2 years ago, The Lancet published a Series of four reports on child maltreatment.1, 2, 3, 4 The Series was intended to provide professionals with a rigorous and up-to-date overview of the scientific evidence. 1 year on, The Lancet asked leading professionals in child health and welfare what question they most needed answered by the scientific published work. Their response, “Are trends in child maltreatment decreasing?”, is addressed by this Review.
Whether trends in child maltreatment are changing is of great importance for children and their families, and for those whose job it is to reduce maltreatment and its consequences. Policy makers and professionals involved in child protection services will hope for a downward trend to vindicate the cost, effort, and painful media scrutiny that they have endured.5 Public health practitioners will draw attention to the contribution of economic and welfare changes, legislation against corporal punishment, and initiatives to improve child wellbeing and parent functioning.5, 6, 7 Over the past 30 years, developed countries' tolerance of child maltreatment has decreased sharply.8 Another major shift has been the broadening of responsibility to all professionals to be alert to the possibility of child maltreatment and to act when they have concerns.9
However, increased responsiveness to child maltreatment inflates the number of reported cases throughout the system.10 The result is more notifications to child protection agencies, more concerns recorded by professionals, and more interventions, including placement of children in care, than previously.10, 11 Expansion of definitions of maltreatment to include emotional abuse and witnessing of intimate partner violence, and changing thresholds for moving from recognition to recording and action, have further increased rates.10, 12, 13, 14 This report addresses these issues in three ways. First, we tried to minimise reporting biases by comparing trends with multiple measures of child maltreatment within a specific country. Second, we examined differences between six countries or states. Our underlying premise is that comparison of trends in countries with similar challenges but different policies provides a natural experiment that could provide insight into the effects of policies. Third, we used routinely recorded data sources and standardised definitions in each country and examined the extent to which variation in indices of child maltreatment is likely to be explained by true differences in occurrence—possibly linked to policy differences—or by random chance, data quality, or case mix.
Key messages
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We recorded no consistent evidence for a decrease or increase in all types of indicators of child maltreatment across the six countries or states (Sweden, England, New Zealand, Western Australia, Manitoba [Canada], and the USA) despite several policy initiatives designed to achieve a reduction.
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Large differences between countries in the rate of contacts with child protection agencies contrasted with little variation in rates of maltreatment-related injury or violent death. This discrepancy shows that governments' responses differ.
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Overall, one or more child protection agency indicators (notification, investigation, officially recognised physical abuse or neglect, or out-of-home care) increased in five of six countries and states, particularly in infants, possibly as a result of early intervention policies.
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Lower levels of maltreatment indices in Sweden than in the USA are consistent with lower rates of child poverty and parent risk factors and policies providing higher levels of universal support for parenting in Sweden.
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High and rising rates of out-of-home care affect a substantial minority of children, especially those of non-white or Aboriginal origin, despite no policy advocating this option and little evidence for its effectiveness.
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To improve the evidence base for child protection policies, governments should facilitate use of anonymised, linked, population-based data from health-care and child protection services to establish the effect of policy on trends in child maltreatment. Rising placements of children in out-of-home care demand urgent assessment with randomised controlled trials.