Peer Reviewed Articles on Child Abuse in the United States

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Improving measurement of child abuse and fail: A systematic review and assay of national prevalence studies

• Ben Mathews,
• Rosana Pacella,
• Michael P. Dunne,
• Marko Simunovic,
• Cicely Marston

ten

• Published: January 28, 2020
• https://doi.org/10.1371/journal.pone.0227884

Figures

Abstruse

Objectives

Child maltreatment through physical abuse, sexual abuse, emotional abuse, fail, and exposure to domestic violence, causes substantial adverse health, educational and behavioural consequences through the lifespan. The generation of reliable data on the prevalence and characteristics of child maltreatment in nationwide populations is essential to plan and evaluate public wellness interventions to reduce maltreatment. Measurement of child maltreatment must overcome numerous methodological challenges. Little is known to appointment about the extent, nature and methodological quality of these national studies. This study aimed to systematically review the most comprehensive national studies of the prevalence of child maltreatment, and critically appraise their methodologies to assist inform the design of time to come studies.

Methods

Guided by PRISMA and post-obit a published protocol, nosotros searched 22 databases from inception to 31 May 2019 to identify nationwide studies of the prevalence of either all five or at least iv forms of child maltreatment. Nosotros conducted a formal quality cess and critical analysis of study design.

Results

This review identified 30 national prevalence studies of all 5 or at least four forms of child maltreatment, in 22 countries. While sound approaches are bachelor for unlike settings, methodologies varied widely in nature and robustness. Some instruments are more than reliable and obtain more detailed and useful data about the characteristics of the maltreatment, including its nature, frequency, and the relationship betwixt the child and the person who inflicted the maltreatment. Nigh all studies had limitations, peculiarly in the level of item captured nearly maltreatment, and the adequacy of constructs of maltreatment types.

Conclusions

Countries must invest in rigorous national studies of the prevalence of child maltreatment. Studies should employ a sound instrument containing advisable maltreatment constructs, and obtain nuanced information near its nature.

Citation: Mathews B, Pacella R, Dunne MP, Simunovic One thousand, Marston C (2020) Improving measurement of child abuse and neglect: A systematic review and assay of national prevalence studies. PLoS 1 15(1): e0227884. https://doi.org/10.1371/journal.pone.0227884

Editor: Abraham Salinas-Miranda, University of Due south Florida, UNITED STATES

Received: September 10, 2019; Accepted: December 31, 2019; Published: January 28, 2020

Copyright: © 2020 Mathews et al. This is an open access article distributed under the terms of the Artistic Eatables Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original writer and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this piece of work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Child maltreatment is common and causes substantial agin wellness, educational and behavioural consequences [1]. Understanding its prevalence and characteristics in nationwide populations is essential to plan and evaluate interventions to reduce maltreatment. Even so, measurement of child maltreatment is known to be far from universal, and when performed must face up methodological challenges. This report systematically reviews the most comprehensive national studies of the prevalence of child maltreatment, and critically appraises their methodologies to help inform future measurement.

Child maltreatment in its v recognised forms is a major public health outcome [2]. Physical and mental diseases are caused through proximal and distal pathways. Immediate concrete injuries and conditions include brain injury and failure to thrive, and a panoply of psychological disorders include feet, depression, and suicidality. Studies have constitute serious effects of concrete abuse [iii,4,5], sexual abuse [six,7], emotional abuse [5,8–x], neglect [5,9,11], and exposure to domestic violence [12–14]. Experiencing multiple forms of maltreatment is common [12], and is associated with more severe outcomes [fourteen,15], including booze and drug corruption, mental disease, interpersonal violence, and sexual risk taking [16].

The adoption of coping mechanisms such every bit smoking, booze and drug apply tin chemical compound the damage by causing diseases in the medium to long term; and chronic stress tin cause coronary artery disease, pulmonary fibrosis, and inflammation [17–22]. Potent mediators include prolonged psychological distress, risky behaviours, social withdrawal and dysfunction, impaired cognitive development, low educational and occupational attainment, and interpersonal human relationship difficulties. A growing body of prove is showing child maltreatment affects brain evolution, shortens telomeres, and produces epigenetic neurobiological changes [23–26]. The disease and economic burdens are substantial: a recent judge of the cost of disability-adapted life years (DALYs) lost across E Asia and the Pacific was 1.88% of the region'due south GDP, equating to $194 billion in 2012 dollars [27].

Equally a global policy imperative, the Un recognises the gravity of kid maltreatment and its consequences. The United Nations Agenda for Sustainable Development includes a target of ending abuse of children [28]. Reliable scientific information on national prevalence is essential to measure progress against this goal, and to inform policy efforts aimed at prevention, early identification and response [29–30].

Nationwide studies of the feel of childhood maltreatment can identify baseline prevalence stratified by maltreatment type, too as of import contextual features including the kid'southward sexual activity, age, and human relationship with the abusive person. Without good measurement techniques and repeated measures over fourth dimension, we lack understandings of baseline measures, of whether maltreatment is increasing or declining, of changes in maltreatment types over fourth dimension, and of the efficacy of policy and practice interventions designed to reduce child maltreatment for the whole population and for key sub-populations.

Despite the necessity for good data in public wellness more often than not and in kid maltreatment in particular, approximately one-half of all countries have failed to written report any kind of robust prevalence estimates [2], and extant studies are often limited to measuring i or few maltreatment types [31]. Accordingly, prevalence estimates are oft inadequately specified, and are nigh certainly underestimated. In improver, existing studies vary widely in design, sample and methods, and oft use non-standardized instruments [5,32]. Where an instrument is non-standardized and untested, the risk may be heightened that the study volition neglect to capture experiences that constitute maltreatment, and may capture experiences that do not constitute maltreatment, hence producing unreliable results. Importantly, the use of unsound maltreatment constructs and operational definitions also compromises the reliability of recorded measures [33–34]. As an instance of this, studies of sexual corruption that do not include non-contact sexual corruption will underestimate prevalence; conversely, studies that include as sexual abuse genuinely consensual acts between peers volition overestimate prevalence. Similarly, studies of fail that practise not consider medical neglect volition underestimate prevalence. Studies of emotional abuse that include non-calumniating yelling will overestimate prevalence.

Optimal methodologies for measuring population characteristics of kid maltreatment can ensure adequate detail is captured to yield reliable, detailed, useful information. For all-time quality estimates, prevalence studies should prefer robust conceptual understandings of maltreatment types and their operational definitions [33]. In addition, prevalence studies need to enquire a series of items to obtain accurate information, rather than a single question which volition tend to underestimate prevalence [35]. Similarly, to avoid underestimates, items should be behaviourally specific, rather than vague, ambiguous or non-specific [36]. All national prevalence studies face methodological and practical challenges, and studies accept unlike approaches [2,12,xiv,thirty]. Ideally, however, all five forms of child maltreatment should be measured simultaneously, since many children feel such poly-victimization and its heightened consequences [ane,14,16]. To provide nuanced, useful data, studies should ask about prevalence, and nearly the specific nature of the acts, their severity, frequency, and timing, and the relationship of the kid to the person inflicting the abuse [33]. These factors influence health outcomes and provide testify nearly specific risk and protective factors and how these may all-time be targeted. Rigorous measurement of kid maltreatment is complex, only is essential to inform prevention efforts and drive nationwide social change [2,14,29,36,37].

Contempo research has reviewed global prevalence estimates [2,31], the nature of population health surveys exploring consequences of kid maltreatment [37], and approaches in studies of youth [38]. Nevertheless, to appointment, there has non been a systematic review and methodological appraisal of high quality national population prevalence studies of child maltreatment to provide a baseline for time to come measurement efforts.

This study aimed to investigate three questions. Offset, what national studies have been conducted of the prevalence and nature of all five, or at to the lowest degree four, major forms of child maltreatment? Second, what methodologies were used in these studies? Third, what does a critical analysis of these studies indicate near the methodological rigour, quality, and applied viability of unlike approaches? The results of our investigation can inform future efforts to generate baseline prevalence estimates, design policy responses, and nautical chart trends over time, every bit more societies face the challenge of babyhood maltreatment.

Methods

Search strategy

Our systematic review was guided by PRISMA [39] (S1 Fig). Nosotros developed a protocol, registered at PROSPERO [40]. #CRD42017068120, https://www.crd.york.ac.great britain/PROSPERO). Adopting our search strategy (S1 File), we searched 22 databases from their inception to 31 May 2019.

Eligibility criteria

We searched for quantitative studies of the prevalence of child maltreatment. Included studies met four criteria: (1) primary empirical studies of the prevalence of iv or five types of child maltreatment: ((i) concrete abuse; (two) emotional or psychological abuse; (three) fail; (iv) exposure to domestic violence; and (v) sexual abuse; (two) studies conducted nationwide using a representative sample of the population; (3) studies involving developed or child participants providing self-reported data about their experience, or studies where adults provided data about their child's experience; (iv) peer-reviewed studies or substantial gray literature.

Screening

As detailed in our search strategy (S1 File), in Phase 1, MS, JD and ED screened records past championship. We removed duplicates using electronic software (Endnote), and removed remaining duplicates about the same report, selecting the publication providing the well-nigh detailed account. In Phase two, BM and RP independently screened records past title and abstruse. Disagreements were discussed between BM and RP to achieve consensus. To identify any further potential eligible studies at this stage that may non have been captured in the search, all co-authors considered if there were any farther known studies requiring inclusion that were not in the Phase 2 shortlist. In Phase 3, BM and RP independently assessed total text of screened in manufactures. Disagreements were discussed between BM and RP to achieve consensus, with reasons recorded. We screened reference lists of included studies to identify whatever further potential eligible studies. Nosotros used a translator to assistance in screening not-English language studies. This process resulted in 23 eligible studies (Fig 1).

Data extraction and assay

Nosotros adult a template to extract lx data items from each study considering design, procedure, sample, instrument, ideals, and subpopulation assay (S2 File). We extracted 45 items nearly the musical instrument, including: name, psychometric data, definitions of maltreatment constructs, number of questions asked about each type, and whether questions explored: (a) the relationship between the kid and the person inflicting maltreatment; (b) nature of the acts; (c) severity (eastward.g., if they caused injuries); (d) frequency. MS and BM extracted these information. We separately tabulated the extracted items each study asked nearly maltreatment, with BM conducting a final double-bank check regarding these (S3 File).

Our critical analysis included an appraisement of the construct validity of study items and the soundness of their operational definition. To inform this assay, we identified robust conceptual understandings of each maltreatment type equally established in the scholarly literature, and adopted these as an evaluative standard. Physical abuse involves intentional acts of physical force past a parent or caregiver, excluding lawful corporal punishment [41]. Sexual abuse involves contact and non-contact sexual acts, inflicted by any adult or child in a position of power over the victim, to seek or obtain concrete or mental sexual gratification, when the kid does not have capacity to provide consent, or has capacity but does not provide consent [42]. Emotional or psychological abuse is inflicted by a parent or caregiver, and includes emotional unavailability, hostile interaction, developmentally inappropriate interaction, failure to admit the kid's individuality, and failure to integrate the child into the social world [43]. Neglect involves parental or caregiver omissions to provide the basic necessities of life suited to the kid'south developmental stage, every bit recognised by the kid's cultural context, including concrete, emotional, medical, environmental, supervisory, and educational neglect [44]. Exposure to domestic violence involves the child witnessing a parent or other family member being subjected to assaults, threats or holding damage past another adult or teenager normally resident in the household [12].

Our critical analysis was also informed by an understanding that prevalence studies must be conducted with low risk of bias to obtain reliable findings. In our analysis, we assessed report rigour, quality and practicability, and used a quality assessment tool designed to assess risk of bias in population-based prevalence studies [45, S4 File]. Using our quality assessment tool, we created an overall take a chance of bias score for each study which summed scores for private items (maximum score 10). RP and CM independently assessed each study considering iv external validity items and 5 internal validity items. Disputes were resolved through an independent third assessor (MD, BM). Our disquisitional analysis farther considered suitability of approach, considering: methodology to recruit the sample and accommodate high-risk sub-samples; assistants method; instrument; soundness of conceptual constructs; ethics; and practical viability.

Results

Systematic review

This review identified 23 articles reporting the results of national studies of the prevalence of all five or four of the recognized forms of child maltreatment. One of these articles reported the results of a study conducted simultaneously in nine countries in the Balkan Peninsula, and eight of these national studies met our eligibility criteria [46]. Accordingly, in total, our review identified 30 national studies, conducted in 22 countries. Studies were published between 2005 and 2019. Extracted data revealed study location, scope, participants, information collection method, and instrument. Table 1 presents the extracted data from included studies. The supporting information details the prevalence rates reported past each study (S5 File).

There were four studies in the U.s. [47–50], three in the UK [51–53], two in Hong Kong [54–55] two in Taiwan [56–57], and ii in Germany [58,59]. There was one study in Denmark [60], holland [61], Switzerland [62], Japan [63], Suriname [64], Saudi Arabia [65], State of israel [66], Southward Africa [67], and Hungary [68]. In the Balkans written report [46], eight met eligibility criteria based on the number of types of maltreatment studied: Republic of albania, Bosnia & Herzegovina, Bulgaria, Croatia, the Erstwhile Yugoslavian Republic of Macedonia, Greece, Romania, and Serbia; in general for our purposes, nosotros treat these as one study. The Turkish report involved three forms of maltreatment, so was excluded from our analyses.

14 studies measured all v maltreatment types [47–51,53,56–57,61,64–68]. Of nine studies measuring four maltreatment types, seven omitted EDV [46,52,58–60,62–63], and two omitted sexual abuse [54–55]. 11 studies measured prevalence throughout childhood and in the past year; ix measured prevalence through childhood just, and 3 measured past year incidence just.

Only nine studies explored all five types of maltreatment across childhood, defined as aged under 18 [48–50,53,64–68]. These studies occurred in seven countries (United states of america, Great britain, Suriname, Saudi arabia, Israel, South Africa and Hungary), and only 3 involved a sample of adults providing data virtually experiences over their entire childhood [53,65,68]. Four studies in Germany, the U.k. and Japan obtained information from adults about all maltreatment across childhood except EDV [52,58–59,63].

Viii studies involved but child participants anile under 18 providing cocky-report information. 3 studies included child and adult participants each providing self-report data. Five studies involved a household's child participant aged nether 18 providing self-report data (4 involved children anile 10–17 and one involved children aged 11–17) and the household'south parents providing proxy data nigh a kid aged under the cut-off. 5 studies involved only adults providing self-study data (24 twelvemonth olds; eighteen–24 year olds; 20–49 year olds; 18 and over). Sample sizes ranged from 1094 to 12,035 participants. V studies adopted measures to recruit high-adventure sub-populations [48,56,60,62,64].

Seven studies were conducted in schools: Taiwan [56–57], the Netherlands [61]. Switzerland [62], Suriname [64], and the Balkans written report [46]. Xi studies were conducted in households by interviews, in Hong Kong [54–55], Hungary [68], the Britain [51–53], Frg [58–59], Japan [63], Saudi Arabia [65], and South Africa [67]. Five studies used remote computer assisted phone interviews (CATI), with 4 in the Us [47–50], and i in Denmark [60]. Data collection fourth dimension ranged from ane calendar month to two years.

Methodologies to recruit the sample and accommodate high-gamble subpopulations also varied. In most studies, the target population was a close representation of the national population. Studies in schools were done in countries with loftier schoolhouse attendance. All studies used random selection. However, few studies used strategies to capture participants from culturally and linguistically various groups, or from high-risk groups such equally those in out of domicile care.

Response rates for household studies generally ranged from 56% to 78%, with i reporting a participation charge per unit of 94.8% [67]. Rates in schoolhouse-based studies showed schools' participation rate ranging from 49%-79%, so with almost 100% response rates from children in participating schools. Response rates in CATI studies ranged from 60% to 79.five%, with more recent studies having lower rates [47–49].

Regarding consent to participate, xviii of the studies involved kid participants exclusively or with adult participants. Ix studies involved only child participants; in these, two required only the child's consent [56,62], ane required the child's consent and parental passive consent [64], one required the child's consent and either passive or agile parental consent [46], and five required parental active consent and the child's consent [54–55,57,61,66–67].

Of the studies involving child participants, vii reported the measures used by inquiry teams when a child was suspected to have been harmed or at chance [46–50,53,67]. Nine studies reported other measures to assistance whatsoever distressed participants [46,48,52,54,56,60,62,64].

Studies used a range of instruments and approaches to measuring each maltreatment type. Table 2 presents key information extracted from the instrument used in each report. Comprehensive details about the maltreatment items are detailed in the supporting information (S3 File).

8 studies used the Juvenile Victimization Questionnaire (JVQ). These studies used dissimilar versions of the JVQ, either using its original course [72], an enhanced form [48–50], or an adapted version [53,62,66–67]. Two studies used the Conflict Tactics Scale Parent-Child version (measuring physical corruption, emotional abuse, and neglect), and the CTS2 (EDV) [54–55]. 2 studies used the ICAST-C, in either its original course [56] or an adapted version [46]. Two studies used the Childhood Trauma Questionnaire [58–59]. Single studies used the Agin Childhood Experiences International Questionnaire [65], the Adverse Childhood Experiences questionnaire [68], and the Lifestyle and Attitudes Towards Sexual Beliefs musical instrument [63]. Four studies used a alloy of instruments [51,57,61,64]. Two studies used self-adult instruments [52,60].

Six studies did not written report psychometric data on musical instrument validity and reliability. Half-dozen studies reported psychometric data on the musical instrument as used [46,54–56,58,72]. Studies using enhanced or adjusted versions of instruments by and large cited the original instrument'south data only did non report further psychometric tests.

Most studies did not define overarching concepts of each form of maltreatment, instead operationalising these concepts into questions most the participant's experiences. Approaches to some only not all forms of maltreatment broadly aligned with the nature of maltreatment concepts every bit established past the scholarly literature. Approaches to physical abuse and sexual corruption were generally sound. Approaches to the construct and operationalisation of emotional abuse were generally sub-optimal, with some exceptions (eastward.g., [46,52]). Neglect was likewise rarely well-operationalised, with some exceptions (eastward.g., [49,52–53,58–59,66].

Studies explored maltreatment experiences in varying depth, reflected by the number and nature of questions asked (Table 2). For sexual abuse, 12 studies asked between five and viii questions. Most studies asked about the human relationship with the person inflicting the corruption, and the nature of the acts; more half asked almost frequency; but few asked near severity. Other notable differences included: two studies beingness limited to sexual corruption past a parent/guardian [51,threescore]; most studies including contact and non-contact acts, but three studies included contact abuse only [62,65,68]; four studies asking merely one question [51,62–63,68].

For physical abuse, viii studies asked only ane question, although these included multiple distinct concepts [47–51,62,63,68]. Six studies asked between five and 9 questions. Near asked near relationship and nature; more than than half asked about frequency; but few asked about severity. A notable difference was in the treatment of spanking on a child'south lesser: vii studies excluded "spanking on your bottom" from the definition of physical abuse [47–l,53,62,66]; four studies included spanking with a bare hand every bit concrete abuse [46,54–56]; and 4 studies included equally concrete abuse beingness hitting or spanked on the bottom only only when done with an implement or hard object [51,52,57,64].

For emotional or psychological abuse, eight studies asked between five and viii questions. Nigh asked about relationship and nature; more than half asked most frequency; just few asked about severity. Other notable differences included: three studies beingness limited to a unmarried generic question [51,61,64]; seven studies using a unmarried chemical compound question [47–51,62,67]; and only 2 studies using a detailed scale of items closely aligned with a sound conceptual model [46,52].

For fail, 12 studies asked between v and 11 questions. Five studies asked one question [47–48,62,63,68]. Most asked virtually relationship and nature; more than half asked near frequency; merely few asked about severity. Six studies asked detailed questions well-nigh multiple dimensions of neglect, and their severity [49–l,52,58–59,66]. Other notable differences included: some studies operationalising neglect very broadly, including a parent having low aspirations [51], or not helping with homework [64]; just one study asking about educational neglect [64]; and one written report omitting concrete and nutritional neglect [46].

For exposure to domestic violence, half-dozen studies asked between vi and eight questions. Most asked most relationship and nature; more than half asked nearly frequency; but few asked most severity. Notable differences were: two studies used the comprehensive CTS2 calibration of 39 items originally devised for use with adult couples [54–55]; and the original JVQ had two physical set on items [72], and later added vi items almost threats or property damage by other family members [48–l].

Risk of bias

Table three sets out the quality assessment and scoring results for each study. Scores ranged from 6 to 10. About studies had relatively high internal and external validity. We concluded that studies scoring nine.five or 10 had minimal bias. Five studies achieved scores of 10: two in Hong Kong [54–55], and one each in Taiwan [56], Israel [66] and South Africa [67]. Five studies achieved scores of 9.5: iii in the U.s. [48–50], one in the Great britain [53], and the Balkans written report [46]. 5 other studies accomplished scores of ix, from Saudi Arabia [65], the UK [52], Germany [62], Hungary [68], and Taiwan [57]. Four studies scored 7, and two scored half-dozen; here nosotros concluded risk of bias was loftier, especially regarding selection bias and non-response bias.

Discussion

This systematic review identified thirty studies of the prevalence of either four or 5 forms of child maltreatment, conducted in 22 nations. In addition, many other studies have been conducted of 3 or fewer maltreatment types, such as studies of sexual, physical and emotional abuse. These have been conducted on a stand-lonely footing [76], or as office of a systematic campaign supported by a global public individual partnership [77]. By 2019, the Violence Against Children Surveys (VACS), which likewise measure the prevalence of physical, sexual and emotional corruption, had been conducted in 16 countries and were being planned in a further eight countries in Africa, Asia and the Caribbean [30,77–78]. Other studies have considered the prevalence of a mixture of peer violence and maltreatment by parents or caregivers [79–eighty]. Accordingly, a good bargain of evidence has been generated about the prevalence of child maltreatment in several dozen nations, representing substantial progress in the international agreement of the epidemiology of child maltreatment. However, this review has highlighted the fact that the vast bulk of nations lack reliable criterion national prevalence data on a comprehensive assessment of maltreatment, including measurement of four or five of the recognised five types of maltreatment, and almost all lack follow-up studies to found trends over time. This study demonstrates the urgent need to deport more than rigorous prevalence studies, peculiarly those by measuring all relevant types of maltreatment, to generate more than authentic understandings of the extent of maltreatment, and to enable progress in reducing kid maltreatment confronting the SDG target.

Our review also shows that there is substantial variation in report participants beyond the unlike studies, limiting comparability and introducing sure strengths and limitations which are important to consider in designing future work. Several studies obtained data using parents as proxies for children nether 10, and reported reliable responses. This approach may capture data near very young children'southward experiences that is otherwise unattainable, although accurate estimates rely on parents being both knowledgeable and truthful in their responses [47]. Yet, the literature reports no evidence of reporter bias in comparisons of adult proxy and youth self-report data [47,48].

Arguably, from a public health perspective, studies provide most comprehensive and reliable estimates when capturing prevalence data over the unabridged span of childhood up to age 18. Furthermore, where a study's participants are children and or young adolescents, past twelvemonth incidence information is useful. Over half of the studies in this review included children equally respondents. In these studies, responses benefitted from existence directly and proximate to the feel likewise as capturing useful stratified data about single year incidence in a closely contemporaneous time menstruation. Developmental bear witness suggests children'southward and adolescents' participation is entirely appropriate. While adolescents may generally differ from adults in the attainment of psychosocial capacities to understand long-term consequences, regulate conduct, and withstand social and emotional pressures, their cognitive chapters is not essentially unlike from that of adults [81–84]. Similarly, apart from those still in early developmental stages, children's cognition and reliable episodic retentiveness is sufficiently adult to enable participation in survey research [85–86]. This justifies the design of instruments for child and adolescent participants, including the conscientious approach of the developers of the Juvenile Victimization Questionnaire in designing an musical instrument suitable for participants as young as viii [72].

Ethically, at that place is no impediment to involving kid and boyish participants [87]. Adolescents and children are cognitively capable of providing their own consent, and are ethically entitled to do and so as autonomous individuals. Moreover, adolescents and children have rights to freedom of expression, and bear the right of participation in matters affecting them. While there remains no consensus on the most justifiable approach to confidentiality and welfare [87–90], nosotros assert that studies can adopt robust measures to residual imperatives of attaining sufficient study participation, while ensuring participant welfare and confidentiality. While confidentiality is a foundational principle in these studies, the exception to this, conveyed to youth participants at the get-go, that cases of current or imminent meaning adventure of danger may be referred to welfare authorities, has been found not to bear upon response rates [38,53]. Alongside this, studies can adopt stepwise approaches drawing on multiple psychological and legal resources to support participants who disclose severe incidents or who experience distress [87]. Nonetheless, it is important not overstate the frequency of distress. Several studies have establish low rates of distress amid youth participants in studies of maltreatment, and the level of youth distress does not differ significantly from that of adults. Furthermore, even distressed participants mostly maintain their involvement was worthwhile [38,91]. A contempo US study, for example, found only 0.eight% of participants aged x–17 reported being "pretty or a lot" upset past answering the questions, and even this did not unduly affect their reported willingness to participate [91]. An associated finding is that children in high-risk sub-populations, such as those in out-of-dwelling house care, have non been well represented, leading to likely underestimates of prevalence and scarce prove about specific risk profiles.

Studies that rely on adults' retrospective accounts offering the substantial benefit of capturing information about experiences across childhood. I limitation of such studies is that they will not obtain recent proximal data of single year incidence. An boosted potential limitation, yet to be fully analysed, may be that retrospective accounts are affected by various kinds of call back bias. We acknowledge that some have argued that retrospective studies do non provide data about child abuse experiences that is as accurate as prospective studies [92–93] and have cautioned against sole reliance on retrospective accounts, peculiarly where prevalence estimates are used to draw causal inferences about the upshot of maltreatment on biomedical diseases. A recent systematic review and meta-analysis concluded that prospective and retrospective measures of childhood maltreatment identify dissimilar groups of individuals [94]. However, it was also recognised that prospective measures may take lower sensitivity than retrospective measures of the experience of maltreatment, and ended that "the low agreement between prospective and retrospective measures cannot be interpreted to directly indicate poor validity of retrospective measures" and that retrospective measures could take greater ability to identify true cases [94]. The well-known discrepancies between truthful maltreatment rates and those recorded in many data sources used for prospective studies is owing to the depression correlation between actual experiences and their representation in official data such as crime statistics and child protection service records. Few maltreatment experiences are e'er brought to the attention of criminal justice agencies or child protection services. The circumspection urged regarding retrospective reports accordingly appears more directed towards studies considering causation of disease than estimation of population prevalence. It is also accepted that lack of validity tends to underreport the experience of abuse [95–97], and studies of test-retest reliability regarding retrospective accounts have indicated general stability over time [98]. We acknowledge that retrospective reports may have compromised validity for various reasons, including motivational factors and memory biases, and measurement features including poorly worded questions [92,94]. Overall, yet, our view is that retrospective studies of kid maltreatment, particularly when well-designed with behaviourally-specific questions grounded in sound constructs of maltreatment, with representative samples of the population, offering the opportunity to obtain sufficiently accurate estimates of the prevalence of child maltreatment experiences.

The 4th finding is that while considerable investment is required for all kinds of arroyo, viable approaches to survey administration are available for diverse geographical settings to suit big and modest nations, and achieve sufficient participation. The implications of this are clear for future study design. School-based studies appeared most ofttimes in small nations, which may more readily facilitate centralised educational sector endorsement for the research, or which may have a high commitment to social inquiry. When school leaders hold for their school to participate, children mostly participate at a very loftier rate. Similarly, household studies identified in this review generally occurred in pocket-size nations. Both school-based and household studies crave substantial numbers of staff, simply may be most feasible where labour costs are manageable and where the social ecology is of sufficient strength to support and perhaps even require directly personal involvement in such research. In larger nations, for reasons of practicability and price, studies used CATI and achieved satisfactory response rates. Mayhap for reasons of cost, and practical difficulty, a challenge remains to capture the experience of culturally and linguistically diverse sub-populations, and hard to reach groups such as children who are non in school, or who are in out of domicile intendance. Future enquiry could consider optimal local strategies to respond to this challenge.

Our fifth finding is that selection, design and testing of an appropriate instrument appears an enduring challenge. In this regard, ii coexisting needs must be balanced past any study: showtime, to be practicable in terms of the time and price required to design, test and administer an instrument and minimise missing data; and second, to reach sufficient comprehensiveness and ensure construct validity by describing maltreatment types in a manner congruent with conceptual understandings [33]. Our review showed that a wide variety of instruments have been used, with psychometric data oftentimes not reported. The JVQ was the instrument about often used in either full-class or brusque-form; moreover, several studies adapted the original JVQ, sometimes calculation a considerable number of items. These adapted versions did not announced to have been subjected to testing. While inconsequential modification of a proven musical instrument obviates the need for re-testing, substantial modification may exist further supported past cerebral testing and test-retest reliability. What is relatively clear is that a proven, sound musical instrument offers both practicable and methodological benefits over a blended tool, or a new unproven instrument.

Our sixth finding is that instruments must soundly operationalise constructs of each maltreatment type by describing them in a style coinciding with sound conceptual understandings. This review and critical appraisement constitute that instruments well-nigh often adopted unsound constructs and operationalisation of neglect, and emotional corruption. In particular, many studies did not consider sufficient operational categories of these maltreatment types every bit required by sound conceptual models, which will lead to under-estimates of prevalence, and volition miss the opportunity to capture important data about the nature of specific experiences. Other studies used broad or vague conceptual expressions, which will have the reverse effect of over-estimating prevalence. This finding provides a contextual demonstration of the problem of unsound constructs compromising reliability and validity in general [33,34], and of the ongoing challenge to this field to adopt sound constructs of maltreatment and sound behaviourally-specific examples of these constructs [99]. Additionally in this regard, many studies asked only one question about a maltreatment type, which leads to underestimates of prevalence [36]. Single-item assessment, fifty-fifty through a compound question involving multiple elements of a construct, cannot capture accurate or nuanced data and should be avoided wherever possible. Finally, we found few questions nearly educational neglect. Arguably, since education is a human being right recognised by the United Nations Convention on the Rights of the Child article 28, and is a status for human flourishing [100] and a protective gene confronting multiple adversities such as child marriage [101], this is a meaning dimension of neglect warranting greater priority. Nosotros recommend particularly close attention to how future studies conceptualise and operationalise these forms of maltreatment.

A seventh finding is that few studies asked detailed follow-up questions about the child'southward relationship with the person inflicting the acts, and the severity and frequency of the acts. Generally, studies using the JVQ asked the virtually detailed follow-upward questions. Obtaining information about the severity, frequency, timing, and relational setting of abuse and neglect is important, since the closeness of the human relationship between the person maltreating the child and the child can have significant effects [102–103], and the timing of maltreatment is too of import, with studies finding effects for both sexual practice and age [104]. From a public health perspective, the measurement of maltreatment should ideally move beyond raw prevalence, and yield sufficiently sensitive and nuanced information about these primal contextual features of the maltreatment to inform future public health policy and prevention efforts, including the indication of priority areas for responses. The addition of such questions presents challenges for instrument pattern and implementation, including the time to administer boosted questions. However, nosotros recommend such questions wherever possible.

Limitations

We reviewed studies measuring the traditional forms of child maltreatment, and excluded studies of adverse childhood experiences conceptualised more than broadly, such as peer bullying and community violence. Some researchers recommend that studies include both maltreatment and these other adversities [37] on the basis that chronic exposure to multiple adversities influences developmental trajectories through the lifespan. Still, we applied rigorous eligibility criteria of 4 or five of the recognized maltreatment categories, all conspicuously associated with adverse sequelae, and which nearly closely reflect specific SDG targets of caregiver abuse and whatsoever sexual violence. Contempo outcomes of the ACE study itself have only focused on these v types and three classes of household dysfunction [18]. Additionally, our data extraction method for the quality assessment was not formally validated, just we adopted an approach similar to that used elsewhere [32,35,45] considering key variables in detail. Similarly, while there were no previously validated adventure of bias measures for this specific type of prevalence study, we used a method with loftier interrater agreement that has been used elsewhere [45], including in prevalence studies of abuse and interpersonal violence [105–106]. Our approach to risk of bias adopted a conservative approach, and reasonably concluded that studies scoring 9.v or 10 had minimal bias.

Conclusions

This systematic review and analysis has shown nationwide studies of the prevalence of kid maltreatment take been conducted, using methods of administration suited to the setting, and involving kid participants, adult participants, or both. However, there are few such nationwide studies of all five or even 4 maltreatment types, leaving substantial gaps in knowledge well-nigh the feel of childhood maltreatment in nearly all countries. Overall, our review and analysis indicates many of the completed studies are more often than not sound, but some take a more comprehensive and conceptually robust approach to provide nuanced, useful data for researchers and policymakers. To enable measurement of progress against the United Nations Calendar for Sustainable Development Goal 16 of reduction of child corruption, many countries need to invest in robust national prevalence studies. Such studies should mensurate exposure to domestic violence in addition to concrete abuse, sexual corruption, emotional abuse, and neglect. Studies should use an musical instrument with demonstrated validity and reliability, and must ensure maltreatment types are operationalised appropriately in the questions asked. If participants are children or adolescents nether age eighteen, studies should capture past year incidence, besides as childhood prevalence. Data should be captured about the specific nature, severity and frequency of the maltreatment, and the relationship of the kid to the person who inflicted the acts. Such data can best inform the evolution and monitoring of nationwide prevention efforts.

Supporting information

Acknowledgments

We acknowledge Juliet Davis, Elizabeth Dallaston, and Andrea Boskovic for providing research assistance. We also thank the journal reviewers for their helpful comments.

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