Motor skills in adolescents with low birthweight

Background   Minor motor problems have been reported in low birthweight children, but few studies have assessed motor skills in adolescents.
Objective   To examine the prevalence of motor problems in adolescents with low birthweight.
Methods   Fifty-four very low birthweight (VLBW: birth weight ≤1500 g), 59 term small for gestational age (SGA: birthweight <10th centile), and 83 control (birthweight ≥10th centile at term) children were assessed with the movement assessment battery for children (Movement ABC) at the age of 14 in a population-based study.
Results   One in four VLBW children [odds ratio (OR) 9.3, 95% confidence interval (CI) 2.5–34.5] and one in six SGA children (OR 4.7, 95% CI 1.2–18.4) had motor problems compared with controls (3.7%). There were no sex differences in motor problems in the VLBW group, and the increased risk was consistent across the continuum of the Movement ABC. For SGA children, the increased risk of motor problems was particularly in manual dexterity in boys.
Conclusion   VLBW and SGA adolescents have increased risk of motor problems compared with control children.     

Inattentive/overactive children with histories of profound institutional deprivation compared with standard ADHD cases: a brief report

Background   The Inattention/Overactivity/Impulsiveness (I/OA) behavioural cluster diagnostic of ADHD is recognized as a characteristic outcome of early institutional care.
Methods   We compared the symptom and neuropsychological profiles of children with a history of I/OA and early severe deprivation (D-I/OA: n  = 13) with standard clinical ADHD cases (S-ADHD; N  = 20) and children who had experienced deprivation but were not pervasively I/OA (ERA-controls; n  = 22). The mean age of testing was around 13 years. D-I/OA and ERA-controls were selected from the English and Romanian Adoptees (ERA) study and had spent their early lives in the extremely depriving Romanian institutions of the Ceausescu regime and were later adopted into UK families.
Results   ADHD symptoms for male D-I/OA and S-ADHD cases showed marked similarities across symptom domains. In contrast, girls with D-I/OA were more similar to ERA controls than to ADHD cases. Longitudinal data suggested that this was due to a remission of symptoms in D-I/OA girls. Neuropsychological profiles of males and females with D-I/OA, however, were similar: both were more impaired than S-ADHD and ERA controls.
Discussion   Children with D-I/OA were more neuropsychologically impaired than S-ADHD despite the fact that only boys showed a persistent pattern of ADHD symptoms. These results need replication in a larger sample with groups matched for gender.     

A longitudinal study of autism spectrum disorders in individuals diagnosed with a developmental language disorder as children

Background   A number of studies have shown that the diagnosis of developmental language disorder (DLD) can be unstable over time, such that young children with a diagnosis of DLD may show symptoms more characteristics of autism spectrum disorder (ASD) at a later date.
Method   To estimate the types and prevalence of ASD 469 individuals with a DLD, consecutively assessed in the same clinic during a period of 10 years, and 2345 controls from the general population were screened for ASD through the nationwide Danish Psychiatric Central Register (DPCR). The mean length of observation was 34.7 years, and the mean age at follow-up 35.8 (range: 28.3–46.7) years.
Results   At follow-up, 10 (2.1%) in the DLD group and two (0.09%) in the comparison group were known in the DPCR with a diagnosis of any ASD ( P < 0.0001; odds ratio = 25.5; 95% confidence interval 5.5–116.9).
Conclusion   Our results provide additional support to the notion that DLD is a marker of increased vulnerability to the development of ASD.     

The impact of childhood conditions and concurrent morbidities on child health and well-being

Background   Understanding the impact of illnesses and morbidities experienced by children and adolescents is essential to clinical and population health programme decision making and intervention research. This study sought to: (1) examine the population prevalence of physical and mental health conditions for children and quantify their impact on multiple dimensions of children's health and well-being; and (2) examine the cumulative effect of concurrent conditions.
Methods   We conducted a cross-sectional school-based epidemiological study of 5414 children and adolescents aged 5–18 years, and examined parental reports of child health and well-being using the parent-report Child Health Questionnaire (CHQ) PF50 13 scales are scored on a 0–100 pt scale with clinically meaningful differences of five points and the presence of childhood conditions (illnesses and health problems).
Results   Asthma, dental, vision and allergies are the most commonly identified health problems for children and adolescents, followed by attention- and behaviour-related problems (asthma 17.9–23.2%, dental 11.9–22.7%, vision 7.2–14.7%, chronic allergies 8.8–13.9%, attention problems 5.1–13.8% and behaviour problems 5.7–12.0%). As the number of concurrent health problems increase, overall health and well-being decreases substantively with mean differences in CHQ scale scores of 14 points (−7.69 to −21.51) for physical health conditions, and 28 points (−5.15 to −33.81) for mental health conditions.
Conclusions   Children's health and well-being decreases linearly with increasing presence and frequency of health problems. Having three or more conditions concurrently significantly burdens children's health and well-being, particularly for family-related CHQ domains, with a greater burden experienced for mental health conditions than physical health conditions.     

注意缺陷多动障碍共患病的诊断与治疗

注意缺陷多动障碍(ADHD)是儿童期常见的行为障碍之一,共患病率达48%,常见的共患病为对立违抗障碍、品行障碍、焦虑障碍、双相障碍、抑郁障碍、抽动障碍、孤独症谱系障碍、学习障碍、物质滥用等,现就ADHD的常见共患病进行介绍,结合相关指南对ADHD及其共患病的诊治进行讨论,以期为儿少科临床医师对该病的了解和处理提供帮助。     

Parental discipline behaviours and beliefs about their child: associations with child internalizing and mediation relationships

Introduction   Internalizing disorders of childhood are a common and disabling problem, with sufferers at increased risk of subsequent psychiatric morbidity. Several studies have found associations between parenting styles and children's internalizing, although few have considered the role of parental discipline. Parental discipline style may exert an effect on children's internalizing symptoms. Anxiety and depression are reliably found to run in families and parental anxiety has been shown to effect parenting behaviour. This study set out to examine the links between parental anxiety, parental discipline style and child internalizing symptoms.
Method   Eighty-eight parents of children aged 4–10 years were recruited through primary schools. All parents completed questionnaires including measures relating to: adult anxiety (State-Trait Anxiety Inventory – Trait version, Penn State Worry Questionnaire), parental depression (Beck Depression Inventory – Fastscreen), parental discipline (The Parenting Scale), parenting-related attributions (Parenting Attitudes, Beliefs and Cognitions Scale) and child psychological morbidity (Child Behaviour Checklist 4–18 version).
Results   Significant correlations were found between both parental anxiety and child internalizing symptoms with ineffective discipline and negative beliefs about parenting. Particularly strong correlations were found between parental anxiety and child internalizing symptoms with harsh discipline. Parents of anxious/withdrawn children were more likely to hold negative beliefs about their child. The link between parental anxiety and child internalizing symptoms was mediated by harsh discipline. The link between parental anxiety and harsh discipline was mediated by parental beliefs about the child.
Conclusion   Discipline style may be an important factor in the relationship between parent anxiety and child internalizing symptoms.     

Short stature: increased in children with severe learning disability

Introduction   'Health for all children' recommends that children should be screened for growth disorders at school entry with a 0.4th centile 'cut-off'. Following the diagnosis of growth hormone deficiency in four children attending local special schools, our aim was to compare the height distribution of children attending special schools with mainstream schools.
Methods   Children at two local special schools were measured using a Leicester height measurer and values converted to standard deviation scores (SDS). Children were categorized according to whether there were known factors that could affect height. The data were compared with those collected from local mainstream schools.
Results   In total, 242 children were registered at the two special schools and 192 children were measured. The mean height SDS of children in mainstream school ( n  = 2301) was similar to national standards at −0.09 (SD 1.02). The mean height SDS distribution of the 192 children in special schools (age range 3.2–18.4 years; median age 11.3 years) was −0.73; 95%CI −0.9 to −0.5. In those with no established diagnosis to explain altered growth ( n  = 120) this was −0.613; 95%CI −0.8 to −0.4. Both pre-pubertal ( n  = 37) and pubertal ( n  = 83) children were short and eight (6.7%) had a height less than the 0.4th centile.
Conclusions   Children attending special school with severe or profound learning disability were shorter than those attending mainstream school. This is still the case following the exclusion of children with a known cause for abnormal growth. This underlines the importance of each child being assessed by professionals with a refined knowledge of normal and abnormal growth.     

Thimerosal and the occurrence of autism: negative ecological evidence from Danish population-based data

Objective   It has been suggested that thimerosal, a mercury-containing preservative in vaccines, is a risk factor for the development of autism. We examined whether discontinuing the use of thimerosal-containing vaccines in Denmark led to a decrease in the incidence of autism.
Design    Analysis of data from the Danish Psychiatric Central Research Register recording all psychiatric admissions since 1971, and all outpatient contacts in psychiatric departments in Denmark since 1995.
Patients   All children between 2 and 10 years old who were diagnosed with autism during the period from 1971 to 2000.
Outcome measures   Annual and age-specific incidence for first day of first recorded admission with a diagnosis of autism in children between 2 and 10 years old.
Results   A total of 956 children with a male-to-female ratio of 3.5 : 1 had been diagnosed with autism during the period from 1971 to 2000. There was no trend towards an increase in the incidence of autism during that period when thimerosal was used in Denmark, up through 1990. From 1991 until 2000, the incidence increased and continued to rise after the removal of thimerosal from vaccines, including increases among children born after the discontinuation of thimerosal.
Conclusions   The discontinuation of thimerosal-containing vaccines in Denmark in 1992 was followed by an increase in the incidence of autism. Our ecological data do not support a correlation between thimerosal-containing vaccines and the incidence of autism.     

An interagency service delivery model for autistic spectrum disorders and attention deficit hyperactivity disorder

Background   A multiplicity of government initiatives advocate increasing shared working between services to ensure that holistic and co-ordinated assessment of need and related shared intervention is available to children and families. Concurrently, there is an increasing demand upon services to provide a wide range of support for children with complex difficulties.
Methods   On the Isle of Wight, joint services have been developing shared practice. The inter-agency service was initiated in 2001 through a 3-year project funded jointly between all services on the Island and the government through the 'Invest to Save' initiative. The project initially focused upon developing a combined process of diagnosis of autistic spectrum disorders (ASD) and the co-ordination of intervention at schools, within families and in the child's community. Gradually, the service extended to include children with a much wider range of difficulties, including those of attention deficit hyperactivity disorder (ADHD), developmental co-ordination disorder and co-morbid diagnoses.
Results   There are 19 000 school-aged children on the Isle of Wight. A total of 1101 referrals have been accepted between June 2001 and May 2007. In total, 201 children have been given a diagnosis of ASD. Overall, 392 children have been given a diagnosis of ADHD or ADHD/Co-morbid. Seventy were co-morbid for ASD and ADHD. The current service is rated as 85% satisfactory by its users, in contrast to the high level of complaint which resulted in the bid for the project initially.
Conclusion   Following the successful conclusion of the 3-year government-funded project Education Services, Social Care and The Health Authority shared the ongoing funding of the current service. This has been operating effectively for over 6 years and has highlighted a wide variety of issues around this style of service delivery.     

'I don't trust you, you are going to tell', adolescents with emotional and behavioural disorders participating in qualitative research

Background   Some groups of young people are considered difficult to reach and study. One such group consists of adolescents with emotional and behavioural disorders (EBD), who have problems with verbal intelligence, thought focussing and paying attention. During a 2-year research study into the preferences of adolescents with EBD regarding drug prevention policy, the author examined these young people's opinions and their experience of participation in research.
Methods   A qualitative, youth-centred method was used, combining group techniques (focus groups, nominal group techniques and feedback sessions) and involving 160 adolescents, aged 12–21 years, with EBD, living in residential settings of the disability sector.
Results   It is possible to carry out qualitative research with young people with EBD. This population is very vulnerable, negatively influenced by their previous experiences and by the social group that they belong to. They have an aversion to 'being studied', and their self-esteem and confidence are low. However, it is possible to build up trust.
Conclusions   It has become clear that there is no reason for excluding adolescents with EBD from participation in research. Research is possible and successful, providing sufficient effort is put into building up trust with these emotionally scarred young people.     

Validity of the Health Profile-Types of the Spanish Child Health and Illness Profile-Adolescent Edition (CHIP-AE)

Objective:  To develop and validate a simplified, easy to interpret scoring system based on the health profile-types taxonomy for the Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE).
Methods:  The CHIP-AE was administered to a 1453 Spanish adolescents. Hierarchic and nonhierarchical cluster analyses, as well as conceptual considerations, were used to identify exhaustive, mutually exclusive health profile-types based in four CHIP-AE domain scores: Satisfaction, Discomfort, Resilience, and Risks. Validity of the health profile-types was assessed by testing expected differences among adolescents according to sex, age, socioeconomic status, and self-reported conditions. Logistic models were built.
Results:  A total of 13 health profile-types (10 that best fitted the data and three additional considered conceptually necessary) were identified. The largest group of adolescents was in the "Excellent health" or "Good health" types (43.4%), although 11.2% were in the "Worst health" profile. According to a priori hypotheses, being a girl (OR = 1.81; 95% CI = 1.26–2.60), older age (OR = 1.80; 1.26–2.57), and self-reported recurrent (OR = 2.49; 1.72–3.60) and psychosocial disorders (OR = 4.38; 2.92–6.56) were associated to the likelihood of a "Worst health" profile-type.
Conclusions:  The Spanish CHIP-AE health profile-types offer a simplified method to describe adolescents' patterns of health, which is valid and similar to the original US taxonomy. This can facilitate interpreting the instrument scores and using it for needs assessment, although additional research is required.     

Severe avoidant/restrictive food intake disorder and coexisting stimulant treated attention deficit hyperactivity disorder

There is a growing body of literature describing the development, clinical course, and treatment of avoidant/restrictive food intake disorder (ARFID), a diagnostic category introduced in the DSM‐5. However, information surrounding complex cases of ARFID involving coexisting medical and/or psychiatric disorders remains scarce. Here we report on two cases of young patients diagnosed concurrently with ARFID and attention deficit hyperactivity disorder (ADHD) who both experienced significant growth restriction following initiation of stimulant medication. The appetite suppressant effect of stimulants exacerbated longstanding avoidant and restrictive eating behaviors resulting in growth restriction and admission to an inpatient eating disorders unit. The implications of ARFID exacerbated by stimulant‐treated ADHD are explored, as well as the treatment delivered. These cases suggest that further research is needed to explore management options to counteract the appetite suppression effects of stimulants, while simultaneously addressing attention deficit symptoms and oppositional behavior. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1036–1039)     

Seasonality of low birthweight in Indigenous Australians: an increase in pre-term birth or intrauterine growth retardation?

We have analysed birthweights of 4,508 Aboriginal and Torres Strait Islander livebirths in the Kimberley region of Western Australia from 1981-93. Mean birthweight varied significantly according to month of birth (F₍₁₁₎=2.57, p =0.003) and low birthweight babies were more common during the wet season. A significant increase in the proportion of very low birthweight (VLBW) babies was observed during the wet season compared with the dry season (OR 2.73; 95% Cl 2.3–3.67; p <0.001); whereas babies weighing 1,500–2,499 g were not significantly more common during the wet season (OR 1.06; 95% Cl 0.96–1.17; p =ns). The results indicate that adverse environmental conditions may be associated with increased risk of VLBW. Since newborns weighing less than 1500 g are very likely to be pre-term (<37 weeks' gestation), the findings also suggest that seasonality of birthweight may be due to an increase in pre-term births rather than an increase in intrauterine growth retardation. Further research is required to identify the underlying causes of an increase in VLBW babies during the wet season.     

Mental health impact for adolescents living with prolonged drought

Background:  A 2004 study showed adolescents living in rural Australia were aware of the impact of drought on self, family and community, but did not report levels of emotional distress higher than adolescents of similar age and gender in the Australian community. It was proposed that the rural lifestyle had helped adolescents build resilience for managing this environmental adversity.
Objective:  To re sample adolescents from the same rural area and determine if this resilience remained after ongoing drought three years later.
Design:  A mixed methods approach using focus groups and a self-report questionnaire.
Setting:  Government Central Schools within the Riverina region of New South Wales.
Participants:  Male and female adolescents ( n =  111) aged 11–17 years completed the self-report questionnaires, while some adolescents ( n =  61) within this group also participated in focus groups.
Main outcome measure:  The Strengths and Difficulties Questionnaire and a Drought and Community Survey for Children comprised the self-report survey.
Results:  Adolescents reported significantly higher levels of emotional distress than those in the previous study ( t (191)  =  2.80, P <  0.01) and 12% of adolescents scored in the clinical caseness range. Thematic analysis showed consistency with the previous study as well as new themes of grief, loss and the impacts of global climate change.
Conclusions:  Results indicate a reporting of lesser well-being than was reported by a comparable group of young people four years earlier. A preventative intervention with a focus on family and community is recommended to address the mental health of adolescents enduring a chronic environmental adversity such as drought.     

The association of change in maternal marital status between births and adverse pregnancy outcomes in the second birth

The relationships between change in marital status between two consecutive births and adverse pregnancy outcomes at the second birth were investigated using linked Washington State 1980–93 white singleton birth certificates. Women who were married at the first birth had lower low birthweight (LBW) and small-size-for-gestational-age (SGA) rates at that birth than single women, and women married at the second birth had lower LBW, SGA and preterm delivery rates at that birth, regardless of marital status at the first birth. Adjusted relative risks (RR) of LBW and SGA were significantly increased for initially married women who were single at the second birth compared with those who remained married (RR equals; 1.4 and 1.3, respectively). Risks of LBW and SGA were significantly decreased among initially single women who married by the second birth, compared with those remaining single (RR equals; 0.7 for LBW and 0.8 for SGA). We conclude that the largely unstudied subgroup of previously married women is at increased risk for adverse pregnancy outcomes. Public health policy and programmes directed at high-risk mothers and infants should be aware of the specific physical and emotional needs of this group of child-bearing women.     

Behaviour problems and social competence deficits associated with symptoms of attention-deficit/hyperactivity disorder: effects of age and gender

Background   Previous research has shown that children with high levels of attention-deficit/hyperactivity disorder (ADHD) symptoms often have a wide variety of associated behaviour problems. However, relatively little is known regarding to what extent these associated behaviour problems are present to the same degree in younger as well as older children and in girls as well as in boys.
Methods   This study used parent ratings to examine effects of age and gender on behaviour problems, social competence, negative impact on everyday life, and family burden among pre-school and school-aged children high in ADHD symptoms ( n  = 60) and comparison children ( n  = 499).
Results   With regard to age, the pre-school children did not differ from the school-aged children on any of the different types of problem behaviour or with regard to social competence. The interactions between age and group were not significant. The behaviour problems of older children did, however, have more negative impact on the child's daily life and induced higher levels of family burden compared with problems of younger children, especially among children with high levels of ADHD symptoms. Boys were more severely affected than girls with regard to ADHD symptom severity, most associated problem behaviours, as well as negative impact and family burden. Significant interactions of ADHD symptoms and gender were also found, which indicated that gender differences were primarily found among children with high levels of ADHD symptoms.
Conclusions   Children with high levels of ADHD symptoms have many associated behaviour problems, even in pre-school years, and boys with high levels of ADHD symptoms are more severely affected compared with girls.     

宁波市中学生注意缺陷多动障碍及相关焦虑情绪调查

了解宁波市中学生注意缺陷多动症状与焦虑情绪发生状况及两者相关性,为有效促进儿童青少年心理健康工作提供依据.方法 采用分层随机整群抽样法,对宁波市4所中学的2 218名学生采用自编一般情况问卷、焦虑自评问卷(SAS)和中文版注意缺陷多动障碍SNAP-ⅣV评定量表(父母版)18项进行问卷调查.结果 中学生焦虑情绪阳性率为14.8%,其中轻度焦虑率为11.1%,中度焦虑率为2.7%,重度焦虑率为1.1%;注意力缺陷多动症状阳性率为5.7%,注意缺陷症状阳性率为4.4%,多动/冲动症状阳性率为1.4%.注意缺陷症状阳性组中,轻、中、重度焦虑的比例分别为24.7%(24/97),8.2%(8/97),3.1%(3/97);多动冲动症状阳性组中轻、中、重度焦虑的比例分别为20.0% (6/30),10.0%(3/30),33.3%(1/30).注意缺陷症状与焦虑的严重程度呈正相关(r=0.13,P<0.01),多动冲动症状与焦虑的严重程度呈正相关(r=0.06,P<0.05).结论 注意缺陷多动症状高评分学生有较高的焦虑情绪阳性率,对焦虑情绪的干预应作为注意缺陷多动症状的治疗维度之一.     

The Malnutrition Screening Tool is a useful tool for identifying malnutrition risk in residential aged care

Background:  The Malnutrition Screening Tool (MST) is a valid nutrition screening tool in the acute hospital setting but has not been assessed in residential aged care facilities. The aim of this secondary analysis was to determine whether the MST could be a useful nutrition screening tool when compared with a full nutrition assessment by Subjective Global Assessment (SGA) in the residential aged care setting.
Methods:  Two hundred and eighty-five residents (29% male; mean age 84 ± 9 years) from eight residential aged care facilities in Australia participated in the study. A secondary analysis of data collected during a nutrition intervention study was conducted. The MST consists of two questions related to recent weight loss and appetite. Although the MST was not specifically applied, weight loss and appetite information was available and an estimated MST score (0–5) was calculated. Nutritional status was assessed by a research assistant trained in using the SGA.
Results:  Malnutrition prevalence was 42.8% (122 malnourished out of 285 residents). Compared to the SGA, the MST was an effective predictor of nutritional risk (sensitivity = 83.6%, specificity = 65.6%, positive predictive value = 0.65, negative predictive value = 0.84).
Conclusions:  The components of the MST have acceptable sensitivity and specificity, suggesting that it can play a valuable role in quickly identifying the risk of malnutrition in the residential aged care setting. Further prospective research using the MST tool against a broader array of objective and subjective nutritional parameters is required to confirm its validity as a screening tool in aged care settings.     

Survey Assessment of Continuation of and Satisfaction with Pharmacological Treatment for Urinary Incontinence

Purpose:  To evaluate treatment satisfaction and compliance with pharmacologic therapy in urinary incontinence patients.
Materials and Methods:  An online survey was returned by 1447 individuals from a nationwide panel of adults who had previously reported treatment for incontinence symptoms and agreed to participate in survey research. Data on demographics, incontinence severity, treatment compliance, and satisfaction were obtained. Logistic regression was used to estimate crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for characteristics associated with pharmacologic treatment dissatisfaction and discontinuation.
Results:  The sample was predominantly female (87%) and white (93%) with a mean age of 56 years. On average, patients urinated 10 times/day and experienced 16 wetting accidents in the week preceding survey. Overall, 25% reported being somewhat or very dissatisfied with treatment. Those who reported a severe effect of incontinence on their lives were most likely to be dissatisfied (OR = 2.82, 95% CI = 1.89–4.23). Discontinuation of drug treatment was reported by 45% of study subjects, with major reasons being poor efficacy (in 41.3% of discontinuations), side effects (22.4%), and cost (18.7%). Predictors for discontinuation included young age (OR = 1.8, 95% CI = 1.2–2.8), experiencing symptoms for 10 or more years (OR = 1.5, 95% CI = 1.1–2.0), and experiencing more than 16 wetting accidents in the last week (OR = 1.6, 95% CI = 1.3–2.1).
Conclusions:  This online survey of self-selected incontinence patients indicated that almost half of those who have received drug treatment for incontinence had discontinued primarily because of lack of efficacy, side effects, and cost concerns. Our findings suggest a substantial degree of unmet need from current therapy among those with incontinence.     

Prevalence of childhood sexual abuse among Mexican adolescents

Background   To determine the characteristics and prevalence of previous child sexual abuse among a group of Mexican junior high school students.
Methods   A total of 1067 adolescents of both genders were selected to fill out a survey about child sexual abuse.
Results   The prevalence of child sexual abuse was 18.7% ( n  = 200). It was more frequent in girls (58%) than in boys (42%). Sexual abuse involved physical contact in 75% of those cases reporting abuse. The aggressors were neighbours (50.3%), relatives (36.8%) and strangers (13.9%). Abuse was committed through deception in 90% of the cases and involved physical mistreatment in 10% of the cases. Of the victims, 14.4% had spoken about the problem and 3.7% had taken legal action. And 9.6% of those surveyed stated that they required psychological counselling.
Conclusions   In the population studied, the prevalency of child sexual abuse was greater than that reported in Mexico City (4.3–8.4%), although it was similar to that found in the Spanish child population (15–23%). The risk of sexual abuse is greater for girls and the principal aggressors are male neighbours, family friends and relatives; the abuse is committed in the home of the aggressor or the victim and very few cases are reported to the authorities.