existing parenting programs that seek to provide support for parents. A possible avenue for intervention would be to discuss findings of studies such as this in the community, to explain and demonstrate alternative disciplinary strategies and to secure cooperation and provide support in using them.

Third, the availability of parenting programs like Lobi Mi Pikin (Chapter 6) is limited Chapter 8 and many parents do not receive the educational support they need. Probably a variety of programs are needed, directed to parents with children in different age groups. Challenges will be the inclusion of fathers and the development of low-cost ways of disseminating essential parenting skills. The wide availability of Internet could be exploited as a way of distributing information, in particular into less accessible areas. 169 Summary & general discussion Furthermore, programs for parents of adolescents (12 years and older) should be developed and evaluated as well. Further research should also aim to explore the factors that affect parenting program attendance, as well as responsiveness to the intervention.

Overall, dropouts and children not sent to school should be included in research as well.

FINAL CONCLUSIONS

The high prevalence rates of child abuse and neglect in Suriname revealed in this thesis, in general suggest that investment in a comprehensive national approach is urgent, especially because of the serious and often lifelong consequences child abuse may imply. In this thesis, a tool that screens for posttraumatic stress disorder – one of the possible negative outcomes of child abuse – was examined in order to identify children at risk in an early stage after a (potential) traumatic event. Corporal punishment, though considered in the Convention on the Rights of the Child as a violation of the integrity and dignity of the child, is still widely accepted and applied in Suriname, despite growing knowledge of its harmful consequences. The implementation of the CRC, however, may have accelerated the discussion about corporal punishment in Suriname. In this thesis, parents/caregivers expressed the need for educational support in developing non-violent forms parenting. The implemented parenting program ‘Lobi Mi Pikin’ (LMP) described in this thesis provides preliminary evidence that LMP may be an effective model of parent training in Suriname. Moreover, it can help guide efforts to reduce the use of CP and encourage positive parenting, thereby preventing child abuse. Clearly, a differentiated set of parenting programs should become widely and easily available in the country, also in the less accessible interior.

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Samenvatting List of co-authors Contributors’ statement PhD portfolio Dankwoord SAMENVATTING

Het doel van dit proefschrift is onderzoek te doen naar kindermishandeling en ver- waarlozing in Suriname. Het proefschrift geeft informatie over de (jaar)prevalentie van kindermishandeling en verwaarlozing in Suriname, met speciale aandacht voor seksueel misbruik. Tevens geeft het inzicht in hoe jongeren en ouders/verzorgers van verschil- lende etnische achtergronden denken over het gebruik en de functie van lijfstraffen. Ook besteedt het aandacht aan de preventie van kindermishandeling door de implementatie en evaluatie van een opvoedprogramma. Tot slot wordt een instrument onderzocht dat screent op posttraumatische stressstoornis, een van de veelvoorkomende gevolgen van kindermishandeling. Met dit instrument kunnen (trauma)klachten bij kinderen vroegtijdig worden gesignaleerd.

Dit hoofdstuk geeft een overzicht van de belangrijkste bevindingen van de voorgaande hoofdstukken en zal richtingen voor toekomstig onderzoek en de klinische praktijk bespreken.

INTRODUCTIE

Hoofdstuk 1 is de introductie van het proefschrift, waarin beschreven wordt wat kinder- 176 mishandeling is, welke gevolgen het heeft en wat het doel is van het proefschrift. Onder kindermishandeling wordt in dit proefschrift het volgende verstaan: kindermishandeling behelst “iedere vorm van voor een minderjarige bedreigende of gewelddadige interactie van fysieke, psychische of seksuele aard, die de ouders of andere personen ten opzichte van wie de minderjarige in een relatie van afhankelijkheid of van onvrijheid staat, actief of passief opdringen, waardoor ernstige schade wordt berokkend of dreigt te worden berokkend aan de minderjarige in de vorm van fysiek of psychisch letsel” (Wet op de Jeugdzorg, 2017). De bescherming van kinderen tegen elke vorm van geweld is een fundamenteel recht dat gewaarborgd wordt door het Internationaal Verdrag van de Rechten van het Kind. Toch is geweld een deel van het leven voor veel kinderen over de hele wereld – ongeacht hun economische en sociale omstandigheden, cultuur, reli- gie of etniciteit – met zowel directe gevolgen als gevolgen die een leven lang kunnen voortduren. Risicofactoren voor kindermishandeling zijn persoonlijke kenmerken van de ouders (bijvoorbeeld middelenmisbruik, mentale problemen of stoornissen, zeer vroeg ouderschap) en het kind (bijvoorbeeld belast door een lichamelijke of verstandelijke beperking), familieomstandigheden (bijvoorbeeld beperkte opvoedvaardigheden, huiselijk geweld) en omgevingsfactoren (bijvoorbeeld armoede, geen sociaal netwerk; Coulton, Crampton, Irwin, Spilsbury, & Korbin, 2007; Gilbert et al., 2009; MacKenzie, Kotch, & Lee, 2011; Sedlak et al., 2010). De prevalentie van kindermishandeling is moei- lijk vast te stellen. Dit komt bijvoorbeeld doordat er op verschillende manieren wordt gemeten, maar ook omdat men het er niet altijd over eens is wat wel en niet gerekend wordt tot kindermishandeling. Verder wordt kindermishandeling over het algemeen veelal ‘verborgen’ gehouden. Vooral in armere landen zijn er vanwege budgetbeper- kingen op het gebied van de epidemiologie van kindermishandeling vaak betrekkelijk weinig gedetailleerde gegevens beschikbaar. Schattingen voor Suriname laten zien dat zo’n 86% van alle kinderen in de leeftijd van 2 tot 14 jaar te maken heeft gehad met (zware) lijfstraffen in de maand voor het interview (UNICEF, 2010). Suriname is geen uitzondering in het Caribisch gebied: uit een cross-regionale studie waar 34 landen aan hebben deelgenomen, blijkt dat de meerderheid van de moeders in Jamaica, Belize, Trinidad en Tobago en Guyana gebruik maakt van lijfstraffen bij kinderen in de leeftijd van 2 tot 12 jaar (Cappa & Kahn, 2011). Sinds Suriname in 1993 het Kinderrechtenver- drag heeft getekend, heeft de overheid verschillende plannen ontwikkeld, uitgevoerd en geëvalueerd om de ‘basiscondities’ voor de implementatie van het verdrag te hpe Samenvatting Chapter 9 verbeteren. In 2016 heeft het Comité van de Verenigde Naties inzake de Rechten van het Kind echter aangegeven dat zij zich ernstige zorgen maakt over de huidige situ- atie op het gebied van kindermishandeling in Suriname en de implementatie van het Kinderrechtenverdrag. Het Comité noemt bijvoorbeeld het gebrek aan opvang voor 177 en informatie over slachtoffers van kindermishandeling. Het Comité heeft de Staat dan ook verzocht gepaste wetgeving en beleid te ontwikkelen en diensten te waarborgen voor de preventie van kindermishandeling en het herstel van slachtoffers (Committee on the Rights of the Child, 2016).

PREVALENTIE VAN KINDERMISHANDELING

Hoofdstuk 2 geeft de resultaten weer van de nationale prevalentiestudie naar kinder- mishandeling en verwaarlozing in Suriname. In totaal hebben 1.391 adolescenten en jongvolwassenen in de leeftijd van 12 tot 22 jaar uit vijf verschillende districten van verschillende etnische achtergronden een vragenlijst over kindermishandeling (Euser et al., 2013; Lamers-Winkelman, Slot, Bijl, & Vijlbrief, 2007) ingevuld. Van de adolescenten bleek 57,1% in het afgelopen jaar te zijn blootgesteld aan kindermishandeling. Tevens is de definitie van kindermishandeling, zoals gebruikt in de informantenstudies van de vierde Nationale Incidentie Studie uit de Verenigde Staten (Sedlak et al., 2010) en de Nederlandse Prevalentiestudie Mishandeling (Euser et al., 2013), toegepast. Hiertoe zijn in totaal 13 items van de vragenlijst geselecteerd, welke volgens getrainde codeurs (NMP, 2010) alle voldeden aan deze definitie van kindermishandeling. De nieuwe defi- nitie betrof items op het gebied van seksueel misbruik, lichamelijke mishandeling en ervaren conflicten tussen ouders. Wanneer deze definitie gebruikt werd, bleek 36,8% van de adolescenten ten minste één vorm van mishandeling te hebben ervaren in het afgelopen jaar. De Nederlandse Prevalentiestudie Mishandeling en de vierde Nationale Incidentie Studie toonden dat respectievelijk 34 op de 1.000 kinderen en 39,5 op de 1.000 kinderen in het afgelopen jaar mishandeld zijn. De huidige studie laat zien dat in Suriname 368 op de 1.000 adolescenten ten minste één vorm van mishandeling hebben ervaren in het afgelopen jaar. Hoewel veel adolescenten hebben aangegeven dat zij hebben blootgestaan aan geweld door hun ouders, zullen zij zich niet (allemaal) mishandeld voelen. De resultaten geven een (zeer) hoge (jaar)prevalentie van kinder- mishandeling in Suriname aan. De studie laat de omvang van dit vraagstuk zien, dat daarom een nationale aanpak vergt.

SEKSUEEL MISBRUIK

In hoofdstuk 3 worden de resultaten van de nationale prevalentiestudie beschreven, met een focus op seksueel misbruik. Met dit onderzoek is getracht meer inzicht te krijgen in de eerder beschreven prevalentiecijfers. In totaal hebben 1.120 adolescenten (in de leeftijd van 12 tot 18 jaar) van verschillende etnische achtergronden een vragenlijst 178 (Euser et al., 2013; Lamers-Winkelman, Slot, Bijl, & Vijlbrief, 2007) ingevuld over kin- dermishandeling, waaronder seksueel misbruik. Meer dan 16% van de jongens en 15% van de meisjes gaf aan in de afgelopen 12 maanden blootgesteld gestaan te hebben aan een vorm van seksueel misbruik. Meisjes rapporteerden aanzienlijk meer seksueel misbruik door een minderjarige binnen de familie dan jongens (jaarprevalentie: 3,6% versus 0,7%). Jongens rapporteerden meer dan meisjes te zijn aangeraakt of te zijn gedwongen door een minderjarige buiten de familie hem/haar aan te raken aan zijn/ haar geslachtsdelen (jaarprevalentie: 8,3% versus 4,1%). De kans op seksueel misbruik (jaarprevalentie) bleek groter te worden, naarmate de adolescenten ouder werden. Mis- bruik onder leeftijdsgenoten bleek het meest voor te komen. Geconcludeerd kan worden dat seksueel misbruik een groot probleem is voor de volksgezondheid in Suriname. De resultaten vergen nieuw onderzoek. Zo dient zelfrapportageonderzoek aangevuld te worden met een informantenstudie onder professionals die beroepsmatig met kinderen te maken hebben, zoals in het onderwijs en de juridische en sociaal-medische zorg. PERCEPTIES VAN ADOLESCENTEN, VERZORGERS EN PROFESSIONALS MET EEN CREOOLSE EN MARRON ACHTERGROND OP LIJFSTRAFFEN

Hoofdstuk 4 beschrijft percepties op lijfstraffen van adolescenten en volwassenen van Creoolse en Marron achtergrond in Suriname, alsook van professionals van Creoolse en Marron achtergrond die met kinderen werken. In totaal zijn twaalf focusgroepdiscussies gevoerd. De studie toonde aan hoezeer het disciplineren van kinderen door het toebren- gen van fysieke pijn en/of ongemak (nog) op grote schaal wordt aanvaard en uitgevoerd in Suriname. Zowel de ouders/verzorgers (waarbij ook de professionals gerekend worden) als de adolescenten zagen lijfstraffen als een noodzakelijke en gerespecteerde vorm van het disciplineren van kinderen. Lijfstraffen moeten in hun ogen worden toegestaan als een ‘laatste redmiddel’ om kinderen op het rechte pad te houden. Deelnemers zagen lijfstraffen als mishandeling wanneer er sprake is van lichamelijk letsel (‘wanneer er bloed vloeit’). Ook werd er gesproken van mishandeling, wanneer deze plaatsvindt als er sprake is van woede en frustratie bij de ouder. Lijfstraffen mogen niet ‘zonder reden’ worden uitgevoerd en werden niet beschouwd als kindermishandeling als het Samenvatting Chapter 9 geïnterpreteerd wordt als ‘in het belang van het kind’. In het algemeen worden lijfstraffen gebruikt wanneer niets anders – minder pijnlijk, zoals het opwekken van angst – meer werkt. De deelnemers kenden het bestaan van het Verdrag Inzake de Rechten van het Kind, dat is geratificeerd in Suriname. Die kennis was echter voornamelijk globaal en 179 betreft een indruk dat kinderen meer rechten hebben dan vroeger. Dat daar ook meer plichten bij horen was doorgaans minder bekend. Gezien de schadelijke effecten voor kinderen bij het gebruik van lijfstraffen, is het belangrijk dat ouders weten dat hierbij voorzichtigheid geboden dient te worden. Tevens is het belangrijk dat hen (meer posi- tieve) alternatieven van opvoeden worden aangeboden. Hierbij kan internet gebruikt worden, daar dit voor een groot deel van de bevolking toegankelijk is.

PERCEPTIES VAN ADOLESCENTEN EN OUDERS/VERZORGERS VAN HIN- DOESTAANSE KOMAF OP LIJFSTRAFFEN

Hoofdstuk 5 beschrijft een tweede kwalitatieve studie. In deze studie zijn 12 focusgroep- discussies gevoerd met betrekking tot de perceptie op lijfstraffen van adolescenten en ouders/verzorgers van Hindoestaanse achtergrond in Suriname. De studie toonde aan dat lijfstraffen veel voorkomen in het leven van de meeste adolescenten. Er was geen duidelijke consensus onder adolescenten en ouders/verzorgers ten aanzien van het gebruik van lijfstraffen door ouders/verzorgers. Terwijl de deelnemers het gebruik van lijfstraffen algemeen aanvaardden als een recht van de ouder, bleek de goedkeuring van lijfstraffen duidelijk afhankelijk van de context waarin deze plaatsvindt. ‘Milde’ lijfstraffen zijn aanvaardbaar voor meer ernstige overtredingen. Argumenten tegen het gebruik van lijfstraffen waren de potentie voor het veroorzaken van leed en pijn bij een kind en agressief gedrag later in het leven, de schade aan de ouder-kindrelatie en het ontbreken van een constructieve of educatieve waarde die inherent zijn aan deze strategie. Hoewel veel deelnemers aarzelden lijfstraffen wettelijk te verbieden, was een aantal van hen van mening dat een dergelijk verbod kan helpen bij het beschermen van kinderen bij wie harde lijfstraffen gebruikt worden. Ouders/verzorgers noemden het ontbreken van alter- natieve opvoedvaardigheden en het belang van opvoedcursussen alvorens een verbod te leggen op lijfstraffen. Zoals het Internationaal Verdrag voor de Rechten van het Kind benadrukt, is er behoefte aan een omgeving die kinderen beschermt tegen geweld. Het is belangrijk ouders hierbij te ondersteunen. Het is daarbij van belang dat ook in de media het gebruik van geweld wordt afgekeurd.

DE OPVOEDCURSUS ‘LOBI MI PIKIN’

Hoofdstuk 6 beschrijft een studie die gericht is op de implementatie van de opvoedcur- sus ‘Lobi Mi Pikin’ (LMP) in Suriname en de evaluatie van de effecten ervan op lijfstraffen en gedragsproblemen bij het kind. In totaal hebben 70 ouders en/of verzorgers van kinderen in de leeftijd van 3 tot en met 12 jaar met externaliserende gedragsproblemen 180 deelgenomen aan de geprotocolleerde opvoedcursus. De gedragsproblemen van het kind en de opvoedingsstijl van de ouder/verzorger zijn beoordeeld met behulp van de ‘Vragenlijst Sterke Kanten en Moeilijkheden’ (Goodman, 1997; Nederlandse vertaling door Van Widenfelt, Goedhart, Treffers, & Goodman, 2003) en de ‘Verkorte Schaal Ouderlijk Gedrag’ (Van Leeuwen & Vermulst, 2004; Van Leeuwen & Vermulst, 2010), voor en na de cursus. De follow-up na vijf weken toonde positieve effecten aan van LMP op alle uitkomstmaten, namelijk een sterke vermindering van (1) totaal probleemgedrag en (2) gedragsproblemen van het kind, een lichte afname van (3) hyperactiviteit en (4) emotionele problemen van het kind, een matige tot grote toename van het (5) zelf- gerapporteerde positieve gedrag van de ouder en een lichte afname van (6) het gebruik van lijfstraffen. Deze studie toonde aan dat LMP een effectieve manier van oudertraining in Suriname kan zijn. Bovendien kan LMP helpen het gebruik van lijfstraffen te vermin- deren en positief opvoeden te bevorderen, waardoor kindermishandeling voorkomen kan worden. Ouders zijn belangrijk in het aanbieden van positieve ervaringen in de kindertijd van hun kinderen. Het is daarom van belang juist hen te steunen en kennis op het gebied van kinderen en hun ontwikkeling aan te bieden. SCREENING OP PTSS

In hoofdstuk 7 wordt het onderzoek beschreven met betrekking tot een screenings- instrument voor een posttraumatische stressstoornis (PTSS), de CRIES-13 (Children and War Foundation, 1998; Nederlandse vertaling door Olff, 2005). Het ervaren van kindermishandeling is vaak gekoppeld aan een verscheidenheid van negatieve gevol- gen, inclusief PTSS. In totaal zijn 65 kinderen uit verschillende instellingen bevraagd naar symptomen van PTSS aan de hand van de CRIES-13. Al deze kinderen zijn in hun verleden blootgesteld aan een of meer vormen van kindermishandeling. The ADIS-C/P (Silverman & Albano, 1996; Nederlandse vertaling door Siebelink & Treffers, 2001), een meetinstrument dat tevens PTSS in kaart brengt, is aanvullend afgenomen bij 26 kinderen en hun ouders. De CRIES-13 blijkt een valide en betrouwbaar meetinstrument te zijn en correleert goed met de ADIS-C/P. Een afkapwaarde van 30 bleek het meest passend voor een balans tussen sensitiviteit en specificiteit van het instrument. We adviseren de CRIES-13 te gebruiken bij kinderen die een (potentieel) traumatische gebeurtenis hebben meegemaakt. Hiermee kunnen kinderen met trauma(klachten) worden opge- Samenvatting Chapter 9 spoord, kan behandeling in een vroeg stadium worden geboden en kunnen chronische symptomen mogelijk beperkt of helemaal voorkomen worden.

CONCLUSIE 181

De hoge prevalentie van kindermishandeling en verwaarlozing in Suriname duidt erop dat een alomvattende nationale aanpak van belang is, vooral vanwege de ernstige en vaak levenslange gevolgen van kindermishandeling. Lijfstraffen, hoewel in het Interna- tionaal Verdrag voor de Rechten van het Kind (IVRK) beschouwd als een schending van de integriteit en de waardigheid van het kind, worden nog steeds algemeen aanvaard en toegepast in Suriname, ondanks de toenemende kennis van de schadelijke gevolgen hiervan. In dit proefschrift is een instrument onderzocht dat screent op posttraumatische stressstoornis – een van de veelvoorkomende gevolgen van kindermishandeling. Met dit instrument kunnen (trauma)klachten bij kinderen vroegtijdig worden gesignaleerd. De uitvoering van het IVRK lijkt de discussie over lijfstraffen in Suriname wel enigszins te hebben versneld. Deelnemende ouders/verzorgers hebben in de focusgroepen gewezen op de noodzaak van opvoedprogramma’s, om zo meer alternatieven voor niet gewelddadige vormen van opvoeden te leren. De geïmplementeerde opvoed- cursus heeft een positief effect laten zien op de opvoedvaardigheden van ouders en de gedragsproblemen van de kinderen. Het is belangrijk deze programma’s op grote schaal te implementeren, ook in het binnenland. REFERENTIES

Cappa, C & Khan, S.M. (2011). Understanding caregivers’ attitudes towards physical punishment of children: Evidence from 34 low- and middle income countries. Child Abuse & Neglect, 35, 1009-1021. Children and War Foundation. (1998). Children’s Impact of Event Scale (CRIES-13). Geraadpleegd februari 2017 via http://childrenandwar.org/wp-content/uploads/2009/04/cries-13_nl1.pdf. Committee on the Rights of the Child. (2016). Convention on the Rights of the Child. Concluding observations on the combined third and fourth periodic reports of Suriname. November 2016, para. 21. Coulton, C. J., Crampton, D. S., Irwin, M., Spilsbury, J. C., & Korbin, J. E. (2007). How neighbor- hoods influence child maltreatment: A review of the literature and alternative pathways. Child Abuse & Neglect, 31, 1117-1142. Euser, S., Alink, L. R. A., Pannebakker, F., Vogels, T., Bakermans-Kranenburg, M. J., & Van IJzen- doorn, M. H. (2013). The prevalence of child maltreatment in the Netherlands across a 5-year period. Child Abuse & Neglect, 37, 841-851. Gilbert, R., Spatz Widom, C., Browne, K., Fergusson, D., Webb, E., & Janson, J. (2009). Burden and consequences of child maltreatment in high-income countries. The Lancet, 373, 68-81. Goodman, R. (1997). The Strengths and Difficulties Questionnaire: a research note. Journal of Child Psychology and Psychiatry, 38(5), 581-586. Lamers-Winkelman, F., Slot, N. W., Bijl, B., & Vijlbrief, A. C. (2007). Scholieren over Mishandeling Resultaten van een landelijk onderzoek naar de omvang van kindermishandeling onder leerlingen van het voortgezet onderwijs [Pupils on Abuse Study]. Duivendrecht: Vrije Uni- versiteit Amsterdam/PI Research. MacKenzie, M. J., Kotch, J. B., & Lee, L. (2011). Toward a cumulative ecological risk model for the etiology of child maltreatment. Children and Youth Services Review, 33, 1638-1647. Olff, M. (2005). Dutch translation of the Children’s Revised Impact of Event Scale (CRIES-13). Children and War Foundation. Geraadpleegd februari 2017 via http://childrenandwar.org/ 182 wp-content/uploads/2009/04/cries-13_nl1.pdf. Sedlak, A. J., Mettenburg, J., Basena, M., Petta, I., McPherson, K., Greene, A., & Li, S. (2010). The Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to congress. Washington, DC: U.S. Department of Health and Human Services Administration for Children and Families. Siebelink, B. M., & Treffers, Ph. D. A. (2001). Nederlandse bewerking van het Anxiety Disorder Interview Schedule for DSM-IV: Child version of W.K. Silverman and A.M. Albano. Lisse/ Amsterdam: Swets & Zeitlinger. Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule for DSM-IV Child Version, Child Interview Schedule. San Antonio, the Psychological Corporation. Van Leeuwen, K. G., & Vermulst, A. A. (2004). Some psychometric properties of the Ghent Parental Behavior Scale. European Journal of Psychological Assessment, 20, 283-298. doi: 10.1027/1015-5759.20.4.283 Van Leeuwen, K., & Vermulst, A. (2010). Handleiding bij de Verkorte Schaal voor Ouderlijk Gedrag [Manual of the short version of the Parental Behavior Scale]. Unpublished document, Catholic University of Leuven, Leuven, Belgium. Van Widenfelt, B. M., Goedhart, A. W., Treffers, P. D. A., & Goodman, R. (2003). Dutch version of the Strengths and Difficulties Questionnaire (SDQ). European Child and Adolescent Psychiatry, 12, 281-289. UNICEF. (2010). Multiple Indicator Cluster Survey-4, Suriname. Monitoring the situation of child- ren and women. UNICEF. Geraadpleegd februari 2017 via http://www.childinfo.org/files/ MICS4_Suriname_FinalReport_Eng.pdf. Wet op de Jeugdzorg. (2017). Geraadpleegd februari 2017 via http://www.nji.nl/Kindermishan- deling-Probleemschets-Definitie. LIST OF CO-AUTHORS

Shandra Bipat Academic Medical Center, Department of Radiology

Frits Boer Academic Medical Center, Department of Child and Adolescent Psychiatry, University of Amsterdam and The Bascule, Academic Center for Child and Adolescent Psychiatry

Rita K. Chotoe-Sanchit Institute for Graduate Studies and Research, Anton de Kom University, Suriname

Tobi L.G. Graafsma Institute for Graduate Studies and Research, Anton de Kom University, Suriname

Carien D.E. de Jonge Academic Medical Center, Department of Child and Adolescent Psychiatry, University of Amsterdam and The Bascule, Academic Center for Child and Adolescent Psychiatry

Susanne de Kruijf The Bascule, Academic Center for Child and Adolescent Psy- List of co-authors Chapter 9 chiatry

Ramón J.L. Lindauer Academic Medical Center, Department of Child and Adolescent Psychiatry, University of Amsterdam and The Bascule, Academic 183 Center for Child and Adolescent Psychiatry

Gerben Moerman Faculty of Social and Behavioral Sciences, University of Amster- dam, the Netherlands

Josta Nieuwendam Institute for Graduate Studies and Research, Anton de Kom University, Suriname

Jaipaul L. Roopnarine Syracuse University, Department of Child and Family Studies, New York, United States of America and University of the West Indies, Family Research Centre, Trinidad and Tobago

Eva Verlinden Amsterdam Public Health Service, Department of Epidemiology, Health Promotion and Healthcare Innovation CONTRIBUTORS’ STATEMENT

A national study on the prevalence of child abuse and neglect in Suriname Inger W. van der Kooij designed the study, collected the data, carried out data analyses and drafted the initial manuscript; Tobi L.G. Graafsma designed the study, supervised data collection and critically reviewed the manuscript; Josta Nieuwendam collected the data; Shandra Bipat supervised data analyses; Ramón J.L. Lindauer critically reviewed the manuscript; Frits Boer critically reviewed the manuscript.

Child sexual abuse in Suriname Inger W. van der Kooij designed the study, collected the data, carried out data analyses and drafted the initial manuscript; Tobi L.G. Graafsma designed the study, supervised data collec- tion and critically reviewed the manuscript; Josta Nieuwendam collected the data; Shandra Bipat supervised data analyses; Ramón J.L. Lindauer critically reviewed the manuscript.

Perceptions of corporal punishment among Creole and Maroon professionals and community members in Suriname Inger W. van der Kooij designed the study, collected the data, carried out data analyses and drafted the initial manuscript; Tobi L.G. Graafsma designed the study, supervised 184 data collection and critically reviewed the manuscript; Josta Nieuwendam collected the data; Gerben Moerman supervised data analyses; Ramón J.L. Lindauer critically revie- wed the manuscript; Frits Boer critically reviewed the manuscript; Jaipaul L. Roopnarine critically reviewed the manuscript

Perceptions of adolescents and caregivers of corporal punishment: A qualitative study among Indo Caribbean in Suriname Inger W. van der Kooij designed the study, collected the data, carried out data analyses and drafted the initial manuscript; Tobi L.G. Graafsma designed the study, supervised data collection and critically reviewed the manuscript; Rita K. Chotoe-Sanchit collected the data; Gerben Moerman supervised data analyses; Ramón J.L. Lindauer critically reviewed the manuscript; Jaipaul L. Roopnarine critically reviewed the manuscript.

Implementation and evaluation of a parenting program to prevent child maltreatment in Suriname Inger W. van der Kooij designed the study, collected the data, carried out data analyses and drafted the initial manuscript; Tobi L.G. Graafsma designed the study, supervised data collection and critically reviewed the manuscript; Shandra Bipat supervised data analyses; Ramón J.L. Lindauer critically reviewed the manuscript; Frits Boer critically reviewed the manuscript.

Use of a screening tool for Post Traumatic Stress Disorder in children in Suriname Inger W. van der Kooij designed the study, collected the data, carried out data analyses and drafted the initial manuscript; Tobi L.G. Graafsma designed the study, supervised data collection and critically reviewed the manuscript; Carien D.E. de Jonge collected the data, Susanne de Kruijff collected the data, Eva Verlinden supervised data analyses, Shandra Bipat supervised data analyses; Ramón J.L. Lindauer critically reviewed the manuscript; Frits Boer critically reviewed the manuscript. Chapter 9

185 Contributors’ statement PHD PORTFOLIO

Workload PhD period: October 2011 – September 2017 Year (ECTS)

PhD training

General courses AMC Graduate School BROK (good clinical practice) 2013 0.9

Oral presentations Prevalence of child maltreatment in Suriname 2014 0.5 European Conference on Child Abuse and Neglect (EUCCAN), Amsterdam, the Netherlands Prevalence of child maltreatment in Suriname 2014 0.5 Caribbean Regional Conference of Psychology (CRCP), Paramaribo, Suriname

Conferences European Conference on Child Abuse and Neglect (EUCCAN), 2014 0.75 Amsterdam, the Netherlands Caribbean Regional Conference of Psychology (CRCP), 2014 0.75 Paramaribo, Suriname 186 Teaching Guest Lecturing Child maltreatment in Suriname, medical students Academic 2012 0.1 Medical Center Lobi Mi Pikin, psychology students Anton de Kom University 2013 0.1

Supervising Psychology students, Lobi Mi Pikin 2013 0.2 Bachelor thesis, S. Gangadin, Anton de Kom Universiteit 2016 0.2 PREKIMI, Prevention Child Abuse Suriname 2016 0.2

Other Fundraising: Stichting Blaka Rosoe 2011 Fundraising: Stichting Maan 2012 Fundraising: Stichting Weeshuis der Doopsgezinden 2012 Opleiding tot Gezondheidszorg (GZ) psycholoog 2014–2016 EMDR basiscursus 2016 Publications

Peer reviewed Van der Kooij, I. W., Nieuwendam, J., Bipat, S., Boer, F., Lindauer, R. J., & Graafsma, T. L. (2015). A national study on the prevalence of child abuse and neglect in Suriname. Child Abuse & Neglect, 47, 153-161. Van der Kooij, I. W., Bipat, S., Boer, F., Lindauer, R. J. L., & Graafsma, T. L. G. (2017). Implemen- tation and evaluation of a parenting program to prevent child maltreatment in Suriname. American Journal of Orthopsychiatry, in press. Van der Kooij, I. W., Nieuwendam, J., Moerman, G., Boer, F., Lindauer, R. J. L., Roopnarine, J. R., & Graafsma, T. L. G. (2017). Perceptions of Corporal Punishment among Creole and Maroon professionals and community members in Suriname. Child Abuse Review, in press. Van der Kooij, I. W., Chotoe-Sanchit, R. K., Moerman, G., Boer, F., Lindauer, R. J. L., Roopnarine, J. R., & Graafsma, T. L. G. (2017). Perceptions of Adolescents and Caregivers of Corporal Punishment: A qualitative study among Indo Caribbean in Suriname. Violence and Victims, state of fi nal acceptance. Van der Kooij, I. W., Bipat, S., Nieuwendam, J., Lindauer, R. J. L., & Graafsma, T. L. G. (2017). Child Sexual Abuse in Suriname. Child Abuse & Neglect, under review.

Other Van der Kooij, I. W., Verlinden, E., De Jonge, C. D. E., De Kruijf, S., Bipat, Boer, S., Lindauer, R. J. L., & Graafsma, T. L. G. (2013). Use of a Screening Tool for Post Traumatic Stress Disorder Phd portfolio Chapter 9 in Children in Suriname. Academic Journal of Suriname, 4, 347-352. Graafsma, T., Van der Kooij, I., De Jonge, C., Verlinden, E., Bipat, S., Boer, F., & Lindauer, R. (2014). Posttraumatische gevolgen en psychosociale problemen na kindermishandeling. Surinaams Medisch Journaal, 1(1), 13-19. 187 DANKWOORD

MIJN DANK SPREEK IK UIT NAAR

Alle kinderen en ouders die hebben deelgenomen aan dit onderzoek. Dank voor jullie openheid, eerlijkheid en hiermee kennismaking met de prachtige Surinaamse cultuur. Ik voel me vereerd dat ik met jullie in gesprek heb mogen gaan – promotor prof. dr. T.L.G. Graafsma, Tobi, voor je eeuwig enthousiasme en positieve instelling, je kennis, kunde, professionaliteit en geduld. De vele gesprekken die ik met jou (per Skype, mail, in jouw werkkamer of op de veranda op blote voeten) heb gevoerd, hebben mij niet alleen gevormd als onderzoeker, maar ook als kinderpsycholoog. Ik heb grote bewondering voor je manier van werken en had me geen betere leermeester kunnen wensen – pro- motor prof. dr. R.J.L. Lindauer, Ramón, vanwege de vele mogelijkheden die je me hebt geboden binnen dit onderzoek en de prettige (en punctuele!) begeleiding – copromotor dr. Shandra Bipat, Shandra, voor het zijn van mijn ‘stok achter de deur’; ik ken niemand die zo snel kan denken, analyseren en organiseren als jij en tegelijkertijd lol kan maken – prof. dr. F. Boer, Frits, jouw positieve mailtjes gaven me altijd het vertrouwen door te gaan – promotiecommissie: prof. mr. J.E. Doek, prof. dr. G.J. Overbeek, prof. dr. N.W. Slot, prof. dr. G.J.J.M. Stams en prof. dr. E.M.W.J. Utens, voor jullie kritisch lezen en het 188 vertrouwen in mijn onderzoek – Stichting Tot Steun, zonder jullie was het onmogelijk geweest dit onderzoek uit te voeren – Henk Rutten van Stichting Blaka Rosoe, Henk en Margriet, voor jullie betrokkenheid, gastvrijheid en de (financiële) mogelijkheden die jullie me boden – Stichting Maan en Stichting Weeshuis der Doopsgezinden, voor het vertrouwen in en de steun aan het onderzoek – Carien de Jonge, Kien, voor het aanbod mee te gaan naar Suriname. Het is een onvergetelijk half jaar geweest: de uren in de kinderhuizen (zonder airco), onze eigen ‘databank’, de partybus met de kinderen, de dinsdagochtenden bij Tobi. Ik zal ze nooit vergeten – Josta Nieuwendam, Josta, voor een deel van de focusgroepen die jij leidde, op jouw eigenzinnige manier. Tijdens onze autoritten vertelde je me over het land en de natuur. Wat een ervaring, hoe we door het binnenland reisden, samen met de politie op een speedboot – Rita K. Chotoe- Sanchit, Rita, voor het andere deel van de focusgroepen dat jij leidde, maar ook voor jouw humor en het ‘oma’ zijn, voor mij en de kinderen in het onderzoek – Meriam May, Meriam, voor je kundigheid en liefde ten opzichte van (het begeleiden van) de ouders. Wat een stress konden de testmapjes opleveren. Ik heb veel respect voor je positieve instelling en doorzettingsvermogen, daar kan menigeen wat van leren – alle trainsters van Lobi Mi Pikin, voor het zorgvuldig verzamelen van de data – alle leidsters binnen de kinderhuizen. Ik heb veel respect voor het werk dat jullie doen – alle leerkrachten en schooldirecteuren die hun medewerking aan het onderzoek hebben verleend – Maya Manohar, Maya, voor alle klusjes en vragen tussendoor die jij altijd kundig beantwoordde – Jaipaul Roopnarine, for your enthusiasm and professionalism. I am looking forward to meet you in real life – Gerben Moerman, Gerben, voor de begeleiding van het kwalita- tieve deel van mijn onderzoek. Jouw enthousiasme en kunde werkten en werken nog steeds inspirerend en aanstekelijk – mijn Paranimfen. Sanne, je bent de liefste zus van de wereld. Een aantal jaar geleden ging je me voor en vroeg je me samen te ‘lachen om de hele poppenkast’. Zullen we dat maar weer proberen? Suus, liefste vriendin. Fijn dat je me wilt bijstaan, zoals je altijd doet – Sus/zan, voor alle printerproblemen en mijn formulierenvrees – alle lieve collega’s in het AMC, teveel om bij naam te noemen na al die jaren. Steeds maar weer valt het me op hoe betrokken jullie zijn – ook nu ik sinds een langere periode thuis werk omdat de gezellige lunches in het AMC te gezellig werden – en wat een geluk ik hiermee heb gehad – collega’s van de Kinderpraktijk, voor jullie vertrouwen in mij en het bieden van de o zo gewilde GZ opleidingsplek. Ik ben blij dat ik dit vak mag uitoefenen – de Evaatjes: Eva Velthorst, Eva Verlinden en Eva Bolle. hpe Dankwoord Chapter 9 Het kan geen toeval zijn; collega’s die Eva heten zijn onmisbaar en daarbij fantastische vriendinnen – Renate Siebes, voor de opmaak van het proefschrift en het aanhoren van mijn gesteggel over de kleur groen – mijn lieve familie, schoonfamilie, vrienden en vriendinnen, teveel om op te noemen, voor jullie vertrouwen in mij. Ik voel me rijk 189 met jullie om me heen – alle mensen die hebben geholpen met het proefschrift en ik vergeten ben te noemen, dank – liefste Willem, om in jouw woorden te blijven: voor het aanhoren van mijn (blijkbaar) ‘eeuwige geneuzel over het proefschrift’. Nog even! Ik leerde je kennen aan de start van het proefschrift. Wie had gedacht dat we tijdens de afronding ervan in verwachting zouden zijn van een dochter? Ik kan niet wachten en kijk uit naar de rest van ons leven!