Elsevier

The Lancet

Volume 373, Issue 9657, 3–9 January 2009, Pages 68-81
The Lancet

Series
Burden and consequences of child maltreatment in high-income countries

https://doi.org/10.1016/S0140-6736(08)61706-7Get rights and content

Summary

Child maltreatment remains a major public-health and social-welfare problem in high-income countries. Every year, about 4–16% of children are physically abused and one in ten is 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 this number are exposed to any type of sexual abuse. However, official rates for substantiated child maltreatment indicate less than a tenth of this burden. Exposure to multiple types and repeated episodes of maltreatment is associated with increased risks of severe maltreatment and psychological consequences. Child maltreatment substantially contributes to child mortality and morbidity and has longlasting effects on mental health, drug and alcohol misuse (especially in girls), risky sexual behaviour, obesity, and criminal behaviour, which persist into adulthood. Neglect is at least as damaging as physical or sexual abuse in the long term but has received the least scientific and public attention. The high burden and serious and long-term consequences of child maltreatment warrant increased investment in preventive and therapeutic strategies from early childhood.

Introduction

Maltreatment of children by their parents or other caregivers is a major public-health and social-welfare problem in high-income countries. It is common and can cause death, serious injury, and long-term consequences that affect the child's life into adulthood, their family, and society in general. The 2006 WHO report on prevention of child maltreatment1 drew attention to the need for this topic to achieve the prominence and investment in prevention and epidemiological monitoring that is given to other serious public-health concerns with lifelong consequences affecting children—such as HIV/AIDS, smoking, and obesity—and it recommended expansion of the scientific evidence base for the magnitude, effects, and preventability of the problem. This Series of four papers critically assesses this expanding evidence base with the aim of informing policy and practice relating to child maltreatment. We focus mainly on high-income countries and eastern European countries that are in economic transition, since the problem and systems for response differ in low-income and many middle-income countries. In this first paper of the Series, we aim to quantify the magnitude of the problem, its determinants, and consequences. The second charts the evidence underpinning recognition and response by professional agencies dealing with children. The third assesses what works for prevention of child maltreatment and associated impairment, and the final paper discusses how consideration of children's rights could enable a more coherent and effective approach to child maltreatment.

Key messages

  • A substantial minority of children in high-income countries are maltreated by their caregivers

  • Repeated abuse and high levels of neglect mean that for many children maltreatment is a chronic condition

  • Parental poverty, low educational achievement, and mental illness are often associated with child maltreatment

  • Child maltreatment has longlasting effects on mental health, drug and alcohol problems, risky sexual behaviour, obesity, and criminal behaviour, from childhood to adulthood

  • Neglect is at least as damaging as physical or sexual abuse in the long term, but has received the least scientific and public attention

  • The high burden and serious, longlasting consequences of child maltreatment warrant increased investment in preventive and therapeutic strategies from early childhood

Section snippets

Burden of child maltreatment and definitions

Child maltreatment encompasses any acts of commission or omission by a parent or other caregiver that result in harm, potential for harm, or threat of harm to a child (usually interpreted as up to 18 years of age), even if harm is not the intended result.2 Four forms of maltreatment are widely recognised: physical abuse; sexual abuse; psychological abuse, sometimes referred to as emotional abuse; and neglect. Increasingly, witnessing intimate-partner violence is also regarded as a form of child

Characteristics of the victim

Understanding what characteristics of parent–child relationships place children at increased risk of maltreatment within a family is complex and beyond the scope of this review. Girls have a higher risk of being sexually abused than do boys, although rates of other types of maltreatment are similar for both sexes in high-income countries.3, 7, 20, 50 In low-income countries, girls are at higher risk for infanticide, sexual abuse, and neglect, whereas boys seem to be at greater risk of harsh

Death from child maltreatment

The most tragic manifestation of the burden of child maltreatment is the thousands of child deaths every year due to deliberate killing (homicide) or neglect (manslaughter). WHO estimated that 155 000 deaths in children younger than 15 years occur worldwide every year as a result of abuse or neglect, which is 0·6% of all deaths and 12·7% of deaths due to any injury.51 Only a third of these deaths are classified as homicide. Furthermore, substantial under-reporting occurs because of insufficient

Long-term consequences of child maltreatment

Since groundbreaking work in the early 1970s drew attention to the battered child syndrome, research designed to quantify the long-term consequences of child maltreatment has grown.80 Here we summarise the evidence for associations between different types of maltreatment and outcomes related to education, mental health, physical health, and violence or criminal behaviour. Findings from cohort studies that prospectively ascertained whether children were maltreated or not, and which followed up

Future research

Child maltreatment is common, and for many it is a chronic condition, with repeated and ongoing maltreatment merging into adverse outcomes throughout childhood and into adulthood. The burden on the children themselves and on society is substantial. At the same time, variation in rates of maltreatment between countries, particularly for infant homicides, and a possible decrease in recent years in sexual and physical abuse in some high-income countries, shows that the present high burden of child

Search strategy and selection criteria

We did a comprehensive search of PubMed, Psychinfo, and Education Resources Information Center (ERIC) for any systematic reviews or overviews related to child maltreatment published after 2000 (to June, 2008) and then scrutinised reference lists of relevant studies. We also searched PubMed, ERIC, and Psychinfo using additional synonyms and indexing terms specific to each outcome. Searches on PubMed were enhanced with the related articles facility for selected studies. Recent psychological

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