An analysis of studies into the prevalence of child abuse and neglect, the recognition by professionals, and the role of prevention and treatment. By Susannah Bowyer
Three articles in the Lancet’s series on child maltreatment
Title: Child maltreatment one. Burden and consequences of child maltreatment in high-income countries, 3 January 2009
Authors: Ruth Gilbert, Cathy Spatz Widom, Kevin Browne, David Fergusson, Elspeth Webb, Staffan Janson
Title: Child maltreatment two. Recognising and responding to child maltreatment, Published online 3 December, 2008
Authors: Ruth Gilbert, Alison Kemp, June Thoburn, Peter Sidebotham, Lorraine Radford, Danya Glaser, Harriet L MacMillan
Title: Child maltreatment three. Interventions to prevent child maltreatment and associated impairment, Published online 3 December, 2008
Authors: Harriet L MacMillan, C Nadine Wathen, Jane Barlow, David Fergusson, John M Leventhal, Heather N Taussig
This first of three papers published in The Lancet, that assess the evidence on child maltreatment by parents or care-givers, sets out the scale of the problem, the second reviews the evidence on recognition and response and the third assesses what works in prevention and the treatment of impairment associated with child maltreatment. Four forms of child maltreatment are widely recognised: physical, sexual and psychological abuse, and neglect. In addition, witnessing adult domestic violence is increasingly regarded as a form of child maltreatment.
Statistics on the frequency and severity of child maltreatment are from three types of data: self-reports from victims, parents’ reports of punishment or patterns of care, and statistics from agencies.
Rates of maltreatment reported through victim and parent reports are 10 times higher than rates reported through child protection agencies. Every year about 4-16% of children are physically abused and 10% are neglected or psychologically abused.
During childhood between 5% and 10% of girls and up to 5% of boys are exposed to penetrative sexual abuse and up to three times these numbers are exposed to any type of sexual abuse. Children exposed to one type of maltreatment are also at high risk of exposure to other types or neglect. Several parental characteristics are risk factors for child maltreatment, including poverty, mental-health problems, low educational achievement, alcohol and drug misuse and exposure to maltreatment as a child. Reports of physical and sexual abuse have decreased by about 50% between the mid-1990s and 2005 in both the USA and England.
Rates of neglect have increased over the same period, and there is growing evidence that neglect can be at least as damaging as physical or sexual abuse.
There has been little decrease in child homicide rates over the past 30 years. The World Health Organisation estimates that 155,000 child deaths occur worldwide every year as a result of abuse or neglect, with biological parents responsible for 80% of cases and step-parents for a further 15%. Child homicide occurs most frequently in infancy – in the UK, 35% of child homicide victims are younger than a year old, and in infancy homicide is equally likely to be perpetrated by either parent.
Long-term consequences of child maltreatment include an association with substantially lower educational achievement than peers with no maltreatment record, increased risk of behaviour problems in children, depression in adolescence and adulthood and what can be a very high risk of attempted suicide for young people in their late twenties. Several studies point to an association between child maltreatment and obesity in adulthood, child sexual abuse and adolescent eating disorders, and increased rates of teenage pregnancy. Abused and neglected children are also at increased risk of criminal activity in adolescence and adulthood.
Recognition and response
Direct evidence that health and education professionals under-report suspected cases of child maltreatment comes from a growing number of studies.
Nurses and doctors
Medical professionals account for a small proportion of reports to child-protection agencies (8.4% in a 2006 US study), but are most likely to be responsible for reporting severe physical abuse that has resulted in injuries or symptoms.
One study of 434 doctors dealing with injured children found that while they had some suspicion that about 10% of 15,000 injury visits attended were caused by child abuse, doctors reported only 6% of these suspicious injuries to child-protection services. Factors affecting reporting included doctors’ expectations that involving child-protection services might produce negative patient outcomes and concerns that reporting would damage the doctor’s relationship with the family.
Research also suggests that maltreatment is under-recognised in children presenting with mental-health problems and that professionals need to consider and, if necessary, report maltreatment when assessing a child’s mental health.
School professionals contribute most reports to child protection agencies (16.5% of reports in an 2006 US study), but are also responsible for failing to report most cases.
Studies from Sweden and the US showed that only 30-37% of cases of child maltreatment known to school staff were formally reported. Reasons for under-reporting include inadequate training, lack of awareness of procedures, uncertainty about what constitutes reasonable grounds for suspicion, teachers’ fears about damaging relationships with child and parents, lack of support from colleagues for making allegations, and judgments about the likely benefits of reporting.
In interviews with staff in 43 schools in the UK, lack of access to qualified social workers to discuss cases, insufficient feedback, and concern about the ability of children’s departments to offer support, all contributed to under-reporting.
There is a lack of evidence about whether education programmes for children in schools (which are the main approach to preventing sexual abuse) reduce occurrence of child abuse.
Social care staff
In adult social care, the strong associations between child maltreatment and parental mental-health conditions or substance misuse underline the need for professionals to consider the welfare of their children.
The recognition and reporting of domestic violence also presents opportunities to identify maltreated children, although in the US and Australia increased police referrals to child-protection services arising out of domestic violence cases led to services becoming overwhelmed.
There is little evidence that interventions can reduce maltreatment even in terms of objective measures such as fewer children presenting at hospitals with injuries.
Two exceptions are the Nurse-Family Partnership programme developed in the USA and the Early Start programme in New Zealand.
Nurse-Family Partnerships have been rigorously evaluated over many years in the USA. One trial showed a 32% reduction in all emergency department visits and a 56% fall in visits for injuries and ingestions, among nurse-visited children compared with the control group. In a 15-year follow up on Nurse-Family Partnerships, child abuse and neglect were detected less often, though this effect was not present in homes where moderate to high levels of domestic violence were reported.
Children in the Early Start programme trials also had significantly lower attendance rates at hospital for injuries than those in the control group.
Studies are under way in the Netherlands and the UK to establish whether these findings can be replicated. The authors point to three common features of these programmes that could be key to their success: first, they were developed as research programmes rather than as service provision methods second, they use workers with tertiary level qualifications and third, both have made substantial investments in ensuring rigourous programme delivery.
There are “promising” findings from the Triple P Parenting Programme, but these are from a single study and further research is needed. Promising findings are also reported in relation to the SEEK model of paediatric primary care developed in Baltimore, USA.
While child maltreatment is common, the variation in rates between countries and the possible decrease over time in physical and sexual abuse in some countries show that high incidence of child maltreatment can be reduced. The authors argue for increased investment in preventive and therapeutic strategies from early childhood.
The evidence underlines the inadequacy of recognition and response. To develop effective, multi-disciplinary work in the field, more study and evidence are needed and science must link with policy.
● Susannah Bowyer is research officer at Research in Practice
Resources and links
➔ Full text copies of the Lancet articles
➔ Research in practice has a range of resources on these issues including: e-learning units on:
➔ Parental Drug Misuse
➔ Domestic abuse and child abuse: research connections for practice
Research briefings on:
➔ Understanding and working with neglect
➔ Domestic violence and child abuse
Research reviews on:
➔ Children and Domestic Violence
➔ Parental Drug Misuse
➔ Professionalism, Partnership and Joined-up Thinking
●The evidence on health, education and other professionals under-reporting to child-protection services underlines the need to develop inter-agency communication and multi-professional working around families with complex needs.
● In particular, the widespread doubts amongst other professionals that “the benefits of reporting suspected cases of maltreatment to child-protection services outweigh the harms” need to be addressed.
● If rates of child maltreatment are, as this evidence suggests, 10 times higher than those rates currently reported to child-protection services, improvements in recognition and referral will have serious implications for services whose capacity is already stretched. “These findings raise questions about the pre-eminence of formal, targeted child-protection services as the common pathway for recording maltreatment, assessing need, and accessing therapeutic and supportive services.”
This article is published in the 26 February edition of Community Care under the headline “Responses to child maltreatment”