Child and Adolescent Multiple Victimization and/or Polyvictimization: A Portuguese Comparative Study

Worldwide, children and adolescents are exposed to violence every day and in countless contexts, whether in the family, at school, or in the community. Child multiple victimization has been the subject of extensive international research because of the impact on child and youth development. A quantitative and comparative study aiming to understand child multiple victimization and/or polyvictimization from the perspective of children is presented. Two groups were studied, with and without psychological counselling, with 20 children each, aged 12–18 years old. All the participants answered to juvenile victimization questionnaire (JVQ). The study was approved by the University Ethics Committee responsible for the study in Portugal, and it was initiated after the obtained consent of the children’s legal guardians. The results indicated that young people frequently experience violent situations, with particular emphasis on conventional crimes, e.g., theft, robbery, vandalism, and assault with or without a weapon, with sexual victimization being less common. The results also show that there is a cumulative experience of violence, which evidences multiple victimization and polyvictimization of the child/adolescent throughout their life. These phenomena are not necessarily more common between populations with clinical follow-up. When the types of violence were compared, multiple victimization and polyvictimization, this study found no differences between the samples with and without psychological counselling. It can be concluded that the multiple victimization or polyvictimization problem is not unusual among the population in the studied age range. It is important to alert to the phenomenon of child/adolescent multiple victimization, aiming at a more effective assessment and intervention among these populations. Raising awareness of the phenomenon of multiple child and youth victimization or polyvictimization is of particular importance for preventing violence at all stages of development.


Introduction
Child and juvenile victimization is a complex, negative social phenomenon with undesirable consequences that can persist over time, significantly affecting the life of the child or adolescent [1][2][3][4][5]. The experience of victimization tends to occur in different contexts of socialization [6,7], with the first exposure to violence occurring within the family [8].
Physical abuse, sexual abuse, bullying, and exposure to domestic violence or violence in the community illustrate particular forms of individual victimization suffered in childhood and adolescence, and can predict other experiences of violence throughout life [2,9,10]. Experiencing situations of violence during important stages of physical and psychological development can compromise psychological adaptation over time [11]. Thus, the international literature that was more focused on developmental victimology has shown that some children and adolescents may experience more than one type of violence throughout their lives [12][13][14], and that these incidents are sometimes interconnected, even if apparently different [15], creating a cumulative risk [16]. Studies in the field of juvenile victimology, and the consideration of the co-occurrence and implications of these for the development of children and adolescents, are important to allow a better understanding of phenomena such as multiple victimization or polyvictimization, and the development of intervention practices that are appropriate for the problem [17,18].
Literature in the area of victimology has reopened the conceptual discussion about the forms of violence experienced and how these experiences can affect a person's adjustment, assuming that more victimization is associated with more psychological maladjustment [1]. The concept of multiple victimization refers to the experience by an individual of two or more forms of victimization [19,20], with research in Portugal focusing primarily on adults [21][22][23] and, later, children and adolescents [5,17,24,25]. According to Finkelhor, Ormrod and Turner [26], the concept of polyvictimization presupposes the experience of four or more types of victimization in a given period of time. According to Obsuth et al. [27], this experience of different types of victimization increases from childhood to adolescence. Children and adolescents are groups that are particularly prone to experiencing various types of victimization from multiple sources and contexts throughout their lives [27][28][29], hence the use of the concept of "polyvictims" [30]. The literature has revealed that polyvictims are more likely to develop depressive symptoms and post-traumatic stress, as well as suicidal ideation and self-harm behaviors [31].
In recent decades, several review studies have established the close association between adverse childhood experiences (ACEs), which can occur through single, multiple, and polyvictimization, and the development of childhood trauma [32][33][34][35]. This approach, centered on ACEs, has been widely theoretically debated [36] and empirically validated by several studies [32,37] seeking to answer several questions and present intervention proposals that prove to be efficient and effective for this problem [38].
It is important to consider the multiplicity of factors that, coming from external environments (e.g., family, peer groups, community), affect human development [6]. In this respect, it is worth noting, for example, the resilience portfolio model [39], which, based on an ecological approach [40], has shown positive results in a psychological intervention with victims of domestic violence [41,42]. Recognizing polyvictimization and its consequences [15], the model's authors advocate an approach that is focused on the multiple strengths of the individual that can guide effective interventions in situations of victimization [39,40,[42][43][44].
Thus, the knowledge gained by the review of international literature on multiple victimization and polyvictimization (in children and adolescents), as well as the recognition of the implications of this experience for their development, made us ask the following question: are situations of violence an integral part of the experience of children and Portuguese teenagers? The present study was justified by the limited research existing in Portugal on the theme of child and youth victimization, and its general objective was to understand the experience of victimization in Portuguese children and adolescents. The specific objectives were as follows: (i) to identify which types of violence are more and less experienced by groups of children and adolescents; (ii) to assess if there are differences between groups (with and without clinical follow-up) regarding the types of violence experienced; and (iii) to measure if there are differences between groups (with and without clinical psychological follow-up) regarding multiple victimization and polyvictimization.
Based on these objectives, the following hypotheses were formulated: Hypotheses 1 (H1). "Exposure to violence" is one of the most reported forms of victimization experienced by children and adolescents, contrary to the idea of an unequivocal concern exclusively for forms of direct intra-family victimization; Hypotheses 2 (H2). Several forms of violence are part of the common experience of children and young people, regardless of the condition of being or not being in clinical follow-up due to an adverse experience in childhood; Hypotheses 3 (H3). Victimization and polyvictimization are phenomena that are widely spread to the child and youth population, regardless of their clinical condition (with or without clinical follow-up).

Materials and Methods
An exploratory, descriptive and correlational study was developed, using a quantitative approach, through a questionnaire survey on victimization of children and adolescents.

Participants
The study included 40 Portuguese children and adolescents, aged between 12 and 18 years (cf. Table 1), selected by a non-probabilistic convenience sampling process, which comprised the following two groups: (i) group 1, consisting of 20 young people without clinical follow-up, from a school in the district of Porto; and (ii) group 2, including 20 young people who were undergoing psychological counselling at a clinic, also in the district of Porto. All those who did not fit into this age group, who presented evident cognitive difficulties, including a low intelligence quotient, expressive or receptive aphasia, were excluded from this participation. Thus, with regard to group 1 (cf. Table 1), it was composed of 20 children and adolescents who attended the 7th (15%), the 8th (55%) and the 9th (35%) grades with an average age of 13.65 years (SD = 0.988), 35% being male and 65% being female. Group 2 (see Table 1), designated as the clinical group, also included 20 young people who were undergoing psychological counselling at a clinic, whose mean age was 13.60 years (SD = 1.635), 60% male and 40% female. Regarding the year of education, 45% attended the 7th grade, 35% attended the 8th grade and the remaining 20% attended the 9th and 10th grades.

Instrument
Data collection was carried out through a questionnaire survey, applied in a standardized and uniform manner. In addition to a brief sociodemographic questionnaire, a translated and adapted version of the juvenile victimization questionnaire (JVQ) was used [45]. This instrument is a self-report measure, and allows "to assess crime, child maltreatment, and other kinds of victimization experiences during childhood" [45], p. 384. JVQ is one of the most used international instruments in the study of multiple victimization. This version of the questionnaire allows the assessment of 38 types of victimization and also includes a version for caregivers and another for children, designed to measure multiple forms of victimization of children and adolescents. JVQ makes it possible to estimate the total rate of child and youth victimization, improve the correspondence of the measure of child and youth victimization with important constructs such as crime and categories of protection of children and adolescents, as well as study the overlap between the forms of child and youth victimization [45,46].
The 36 items in this version of the JVQ are divided into five general areas referring to the following typologies (see Table 2): conventional crime (C1 to C9) (e.g., C1-robbery: "In the last year, did anyone use force to take something away from you that you were carrying or wearing?"); child maltreatment (M1 to M4) (e.g., M1-physical abuse by caregiver: "Not including spanking on your bottom, in the last year, did a grown-up in your life hit, beat, kick, or physically hurt you in any way?); peer's and sibling's victimization (P1 to P6) (e.g., P1-gang or group assault: "Sometimes groups of kids or gangs attack people. In the last year, did a group of kids or a gang hit, jump, or attack you?"); sexual victimization (S1 to S8) (e.g., S1-sexual assault by known adult: "In the last year, did a grown-up YOU KNOW touch your private parts when you didn't want it or make you touch their private parts? Or did a grown-up YOU KNOW force you to have sex?"); witnessing and indirect victimization (W1 to W9) (e.g., W1-witness to domestic violence: "In the last year, did you SEE one of your parents get hit by another parent, or their boyfriend or girlfriend? How about slapped, punched, or beat up?"). Two other items of exposure to violence are about gun violence (G1 and G2) (e.g., G1-gun violence (use): "At any time in (your child's/your) life, did anyone hurt or threaten (him/her/you) with a real gun?") [45]. For each question of items, the child can answer "yes", "no" or "not sure". The questionnaire shows good reliability, with an alpha of Cronbach (α) of 0.92. - The questionnaire can be used in an interview format (with children under the age of 8 years), or in a self-report format (between 8-18 years), which is the case in this study [45]. Test reliability and JVQ construct validity were established in successive samples using the instrument and helped in the development of this victimization questionnaire [47].

Procedures
To carry out this study, authorizations were previously requested to the authors of the original study for the use of a translated version of the JVQ into Portuguese. The questionnaires were individually administered, on a day and time agreed between the participants and the responsible investigator, in a room reserved for this purpose. The researcher informed the participants of the objectives of the study and the voluntary and anonymous nature of participation in it. Young people who agreed to participate in the study had to fill out the informed consent before completing the instrument protocol. Written authorizations and consents were placed in an envelope designed for this purpose, so as not to allow them to be paired with the questionnaires, thus guaranteeing the anonymity of the participants. The average filling time was about 20 min.
For cases in which there were reports of victimization experiences, some contacts for psychological support were indicated to the participants.

Data Analysis
Data were treated confidentially and subsequently subjected to statistical analysis using the Statistical Package for Social Sciences (SPSS), version 27 for Windows, with descriptive and inferential statistical analyses. To explore the sociodemographic variables, absolute and relative frequencies for JVQ items, types of violence and victimization categories (multiple victimization and polyvictimization), descriptive analyses were performed. Differences between categorical variables groups were analyzed using Pearson's chi-square test (χ 2 ), considering a p-value < 0.05.

Results
Considering only the answers given with "yes" or "no" (excluding omitted cases or those whose answer was "not sure"), the results show (cf. Table 2) that question W4 (witness to assault without weapon: "At any time in your life, in real life, did you SEE anyone get attacked or hit on purpose WITHOUT using a stick, rock, gun, knife, or something that would hurt?") was the most answered in the affirmative form (n = 18; 45%), followed by question C5 (assault without weapon: "Sometimes people are attacked with sticks, rocks, guns, knives, or other things that would hurt. At any time in your life, did anyone hit or attack you on purpose with an object or weapon? Somewhere like: at home, at school, at a store, in a car, on the street, or anywhere else?") (n = 17; 42.5%).
On the other hand, questions C8 (kidnapping: "When a person is kidnapped, it means they were made to go somewhere, like into a car, by someone who they thought might hurt them. At any time in your life, did anyone try to kidnap you?"), S2 (non-specific sexual assault: "At any time in your life, did a grown-up you did not know touch your private parts when they shouldn't have, make you touch their private parts or force you to have sex?"), S3 (sexual assault by peer/sibling: "Now think about other kids, like from school, a boyfriend or girlfriend, or even a brother or sister. At any time in your life, did another child or teen make you do sexual things?"), S8 (rape & sexual misconduct (with drugs use): "Has anyone ever had sex or tried to have sex with you when you didn't want to, when you were drugged or drunk?"), W6 (murder of family member or friend: "At any time in your life, was anyone close to you murdered, like a friend, neighbour or someone in your family?") and W9 (exposure to war or ethnic conflict: "At any time in your life, were you in the middle of a war where you could hear real fighting with guns or bombs?") were answered in the negative form by all the participants (n = 40; 100%). Table 2 also shows that there is not a homogeneous distribution of the experience of victimization by one group or another.
The descriptive analysis for the five types of JVQ: conventional (cf. Table 3) revealed that in group 1, conventional crime was the most experienced (85%), followed by exposure to violence (75%) and victimization by peers (70%). In group 2, the most experienced typology was exposure to violence (75%), followed by conventional crime (70%). In both groups (1 = without counselling; 2 = with counselling), sexual victimization was the least experienced (group 1 = 10%; group 2 = 15%), as well as child maltreatment (group 1 = 25%; group 2 = 40%). However, it cannot be stated that these two previous and quite intrusive forms of victimization are completely non-existent in the lives of any of the participants.
The differential analyses carried out for the two groups for the five typologies revealed that they do not differ in terms of victimization experience in any of the categories.
As can be observed in Table 4, 85% (n = 17) of the young people in group 1 experienced two or more types of victimization. In group 2, 70% of young people (n = 14) assumed that they had suffered from two or more types of victimization. Taking the concept of polyvictimization as a reference, both groups 1 and 2 had the same values (n = 5), that is, 25% of young people in each group admitted to having experienced four or more types of victimization, thus being polyvictims (cf. Table 4).

Discussion
In order to know which situations of violence constitute the experience of victimization of children and adolescents, a study with a sample (two groups: 1 = without counselling; 2 = with counselling) of Portuguese children and adolescents aged between 12 and 18 years was carried out. The results revealed that different situations of violence are part of the ACEs, which corroborates the literature on the subject [10,12,14,32]. The results showed that certain forms of violence, such as conventional crime (e.g., theft, robbery, vandalism, assault with or without the use of a weapon, attempted robbery) and exposure to violence (e.g., testimony of domestic violence, testimony of assault with or without a weapon, testimony of homicide), tended to be situations that were commonly experienced by the participants and that sexual victimization (e.g., unspecific sexual assault, rape, attempted rape, sexual exposure, sexual harassment in a verbal form) are less reported in both the constituted groups. It should be noted that if all behaviors do not have the same degree of personal intrusiveness, it is possible that some acts may be less reported, in the same way that, as some authors refer [28,48], they may not even remember some situations because some time has passed, or some situations of victimization may have happened before the memory capacity of any of the victims is already well structured.
The results also reveal that the experience of victimization can be cumulative, resulting in multiple victimization (two or more experiences) or in polyvictimization (more than four situations of victimization). The literature alerts us to these phenomena, and emphasizes that children and adolescents can be exposed to violence and crime in different contexts (home, school, community), as shown by international studies [1,10,14,26,29,33,45]. This finding is particularly relevant to the need to produce a timely diagnosis of these situations, given the negative impact that the experience of adverse situations has on the development of children and adolescents, in the short, medium and long term [2,31,43,49].
The results also revealed that there are no significant differences either in terms of the types of violence experienced, or in the phenomena of multiple victimization or polyvictimization between the group of children in clinical follow-up and those who were not psychologically monitored. These results may suggest that child victimization is a widespread phenomenon across the entire child and youth population [19,[27][28][29]. Conventional crime or exposure to violence and victimization are reported to be part of the common experiences of children and adolescents in the context of socialization [50], not appearing to be significantly more represented in one group than in another. Regardless of the reasons for its occurrence, children who were under psychological follow-up showed a similar experience, in typologies and frequency, to the group considered normative or without clinical signs.
Studies warn that when children and adolescents are victimized in different ways and in different contexts, they may be more likely to be more affected in their psychological adjustment than those children and adolescents who suffer from a single type of victimization, even if it is over a long period of time [26,33]. Studies also confirm that when one type of victimization occurs, it can become a predictor for the occurrence of other victimizations [10,26]. It was found that although the percentage of polyvictims was low, there are records of children who experience four or more forms of violence, having the experience of exposure to conventional crime in their history [50]. The opening of young people to contexts other than family, such as school and the community, widen the possibility of confronting various situations of violence, with victimization by peers being an example of this. Thus, some of the victimizations that occur are age-related vulnerabilities, which may be related to dependence on others for protection and limited ability to move away from dangerous situations [15].
Violence is one of the most harmful experiences among young people. If competing with other risk factors, it seriously complicates the prevention and improvement of the effects of exposure on healthy development [43,51], hence the need for early signaling. Other types of victimization were less indicated, and may also be more difficult to detect or reveal [28], such as sexual victimization or exposure to domestic violence, but they cannot be not excluded from the possible experience of children and adolescents in this sample.

Conclusions
Multiple victimization or polyvictimization of children and adolescents have proved to be worrying phenomena, either because of the scientific evidence that points to its presence or because of the negative implications that international studies have confirmed to exist throughout the person's development. Since young people are exposed to violence every day and in different contexts, the entire study on this theme serves to guide efforts in terms of prevention, but also to search for interventions that prove to be more effective.
The study carried out revealed that there are no significant differences between the groups (with and without counselling), proving that victimization is an adverse experience that affects the entire child-juvenile population in different contexts of socialization, integrating much of the daily lives of children and young people throughout their lives, regardless of whether we are dealing with groups with previous clinical conditions or not. The possibility of this experience with violence being the justification for clinical follow-up cannot be excluded.
Although the previously defined objectives were met, we are aware of some limitations. This is an exploratory study, carried out only in a school in the district of Porto, Portugal, with a small sample, from an urban environment, which are aspects that do not allow the generalization of the results to the Portuguese population. Gender balance was not present in the sample, and this is considered a limitation in this comparative research. Another possible limitation is related to the fact that a self-report instrument was used, with the participants being the exclusive source of information, which may be overvalued, underestimated, or even not shared due to some external or even internal constraint.
It is also important to explain that, in this study, victimization was analyzed based on the occurrence of facts, without considering other factors, such as onset, duration, frequency, or severity of the acts, or the type of aggressor. Accordingly, we cannot extrapolate aspects related to the impact of the victimization, nor if the impact, if any, would necessarily be related to the victimization experience. Furthermore, data were collected whilst preserving confidentiality and anonymity, so for ethical and deontological reasons, it was not possible to ask follow-up questions for sensitive victims, or even understand the reasons for the clinical follow-up of the study participants. Thus, to promote an eventual signaling or request for help, the contacts and information from victim support organizations were provided to all the participants.
As a proposal for future investigations, it is suggested to carry out more studies on multiple victimization of children and youth for other geographical areas of the country, as far as possible, in the form of both representative and longitudinal studies, at the level of prevalence, to investigate short-, medium-, and long-term impacts. Studies in a spatiotemporal approach would also be important, in the form of epidemiological surveillance to detect ecological variations in risk and assess the effectiveness of initiatives to reduce that risk. In cases of the existence of multiple victimization, it would be pertinent to understand the consequences that result from this experience, and whether, according to the studies, the trauma would be due to the experience of multiple victimizations or would be derived from a highly compromising experience. All forms of victimization should be considered as part of the set of risk factors for interpersonal violence in future global comparative risk assessments.
This study proved that the experience of one or more forms of violence is relatively common. Knowing the implications of this exposure, as the literature in the area helps to understand, it is urgent to make people aware of the existence of these phenomena (single, multiple, multi-victimization), and for their immediate signaling and prevention. It is of crucial importance that technical (e.g., teachers) and non-technical (e.g., support staff) individuals are able to identify children who experience multiple victimization and polyvictimization, whose negative impact can cause trauma and have repercussions in their development and adult life. This implies a positive approach, an opening to know the experiences lived by the child, knowing how to recognize the simultaneity of risk factors that act in different contexts and redesigning the intervention strategy, focusing on acting on the strengths of each child or adolescent that allow them to be resilient to the negative experiences of the past. Funding: This work was financially supported by Portuguese national funds through the FCT (Foundation for Science and Technology) within the framework of the CIEC (Research Center for Child Studies of the University of Minho) projects under the references UIDB/00317/2020 and UIDP/00317/2020.

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by Ethics Committee of the University Fernando Pessoa (UFP), having been approved in 20 December 2016, no specific reference assigned, date acting as reference ID).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data are not publicly available due to General Data Protection Regulation (GDPR).

Conflicts of Interest:
The authors declare no conflict of interest.