Abstract
Introduction:
It is known that family dysfunctions increase the risk of abuse, neglect and delinquency in children. On the other hand, family belonging was shown as one of the protective factors against these types of risks. In this study, it was aimed to investigate the relationship between family belonging and various risk factors for children and their families who are being treated in a mental health clinic with the decision of health measure.
Method:
The study group consisted of 57 adolescents who were treated with a health measure decision, and the control group consisted of 42 adolescents who were treated in the same clinic without any health measure, both groups were over the age of 14. The Parenting Style Scale and The Family Belonging Scale were applied to the participants who took part in the study on a voluntary basis. Data in the sociodemographic information form were updated with the help of parents.
Results:
Children with health measure decisions had higher rates of grade repetition, exposure to a negative life event, domestic physical and verbal violence, living in a fragmented family system, presence of mental illness in the mother, and a history of delinquency in family members compared to children in the control group. It was found that children’s participation in social activities, and the education and income levels of the parents were lower. Additionally, authoritarian and negligent parenting styles were more pronounced and family belonging was lower in the same group. In the regression analysis, it was revealed that the family belonging of children who had been followed up with a health measure desicion, increases with the participation in social activities and decreases with physical violence.
Conclusion:
Our study supported that in studies targeting children at risk or in need of protection, family-oriented interventions are protective, preventive and curative.
Keywords: Abuse, child, family belonging, neglect, parenting style
INTRODUCTION
Children who are neglected in terms of care, education or health and as a consequence whose physical and psychosocial development is at risk are defined by the law (Act No. 2828 on Social Services, and Law No. 5395 on Child Protection) as ‘Child in Need of Protection’ (1,2). Every social state, takes legal and administrative precautions in order to reduce the number of child in need of protection, and signs international contracts relating to the matter. In this respect, in our country, some legislative regulations take place within the framework of Law No. 5395 on Child Protection. This law defines some precautions in order to secure psychosocial well-being of children in need of protection by preventing neglect, abuse and crime involvement of these children and reducing the risk factors. These precautions consist of counseling, education, care, health and shelter measures. It is recommended to take counseling, education and health measures in case the education and health needs of the child are not fulfilled properly and in the presence of negative parental attitudes; whereas care measure must be considered as a last measure and put into practice in cases where the care-giver could not fulfill their responsibilities (1).
Highlights
Inadequate family functions are among the risk factors for child abuse and neglect.
Sense of family belonging and positive parent-child relationship are protective for mental health.
Family belonging was lower in children under health measure.
Authoritarian and negligent parenting styles are more pronounced in these children.
In our country, a considerable number of children who are offered health service support in accordance with health measure decision consists of children who are sent to mental health clinics for psychiatric evaluation and/or treatment. In other words, children who are evaluated by judicial authorities for sexual or physical abuse or crime involvement reasons; or children whose psychosocial or physical development is considered at risk and who are evaluated by Directorate of Family and Social Services are within the scope of health measure decision. Among these groups, children who are in need of psychological support are detected and that support is guaranteed by state follow up.
When risk factors for child neglect and abuse considered, it is seen that any negativity related to the family is important. It is stated that parent’s negative attitudes and behaviors towards their children and inadequate family functions increase the risk of neglect and abuse of children, and also cause behavioral problems and delinquency in children. (3,4). Sense of family belonging was defined as “individuals contentment in their relationship with parents and feeling like part of the family” and this is one of the concepts used for understanding child-parent relationship (5). It is considered that sense of family belonging and good quality of parent-children relationship are related to psychological well-being of children (6). Some research also has shown that family belonging is a protective factor against emotional distress, suicidal thought/behavior, substance use, early sexual experience, academic failure and delinquency in adolescents (7).
Participants of this study consisted of children who had taken follow-up care in our hospital in accordance with court’s health measure decision order. It was observed that, in our country, there are many studies that addresses children in need of protection, but there is not enough study about the children protected by decision of health measure, also previous studies were limited only to sociodemographic and clinical aspects of the subject (8,9). The purpose of this study was to investigate the relationship between sense of family belonging and risk factors for family and children, in a group of children with the decision of health measure, and who are in need of protection. When compared with children who received a treatment and followed-up in our clinic without any health measure decision, children who have health measure decision are expected to have lower sense of family belonging, and they experienced negative parental attitudes and other risk factors more often.
METHOD
Participants
The study group of this research consisted of 57 adolescents over the age of 14 who were issued “health measure” court decision and treated as outpatient in Kocaeli University Medical Faculty Department of Child and Adolescent Psychiatry between the dates January-August 2020. All voluntary adolescents who comply with the research criteria included in the study in sequential order. Control group consisted of 42 adolescents, who don’t have health measure decision and who were treated in our outpatient clinic during the same time interval, their age range was similar to the first group. Severe psychological disorders such as mental retardation, autism spectrum disorder, and schizophrenia were accepted as exclusion criteria, because such diseases may prevent answering research materials. All voluntary adolescents who were treated in our outpatient clinic and who did not show any exclusion criteria included in the study between the specified dates.
MATERIALS
Sociodemographic Information Form
This form was developed by researchers and contained descriptive characteristics about children and their families. In the form, child’s age, gender, number of siblings, birth order, school attendance, grade repetition, participation in social activities and exposure to negative life events were asked, also information about their families, such as age of the mother and father, educational level of parents, mental illness presence, monthly income, family structure, criminal involvement in the family, substance use history, domestic verbal and physical violence, were gathered.
Parenting Style Scale
The Parenting Style Scale was developed by Lamborn et al (1991), and the Turkish adaptation of the scale was made by Yılmaz in 2000 (10).
Factor analysis results of 26 items of the original scale showed that this scale had three factors: acceptance/involvement, strictness/supervision, and psychological autonomy. As a result of evaluations based on these three dimensions, parenting styles classified as democratic, permissive-negligent, authoritative, and permissive-indulgent.
Turkish reliability and validity study showed that, in high school students reliability and internal consistency coefficient was 0.82 and 0.70 in acceptance/involvement subscale, 0.88 and 0.69 in supervision subscale, 0.76 and 0.66 in psychological autonomy subscale. It was emphasized that test re-test reliability of the scale was high, internal consistency was relatively low but still sufficient (10).
Family Belonging Scale
Family Belonging Scale which consisted of 17 items developed by Mavili, Kesen and Daşbaş (2014) for determining the individual’s sense of belonging to family. In the scale, 12 items (items 1, 3, 4, 6, 7, 10, 11, 12, 13, 14, 15 and 17) evaluated ‘sense of self belonging subscale’, the remaining five items (items 2, 5, 8, 9 and 16) evaluated ‘family sense of belonging subscale’. Total of both subscale scores gave ‘sense of family belonging total score’. The scale is a five-point-Likert-type scale and items 5, 7, 9 and 12 were negative items and reverse scored. Higher scale scores indicated higher sense of family belonging. Internal consistency coefficient (Cronbach Alfa) of the scale was 0.94 (11).
Procedure
Our research began with Kocaeli University Noninvasive Clinical Researches Ethic Committee’s decision of approval dated 21.01.2020, 2020/7 project no and numbered KÜ GOKAEK 2020/1.14, and conducted on voluntary basis. Information about research was provided to all adolescents and their parents, and they participated in research after reading and signing the informed consent form. After their routine follow-up, adolescents were asked to fill Family Belonging Scale and Parenting Style Scale, and parents were asked to review information in Sociodemographic Information Form.
Analysis
Statistical evaluation was computed by Statistical Package for Social Sciences for Windows (IBM SPSS) version 20.0 (IBM Corp., Armonk, NY, USA) packaged software. Suitability of data to normal distribution was evaluated by the Shapiro Wilk Test. Numeric variables were given as median (25. - 75. percentile) and frequency (percentages). Difference between groups for non-normally distributed numeric variables were determined by Mann Whitney U Test. In categorical variables, Fisher’s Exact Chi-Square Test, Yates’ Chi-Square Test and Monte Carlo Chi-Square Test were used in order to evaluate group differences. Relationship between numeric variables was evaluated by Spearmen Correlation Analysis. In order to determine independent variables that effect Belonging subscales, multiple linear regression analysis was applied. In two-way tests, p<0.05 was accepted as statistically significant.
RESULTS
Ninety nine children participated in our study, 57 children were in study group and 42 of them were in control group. Statistical analysis between study group and control group showed that, average score differences between groups in terms of age average, number of siblings and birth order were statistically significant (in sequence, p=0.011, p=0.001, p=0.002). Also, children who participated in our study answered questions about grade repetition, social activity participation, and experiences of negative life events, and statistical analysis of their answers showed that the difference between the average scores of two groups were statistically significant (in sequence, p=0.001, p=0.001, p=0.001). According to this, it drew attention that in study group, grade repetition was high, only few children participated in social activities and most of them experienced negative life events. In comparison to the control group, it was seen that family’s monthly income level was lower, educational level of the mother and father was lower and most children live in fragmented family system (p=0.001, p=0.001, p=0.008, p=0.001) in the study group. Additionally, it was detected that in the study group, mothers’ mental illness rate, domestic verbal and physical violence experience of children, and crime involvement among family members were higher compared to the control group, differences between groups were statistically significant (in sequence, p=0.001, p=0.001, p=0.001, p=0.001) (Table 1).
Table 1.
Sociodemographic features according to the groups
| Sociodemographic features of the children and their families | Study Group (n=57) | Control Group (n=42) | p | |||
|---|---|---|---|---|---|---|
| Number | % | Number | % | |||
| Gender (Girl) | 44 | 77.2 | 29 | 69 | 0.497a | |
| Age (Median (25-75)) | 16 (14-17) | 15 (14-16) | 0.011b | |||
| Number of siblings (except participant) (Median (25-75)) | 2 (1-3) | 1 (1-1) | <0.001b | |||
| Birth order (Median (25-75)) | 2 (1-3) | 1 (1-2) | 0.002b | |||
| School attendance | 47 | 82.5 | 37 | 88.1 | 0.624a | |
| Grade repetition | 24 | 42.1 | 4 | 9.5 | 0.001a | |
| Participation in social activities | 11 | 19.3 | 26 | 61.9 | <0.001a | |
| Negative life events | 48 | 84.2 | 12 | 28.6 | <0.001a | |
| Age of mother (Median (25-75)) | 41 (37-46) | 41 (39-44) | 0.518b | |||
| Age of father (Median (25-75)) | 45 (41-51) | 45 (41-51) | 0.702b | |||
| Monthly income | Below the minimum wage | 37 | 64.9 | 3 | 7.1 | <0.001a |
| Minimum wage-3000 TL | 14 | 24.6 | 9 | 21.4 | ||
| Above 3000 TL | 6 | 10.5 | 30 | 71.4 | ||
| Family structure | Nuclear | 20 | 35.1 | 34 | 81 | <0.001a |
| Extended | 3 | 5.3 | 4 | 9.5 | ||
| Fragmented (Divorse) | 32 | 56.1 | 4 | 9.5 | ||
| Fragmented (Death) | 2 | 3.5 | 0 | 0 | ||
| Mother’s education level | Elementary school and lower | 34 | 59.7 | 12 | 28.6 | 0.001a |
| Secondary school | 14 | 24.6 | 9 | 21.4 | ||
| High school | 7 | 12.3 | 11 | 26.2 | ||
| University and higher | 2 | 3.5 | 10 | 23.8 | ||
| Father’s education level | Elementary school and lower | 30 | 52.7 | 10 | 23.8 | 0.008a |
| Secondary school | 8 | 14 | 3 | 7.1 | ||
| High school | 14 | 24.6 | 17 | 40.5 | ||
| University and higher | 5 | 8.8 | 12 | 28.6 | ||
| Mental illness in mother | 21 | 36.8 | 1 | 2.4 | <0.001a | |
| Mental ilness in father | 6 | 10.5 | 3 | 7.1 | 0.729a | |
| Domestic verbal violence | 47 | 82.5 | 6 | 14.3 | <0.001a | |
| Domestic physical violence | 32 | 56.1 | 1 | 2.4 | <0.001a | |
| Criminal involvement in the family | 20 | 35.7 | 1 | 2.4 | <0.001a | |
| Substance use in the family | 8 | 14 | 2 | 4.8 | 0.380a | |
a: Chi-Square Test, b: Mann Whitney U Test.
When the study group was compared with the control group in terms of mental disorder diagnosis, children in the study group had more mental disorder diagnoses (p=0.007), and they displayed higher incidence of conduct disorder and adjustment disorder (p=0.025, p=0.026) compared to the control group. When Parenting Style Scale answers of groups were assessed, in the study group, children’s parents were more negligent and authoritarian in comparison to the control group’s families, and in the control group, parents had more democratic attitudes and it was detected that the difference between groups was statistically significant (in sequence p=0.001, p=0.02, p=0.001). When groups were compared according to Family Belonging Scale responses, children’s family belonging, self-belonging and sense of family belonging total scores were low in the study group in comparison to the control group children (in sequence p=0.001, p=0.001, p=0.001) (Table 2).
Table 2.
Results of psychiatric evaluation of the children
| Results of psychiatric evaluation | Study group (n=57) | Control group (n=42) | p | |||
|---|---|---|---|---|---|---|
| Number | % | Number | % | |||
| Children’s Psychiatric Diagnoses | 57 | 100 | 39 | 92.9 | 0.007a | |
| Clinical Diagnoses | ||||||
| Major Depressive Disorder | 23 | 40.4 | 9 | 21.4 | 0.070a | |
| Posttraumatic Stress Disorder | 5 | 8.8 | 0 | 0 | 0.070a | |
| Anxiety Disorder | 6 | 10.5 | 9 | 21.4 | 0.226a | |
| Attention Deficit Hyperactivity Disorder | 14 | 24.6 | 15 | 35.7 | 0.326a | |
| Conduct Disorder | 11 | 19.3 | 1 | 2.4 | 0.025a | |
| Adjustment Disorder | 3 | 5.3 | 0 | 0 | 0.026a | |
| Specific Learning Disorder | 1 | 1.8 | 0 | 0 | 1.000a | |
| Bipolar Disorder | 1 | 1.8 | 1 | 2.4 | 1.000a | |
| Substance Use Disorder | 1 | 1.8 | 0 | 0 | 1.000a | |
| Obsessive-Compulsive Disorder | 0 | 0 | 2 | 4.8 | 0.177a | |
| Conversion Disorder | 0 | 0 | 2 | 4.8 | 0.177a | |
| Scales | ||||||
| Parenting Style Scale | Negligent | 35 | 61.4 | 1 | 2.4 | <0.001a |
| Democratic | 22 | 38.6 | 41 | 97.6 | ||
| Indulgent | 46 | 80.7 | 41 | 97.6 | 0.02a | |
| Authoritative | 11 | 19.3 | 1 | 2.4 | ||
| Family Belonging Scale (Median (25-75)) | Family sense of belonging subscale | 10 (8-13) | 20 (17-22) | <0.001b | ||
| Sense of self belonging subscale | 34 (25-41) | 54 (49-57) | <0.001b | |||
| Family sense of belonging total score | 44 (34-51) | 73 (67-78) | <0.001b | |||
a: Chi-Square Test, b: Mann Whitney U Test.
All variables (concerning definitive characteristics and psychological evaluation of the study group children and their families) and the relationship between these variables and sense of family belonging total scores were assessed with correlation analysis. It was found that there was a relationship between only the variables presented in Table 3 and sense of family belonging total scores. In accordance with this analysis, it was determined that presence of mental illness in the mother and child’s social activity participation was positively related with sense of family belonging (Table 3). Also, it was detected that sense of family belonging has a negative relationship with birth order, psychiatric medication use, presence of Posttraumatic Stress Disorder (PTSD), grade repetition, presence of domestic verbal and physical violence (Table 3).
Table 3.
Variants related with sense of family belonging total score in the correlation analysis
| Variants related with sense of family belonging total score | r (p) |
|---|---|
| Domestic physical violence | -0.485 (<0.001) |
| Psychiatric medication usage | -0.386 (0.003) |
| PTSD | -0.372 (0.004) |
| Mental illness in mother | 0.308 (0.020) |
| Domestic verbal violence | -0.281 (0.034) |
| Birth order | -0.278 (0.036) |
| Grade repetition | -0.278 (0.036) |
| Participation in social activities | 0.277 (0.037) |
PTSD: Posttraumatic Stress Disorder.
In correlation analysis, variables related to sense of family belonging were analyzed with linear regression analysis, and it was found that among analyzed variables, only social activity participation and domestic physical violence had a statistically significant relationship with family sense of belonging. It was noticed that family sense of belonging increased in children who participated in social activity, on the other hand sense of family belonging decreased in children who were exposed to domestic violence (Table 4).
Table 4.
Linear regression analysis of the variables effecting sense of family belonging in children with health measure decision
| Independent variables | Beta (95% CI) | t | Sig. (p) |
|---|---|---|---|
| Domestic physical violence | -6.537 (-12.709_-0.365) | -2.131 | 0.038 |
| Participation in social activities | 7.217 (0.147_14.2888) | 2.053 | 0.046 |
| PTSD | -7.932 (-17.312_1.438) | -1.703 | 0.095 |
| Mental illness in mother | 4.335 (-1.418_10.089) | 1.516 | 0.136 |
| Psychiatric medication usage | -4.222 (-12.363_3.920) | -1.043 | 0.302 |
| Grade repetition | -2.900 (-8.654_2.854) | -1.014 | 0.316 |
| Domestic verbal violence | -2.105 (-10.478_6.269) | -0.506 | 0.615 |
| Birth order | -0.299 (-2.114_1.516) | -0.331 | 0.742 |
CI: Confidence Interval; PTSD: Posttraumatic Stress Disorder; Sig.: Significance;
DISCUSSION
In this study, two groups of children at the same age range were compared based on the relationship between sense of family belonging and risk factors for the child and family. The first group consisted of children with the legal decision of health measure and the second group without the decision of health measure and both groups were followed-up in our outpatient clinic. Children who are followed-up and treated in our department with the decision of health measure, consist of children who were sent to our clinic by judicial authorities for sexual abuse and crime involvement reasons and by Directorate of Family and Social Services for neglect and/or abuse reasons. In our outpatient clinic, sexually abused children received treatment mainly in our “trauma clinic”, and children who are neglected, abused or involved in crime received treatment and followed-up in our “health measure clinic” in line with health measure.
It was found that mental illness presence in the family was related with these children’s psychosocial troubles and poor school adjustment (12,13). Also, low socioeconomic level, low educational level of parents, presence of mental illness in parents and fragmented family structure appeared as risk factors for neglect and abuse experiences of children (14,15). In our study, it appeared that in the study group, children’s families had lower income and lower educational levels, grade repetition among these children were higher and only few of them participated in social activities, also their exposure to physical and verbal violence were higher. Mental illness presence in the father did not differ between groups, but when it came to mental illness presence in the mother, the rates were higher in the study group. It is known that from the early stages of a child’s life, functioning and impact of mother is dominant. Accordingly, in line with our study results, mental illness presence in the mother might cause more negative outcomes in supporting the child, and protecting him/her from risks, moreover, it could be inferred that this might cause emotional disturbance in the child. Furthermore, higher mental illness presence in the mother of children with the decision of health measure might be related to the caregiver parent’s family burden and high level of stress in fragmented family structure (16). In our study, it was found that children with the decision of health measure live mostly in fragmented family structures, on the other hand, data was not collected about whether these children live with their mothers or fathers, and also there was no data about the support of other family members and adults.
In the literature, a lot of studies show that parental inadequacy in child rearing create a psychological problem development risk in the child, and also there are studies that uncover the relationship between negative parenting attitudes and psychological disorders in the child (17). Likewise, according to researchers, children who are kept under heavy grip, who have negative and problematic intrafamilial relations, tend to show delinquent and violent behaviors, and experience severe problems with other people, compared to children who grow up in indulgent and democratic families with strong sense of belonging (18). In line with the literature, it was seen that parents of children with the decision of health measure were more negligent and authoritarian, compared to the parents of the control group. Also children protected by decision of health measure had more psychological disorder diagnoses, showed high rates of conduct disorder and adjustment disorder compared to the children in the control group. Higher psychiatric disorder rates in the children with health measure may be associated with the fact that health measure decision is likely to be given to the children who has significant psychological problems; also it may be associated with the fact that among the children in juvenile justice system, the rates of psychiatric disorders were higher (19). Children in our health measure clinic consist of children who are neglected and/or abused and/or involved in crime. As a consequence, our finding on high rates of conduct disorder diagnosis is an expected outcome. It was indicated that children who are neglected and abused, show more problematic behavior and their crime involvement risk rises (14,15).
Hardway and Fuligni’s (2016) research showed that, adolescents whose parents had high educational level feel strong connection with their parents (20). Aslantürk (2017) carried out a research with university students, and found out that individuals who lived in single parent families had lower family belonging than individuals who lived in biparental families (21). Our study showed that in the study group, rate of fragmented families was high, and educational levels of parents were low compared to the control group. When groups were compared based on Family Belonging Scale answers, children’s family, self-belonging and total sense of family belonging scores were low in the study group in comparison with the control group. Based on this information that might be related to sense of family belonging, factors associated with sense of family belonging were evaluated by correlation and linear regression analyses in our research. It was found that sense of family belonging was positively correlated with presence of a mental disorder in mother and child’s participation in social activities; also, sense of family belonging was negatively correlated with birth order, psychiatric medication use, presence of a PTSD diagnosis, grade repetition, and exposure to domestic physical and verbal violence. In linear regression analysis, it was observed that only two variables were related with family belonging. It was found that children’s sense of family belonging increased with social activity participation, and decreased with being exposed to physical violence. When the literature was reviewed, it was seen that studies focusing on factors that affect family belonging were limited, also, these studies evaluated components that might affect family belonging based on entirely different variables. For instance; in a study that was conducted with delinquent adolescents in a penal institution and children’s education center; number of siblings, fragmented family structure, imprisonment of a parent, substance use of the father, the child’s run-aways from home were defined as components that are negatively correlated with family belonging. It was detected that children who had a higher family belonging also had a higher life satisfaction (18). In another study, it was stated that both parents perceiving the relationship with their children as good quality affects family belonging positively (7). Aslantürk et al. (2020) performed a study with university students, and they found out that students who were living in a nuclear family had higher family belonging compared to students living in an extended family; students who were living with their parents had a higher family belonging compared to the students in a fragmented family; and the ones who were living in a democratic family structure had a higher family belonging compared to other family structures. It was indicated that adolescents who were exposed to or witnessed violence had a lower family belonging, on the other hand, adolescents who spent quality time with their family, who could express their feelings and who felt understood had a higher family belonging (22). Domestic violence affects family belonging negatively and that finding was confirmed in our study as well. Therefore, precautions such as reducing violence against children, assisting proper family discipline methods, and bringing proper social activities into action in order to ensure children’s healthy social development support not only family belonging but also psychological development.
Data was based solely on adolescents’ feedbacks, sample size was not large enough, and data concerning causes of decision of health measure was not collected; these were some of the limitations of our research. In future studies, parents’ participation to the evaluation process together with children, a larger sample group, and information about causes of the children’s judicial system record and children’s social environment/family structure will enable a more comprehensive assessment. Among other researches focusing on the same subject and that were conducted in our country, our research is the first one to evaluate the relationship between parenting styles and sense of family belonging (in accordance with various variables), in a group of children with the decision of health measure, and it also contributes to the literature in terms of factors affecting family belonging. Our study is important also because it emphasizes that children who faced judicial authorities due to criminal behavior need as much protection and support as the children who are neglected and abused. In other words, our research is valuable because it indicates that we need to consider all children who encounter judicial system in a way regarding children’s high benefit and need of protection. Additionally, our research points out the protective and preventive aspect of family based intervention, especially in studies targeting children at risk. Also, our research results will guide mental health workers in clinical practices to plan treatment of children with health measure decision.
The authors would like to thank Professor Dr. Canan Baydemir, for assistance with statistical analysis of the study.
Footnotes
Ethics Committee Approval: Our research began with Kocaeli University Noninvasive Clinical Researches Ethic Committee’s decision of approval dated 21.01.2020, 2020/7 project no and numbered KÜ GOKAEK 2020/1.14, and conducted on voluntary basis.
Informed Consent: Information about research given to all adolescents and their parents, and they participated in research after reading and signing the informed consent form.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept- ŞGŞ, AC; Design- ŞGŞ, YD, GÜ, NNO, AC; Supervision- ŞGŞ, YD, GÜ, NNO, AC; Resource- ŞGŞ, YD, GÜ, NNO, AC; Materials- ŞGŞ, YD, GÜ, NNO, AC; Data Collection and/or Processing- ŞGŞ, YD, GÜ, NNO; Analysis and/or Interpretation- ŞGŞ, YD, GÜ, NNO, AC; Literature Search- ŞGŞ, YD, GÜ, NNO, AC; Writing- ŞGŞ, YD, GÜ, NNO, AC; Critical Reviews- ŞGŞ, YD, GÜ, NNO, AC.
Conflict of Interest: The authors declared that there is no conflict of interest.
Financial Disclosure: The authors have no funding for this study.
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