Youth self-report of child maltreatment in representative surveys: a systematic review

Jessica LaurinFootnote *, MA; Caroline WallaceFootnote *, BSc; Jasminka Draca, BHSc; Sarah Aterman, BAH; Lil Tonmyr, PhD

https://doi.org/10.24095/hpcdp.38.2.01

This evidence synthesis has been peer reviewed.

Author references:

Public Health Agency of Canada, Ottawa, Ontario, Canada

Endnote *

These authors contributed equally to this work.

Return to first endnote * referrer

Correspondence: Lil Tonmyr, Public Health Agency of Canada, 785 Carling Ave, 7th floor, Ottawa, ON K1A 0K9; Tel: 613-240-6334; Email: Lil.Tonmyr@canada.ca

Abstract

Introduction: This systematic review identified population-representative youth surveys containing questions on self-reported child maltreatment. Data quality and ethical issues pertinent to maltreatment data collection were also examined.

Methods: A search was conducted of relevant online databases for articles published from January 2000 through March 2016 reporting on population-representative data measuring child maltreatment. Inclusion criteria were established a priori; two reviewers independently assessed articles to ensure that the criteria were met and to verify the accuracy of extracted information.

Results: A total of 73 articles reporting on 71 surveys met the inclusion criteria. A variety of strategies to ensure accurate information and to mitigate survey participants' distress were reported.

Conclusion: The extent to which efforts have been undertaken to measure the prevalence of child maltreatment reflects its perceived importance across the world. Data on child maltreatment can be effectively collected from youth, although our knowledge of best practices related to ethics and data quality is incomplete.

Keywords: abuse, neglect, violence, data quality, ethics, adolescence, teenager, systematic review

Highlights

  • Data on child maltreatment can be collected responsibly and ethically from youth in a way that protects their health and well-being.
  • Youth rarely expressed concerns about answering child maltreatment questions on self-report surveys.
  • No nationally representative self-report survey focussed on Canadian youth that includes child maltreatment variables was identified from our database search.
  • Few reliable and valid self-reported measures of child maltreatment currently exist.

Introduction

The consequences of child maltreatment—a public health issue that poses unique challenges to quantify and study—extend well beyond the immediate harm inflicted. For example, a history of child maltreatment has been shown to interfere with adolescent development and to raise the risk of some of the leading causes of morbidity and mortality.Footnote 1 These include alcohol-related injury, drug use, self-harming behaviour, suicide and exposure to violence.Footnote 2,Footnote 3,Footnote 4,Footnote 5

A growing body of research is aimed at estimating the extent of child maltreatment, and understanding the dynamics and mechanics of its association with health outcomes.Footnote 6 Population-representative surveys provide the opportunity to quantify child maltreatment prevalence and to assess its risk in relation to other health-related and social conditions. Of course, in surveys that address a broad range of health-related content, space limitations and competing interests challenge the inclusion of child maltreatment measures. However, the potential contribution of such surveys in improving our understanding of the prevalence, risk factors and impact of child maltreatment is becoming increasingly appreciated—both in Canada and elsewhere.Footnote 7 Population-based data from other countries provide the basis for international comparisons, from which the influence of cultural, social and policy practices on any differences observed can be considered.Footnote 8,Footnote 9

The ethical aspects of child maltreatment survey research are crucial. The sensitive nature of the subject matter and the consequential risk of emotional distress to respondents call for measures to protect confidentiality, administer questions with appropriate sensitivity, obtain informed consent, and potentially provide follow-up interventions.Footnote 10 Procedures to address such matters should be clearly delineated, and included as an elemental component of any survey or research report.

Quality of data is an important consideration and should be evaluated in any survey-based research on child maltreatment. Various factors influence the quality of information a respondent provides, such as age and developmental stage. Surveying young people about experiences of child maltreatment has the advantage of being relatively recent to the exposure, so recall bias is likely lower than it would be in a survey of adults. The reliability of self-reported information from adolescents is greater than that from younger children, by virtue of their more advanced cognitive development.Footnote 11 Specifically, research suggests that children under the age of 10 years may not be reliable respondents for a survey on experiences of maltreatment.Footnote 12 Other potential impediments to the disclosure of accurate information include distress, discomfort and embarrassment generated by the memory of events.Footnote 13,Footnote 14,Footnote 15,Footnote 16

A review article published in 2000 addressed methodological and ethical considerations in asking children about their exposure to physical and sexual abuse.Footnote 17 The authors identified 14 self-report studies that garnered information directly from children; the approaches used to elicit information varied greatly.Footnote 17 While the review provides much worthwhile information, it was limited to surveys conducted before 1999; the surveys focussed on physical and sexual abuse and were not representative of the general population. The authors noted considerable variation in data collection methods, wording and number of maltreatment questions as well as consent procedures. Consequently, the estimates of physical and sexual abuse varied considerably.

This systematic review is aimed at increasing our understanding of child maltreatment data captured in self-reported surveys with youth. The specific objectives are to (1) identify representative surveys that have collected data from youth on child maltreatment and factors influencing prevalence (thus not clinical samples); (2) examine the quality of methods used to measure child maltreatment; and (3) assess practices and procedures undertaken to address ethical issues.

Methods

This systematic review was done according to the PRISMA guidelines.Footnote 18 (Protocol is available upon request from the corresponding author).

Identification (search strategy)

A search for peer-reviewed articles published from January 2000 through March 2016 was conducted in the following online databases: Embase, Medline, PsycINFO, Global Health, Social Policy and Practice, ERIC, Social Services Abstracts, Sociological Abstracts, and ProQuest Public Health. Search terms used included: youth, adolescent, young adult, child, abuse, maltreatment, violence, neglect, assault, rape, representative, national, and school surveys. The complete search strings employed are available upon request from the corresponding author. In addition, the reference lists of included articles were examined to identify additional articles for potential inclusion as well as discussions with experts.

The following were the criteria for inclusion of articles in the review:

  • published in English;
  • primary study (i.e. not review or editorial);
  • data collected after 1999;
  • data sources limited to school or representative population-based surveys (the latter defined as those which were described that way by the authors of the articles and/or had been sampled and weighted in order to accurately reflect the members of the entire population);
  • cross-sectional design;
  • age range of respondents was 10 to 18 years (core age group); in some cases, age ranged up to 24 years;
  • victim's age at time of exposure to maltreatment was under 18 years;
  • reported perpetrator of maltreatment was a parent or other caregiver (except for sexual abuse, for which the perpetrator could be anyone, however articles were still not included if they focused on peer or online victimization);
  • analysis was conducted using the entire sample of the specified age group (ages 10 to 18).

It should be noted that we limited the inclusion to cross-sectional studies to ensure the inclusion of the largest numbers of surveys. In addition, since the primary purpose of this article is not to determine associations but instead the feasibility of collecting child maltreatment data from youth to estimate prevalence, cross-sectional studies are appropriate. The benefit of including longitudinal studies would be limited, considering that child maltreatment questions are rarely asked in the first wave of a longitudinal study but rather in the later waves where attrition may be an issue.Footnote 19,Footnote 20

Screening/eligibility (selection process)

Figure 1 shows the process of selecting the articles included in this study. The database search identified 4383 articles; expert consultation and search of reference lists identified another 31 articles. Removing duplicates yielded 3885 articles, and screening by titles and abstracts led to 220 articles to be fully assessed. To these articles, the inclusion criteria noted above were applied by two reviewers independently (J.L., L.T.). The percentage agreement between the coder pairs was 97.9% for titles and abstracts. Articles were excluded when the articles addressed adults' retrospective reports of childhood maltreatment, substance abuse, non-representative samples, newspaper articles, conference abstracts, commentaries, and letters to the editor. Each reviewer also catalogued the reported prevalence of maltreatment by type. Although specific definitions of child maltreatment varied somewhat among the articles, they were conceptually similar enough that the Public Health Agency of Canada's (PHAC) classifications could be applied such as emotional maltreatment (EM), neglect (NG), exposure to intimate partner violence (EIPV), physical and sexual abuse (PA and SA)Footnote 21 (Table 1).

Figure 1. Flow of information through the different phases of the review

Figure 1. Flow of information through the different phases of the review. Text description follows.
Figure 1: Flow of information through the different phases of the review - Text Description

This figure shows the process of selecting the articles included in this study. The database search identified 4383 articles; expert consultation and search of reference lists identified another 31 articles. Removing duplicates yielded 3885 articles, and screening by titles and abstracts led to 220 articles to be fully assessed. Of these, 73 met the inclusion criteria, representing 71 surveys.

Table 1. Definition of child maltreatment
Types of maltreatment Forms of child maltreatment Questions used to measure child maltreatment
Sexual abuse Kissing, caressing, fondling and oral sex How many times has another person touched, grabbed, pinched or brushed against you in a sexual way (which you did not want)?Footnote 22
Students were asked by their parents to touch the latter's sex organs, or if their own sex organs have been touched by their parents.Footnote 23
Episodes of unwanted oral sex.Footnote 4
Attempted rape and rape Attempts intercourse, completed intercourse and attempts at anal intercourse.Footnote 24
We define [rape] as someone either having sexual intercourse with you or penetrating your body with a finger or object when you did not want them to, either whether by threatening you, by using force or when you were so small that you didn't know what was happening.Footnote 25
Somebody tried to undress you in order to have sex with you, had vaginal intercourse [against your will].Footnote 26
Exposure to pornography, masturbation, flashing Did anyone show you pornographic material?Footnote 27
Somebody exposed himself/herself indecently to you [against your will].Footnote 26
Did anyone make you look at their private parts by using force or surprise, or by "flashing" you?Footnote 12
Verbal sexual abuse How many times have you had unwanted sexual comments or jokes directed at you?Footnote 22
Did anyone hurt your feelings by saying or writing something sexual about your body?Footnote 12
Online victimization Did anyone on the Internet ever ask you sexual questions about (himself/herself/yourself) or try to get you to talk online about sex when you did not want to talk about those things?Footnote 28
Nude photograph(s)/video(s) being uploaded on the Internet against your will.Footnote 29
Commercial sex Have you ever experienced that the person/s you met [online] gave you money or a gift in order to have sex with you?Footnote 26
To be engaged in transactional sex.Footnote 30
Self-defined Have you ever been sexually abused?Footnote 1
Physical abuse Corporal punishment/physical punishment Your parents spank you on the bottom with their bare hands, hit you on the bottom with something like a belt, ruler, a tick, sweeper or some other hard object, slap you on the hand, arm or leg, pinch you or shake/push you?Footnote 31
Severe physical punishment resulting in bruises or other forms of injuries.Footnote 32
Acts traditionally seen as forms of corporal punishment: hair pulling, whipping, smacking.Footnote 33
Slapped/hit with hand or hard object, punched, beaten Physical maltreatment and severe physical maltreatment like slapping, hitting [...] and [...] beating.Footnote 34
Being beaten [...] by a family member.Footnote 35
Thrown, pushed, knocked down, shaken, kicked Has any adult ever [...] thrown something at you? (followed by question to specify the caregiver).Footnote 36
Being thrown across the room or against the wall, car, floor or other hard surface by an adult in charge, so that [you] were hurt pretty badly.Footnote 4
Burned, scalded, choked, head held under water, tied up "Severe physical maltreatment such as [...] burning."Footnote 34
Being grabbed around the neck or choked by an adult in charge.Footnote 4
Your parents grab you around the neck and choke you, burn or scald you on purpose.Footnote 31
Used weapon against Has any adult [...]threatened you with a weapon, such as a knife, stick, a gun?Footnote 36
Attacked or threatened with a gun, knife, other weapon or other object?Footnote 4
Self-defined Having experienced physical violence or having experienced severe physical violence.Footnote 15
Emotional maltreatment Verbal abuse, belittling An adult made child scared or feel really bad by name calling, saying mean things.Footnote 1,Footnote 13
Did you get scared or feel really bad because grown-ups in your life called you names, said mean things to you?Footnote 37
Terrorized, threatened Threatening to use a gun or knife.Footnote 38
 Your parents threaten to spank or hit you but did not actually do it.Footnote 23
Inadequate nurturing/affection Not talking to the child.Footnote 39
Did you get scared or feel really bad because grown-ups in your life [...] say they didn't want you?Footnote 37
Isolated/confinement Isolated, confined in a dark room.Footnote 32
Neglect Supervisory Having inadequate supervision and being required to do age-inappropriate chores.Footnote 40
Physical When someone is neglected it means that the grown-up in their life did not take care of them the way they should [...] [by] make[ing] sure they have a safe place to stay.Footnote 37
Not receiving adequate food or clothing.Footnote 40
Medical When someone is neglected it means that the grown-up in their life did not take care of them the way they should [...] [by] taking them to the doctor when they are sick.Footnote 37
Exposure to intimate partner violence Physical abuse The young person witnessed his/her parents physically abusing each other.Footnote 41
Adolescent observed parents punched, hit or beat up one another, choked one another, hit one another with an object.
Emotional maltreatment Asked whether if they had ever [...] witnessed severe arguments between their parents.Footnote 2
Adolescent observed parents [...] threatening one another with gun, knife or other weapon.Footnote 4

We modified a coding key previously used in assessing adults' retrospective exposure to childhood maltreatment.Footnote 6 Reliability and validity of the maltreatment measures were noted when reported. Documentation of procedures related to ethics focused on any steps taken to protect confidentiality, offer respondents support, or ease their distress during/following the survey (see Table 2). Information related to survey administration and measures to evaluate data quality were collected from the articles. As well, external sources (e.g. articles or websites) cited in the articles were consulted for information regarding validity and reliability of child maltreatment measures; in some cases, these sources also provided insights into how maltreatment was conceptualized for a survey, or clarified survey procedures. When information in an article included in the review was inconsistent with that provided in an external source, the former took precedence; if information in articles selected for review and pertaining to the same survey conflicted, the article more closely addressing the objectives of the study was used.

As a final step, to verify that the selected articles met the inclusion criteria and to ensure the accuracy of all extracted information, the articles were assessed by two additional reviewers (C.W., S.A., or J.D.); any disagreements were discussed until consensus was reached.

Table 2. Approaches to increase respondent's comfort and response rate
Definitions
Approaches to increase comfort Assent: Participants who are legally too young to give informed consent, express willingness to participate in research, since they are old enough to understand the purpose of the research.
Consent: Voluntary agreement of an individual, or his or her authorized representative, who has legal capacity to give consent.
Active consent: Parent or legal guardian is required to sign and return a form if they approve their child's participation.
Passive consent: Parent or legal guardian is required to notify the school or researchers if they refuse to allow their child's participation in the research.
Confidentiality: Measures undertaken to protect secrecy after the data were collected.
Privacy: Measures taken to ensure respondent privacy during data collection.
Anonymity: No identifying information was collected.
Safe settings: The presence of reassuring figures such as teachers and nurses, and also environmental features to maximize the participant's comfort.
Voluntary: The choice of participating in the study was left to the participant.
Withdraw: Participants were notified they could terminate the survey at any time during data collection.
Approaches to increase response rate Incentive: Material reward offered to participate in the study.
Time to complete questionnaire: Time needed to finish survey was recorded.
Call-backs: Participants unavailable at the time of data collection were contacted later and given a chance to participate.

Results

From the 3885 articles identified in the online search, 220 were screened in according to the abstract and title. Of these, 73 met the inclusion criteria, representing 71 surveys. Table 3 describes the characteristics of each sample, survey methodology, measures of child maltreatment, reliability and validity, response rates and any steps taken to enhance the response rate, approaches and protocols designed to comfort or reduce the distress of participants, and types of child maltreatment. Schools were most often the place of data collection. Most data were collected via self-administered questionnaire, data were also provided by face-to-face and telephone interviews independent of location. Eleven measures were used and often modified from the original iteration. The Juvenile Victimisation Questionnaire (JVQ) was used most often (eight times), followed by different versions of the Conflict Tactics Scale (CTS) (six times) and the International Society for the Prevention of Child Abuse and Neglect child abuse screening tool—Child (ICAST-CH) (four times). Thirty-seven articles did not provide any information on the specific measures used. In addition, few articles provided information regarding the reliability and validity of measures used. Respondents' response rates ranged from 40.4% to 99.9%. The majority of articles mentioned approaches taken to comfort respondents, although specific information on procedures to reduce distress was scarce.

Table 3. Characteristics of reviewed studies
Country References Survey name and year Method of data collection Sample characteristics Child maltreatment measures and reliability and/or validity Response rate Approaches Procedures to deal with participant distress Child maltreatment types
to increase response rate to increase comfort SA PA EM NG EIPV
Incentive Time to complete questionnaire Call-back Assent Consent Confidentiality Privacy Anonymity Safe settings Voluntary Withdraw
Brazil

Horta et al., 2014Footnote 42

Malta et al., 2014Footnote 43

National Adolescent School-based Health Survey [PENSE], 2012 Self-administered questionnaire 109 104 students, grade 9 Table 3 footnote Student: 83% Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote N/A N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote N/A N/A N/A
Canada

Saewyc & Tonkin, 2008Footnote 1

Tonkin et al., 2004Footnote 44

Tonkin, 2005Footnote 45

Saewyc et al., 2006Footnote 46

British Columbia Adolescent Health Survey (BC AHS), 2003 Self-administered questionnaire ≈ 30 500 students grade 7–12 Table 3 footnote School: 76.3% Table 3 footnote < 45 min Table 3 footnote N/A P Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Provided respondents with information of support services; gave sensitivity training to interviewers. Table 3 footnote N/A N/A N/A N/A

Saewyc & Chen, 2013Footnote 22

Saewyc &Green, 2009Footnote 47

BC AHS, 2008 Self-administered questionnaire 29 315 students age 12–19 Table 3 footnote

School: 84.7%

Student: 66%

Table 3 footnote < 45 min Table 3 footnote N/A Y/P Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A Provided respondents with information of support services; gave sensitivity training to interviewers. Table 3 footnote N/A N/A N/A N/A
Cyr et al., 2013Footnote 37 Quebec, 2009 Telephone interview 1400 youths age 12–17 JVQ (adolescent version) Table 3 footnote Table 3 footnote 23 min Table 3 footnote N/A N/A Table 3 footnote N/A Table 3 footnote N/A N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
China Lau et al., 2005Footnote 48 Survey of Drug Use Among Students, 2000 Self-administered questionnaire 93 060 students age 12–19 Table 3 footnote Student: 87.3% Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote N/A N/A N/A
Chan et al., 2013Footnote 29 2009-2010 Self-administered questionnaire 18 341 students age 15–17 in 6 Chinese cities JVQ
α 0.97 (modified SA)
Student: 95.8% Table 3 footnote Table 3 footnote Table 3 footnote N/A Y N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Provided respondents with information of support services;  gave sensitivity training to interviewers. Table 3 footnote N/A N/A N/A N/A
Chan, 2011Footnote 34 2004 Face-to-face interview 1094 Chinese children age 12–17

CTS
EIPV: α 0.76–0.89

CTSPC
α 0.82–0.88

Student: 70.0% Table 3 footnote Table 3 footnote Table 3 footnote N/A Y/P Table 3 footnote N/A N/A N/A N/A N/A Provided respondents with information of support services. N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote

Leung et al., 2008Footnote 31

Wong et al., 2009Footnote 23

Tang, 1994 in Tang, 2006Footnote 49

2005 Self-administered questionnaire 6593 students age 12–16 CTSPC
α 0.70–0.86
School: 89.0% Student: 99.7% Table 3 footnote 30 min Table 3 footnote N/A Y Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A
Croatia Aberle et al., 2007Footnote 32 2005 Self-administered questionnaire 2140 students age 14 and 18 Table 3 footnote Table 3 footnote Table 3 footnote 45 min Table 3 footnote N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A
Ajdukovic et al., 2013Footnote 50 2011 Self-administered questionnaire 3175 students age 11, 13 and 16 ICAST-CH modified
SA: α 0.68
Table 3 footnote Table 3 footnote 45 min Table 3 footnote N/A P/Y Table 3 footnote ,Table 3 footnote a N/A Table 3 footnote Table 3 footnote N/A N/A Provided respondents with information and telephone numbers of appropriate support services. Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A
Denmark Ellonen et al., 2011Footnote 33 Danish Youth Health Survey, 2008 Self-administered questionnaire 3943 students age 15–16 Danish CTS School: 35.0%
Student: 82.0%
Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A Table 3 footnote N/A N/A N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A Table 3 footnote
Helweg-Larsen & Larsen, 2006Footnote 24
Helweg-Larsen et al., 2011Footnote 51
Frederiksen et al., 2008Footnote 52
2002 Self-administered questionnaire 6203 students age 15–16 Table 3 footnote School: 56.0% Table 3 footnote Table 3 footnote Table 3 footnote N/A Y Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Provided respondents with information of support services. Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote
Van Gastel et al., 2013Footnote 53 Public Health Service School, 2007 Self-administered questionnaire 10 324 students age 11–16 Table 3 footnote School: 71.0%
Student: 84.0%
Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A N/A Table 3 footnote Table 3 footnote N/A N/A Provided respondents with information of support services. Table 3 footnote N/A N/A N/A Table 3 footnote
Finland Ellonen et al., 2011Footnote 33 The Finnish Child Victim Survey, 2008 Self-administered questionnaire 5762 students age 15–16 Finnish CTS School: 88.0% Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A Table 3 footnote N/A N/A N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A Table 3 footnote
Lepistö et al., 2010Footnote 38
Sariola & Uutela, 1992Footnote 54
2007 Self-administered questionnaire 1393 students age 14–17 Table 3 footnote Student: 78.0% Table 3 footnote Table 3 footnote Table 3 footnote N/A Y Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A Table 3 footnote
Ghana Ohene et al., 2015Footnote 55
WHO, 2017Footnote 56
Ghana Global School-Based Student Health Survey (GSHS), 2012 Self-administered questionnaire 1984 senior school students Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A P N/A N/A Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Germany Bussmann, 2004Footnote 39 2002 Face-to-face interview 2000 youths age 12–18 Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A N/A N/A N/A N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A Table 3 footnote
Greece Fotiou et al., 2014Footnote 57 Greek Nationwide School Survey on Substance Use, 2011 Self-administered questionnaire 24 006 students age 15–19 N/A School: 91.0%
Student: 86.4%
Table 3 footnote Table 3 footnote Table 3 footnote N/A P/Y N/A N/A Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote N/A Table 3 footnote N/A N/A
Haiti Flynn-O'Brien et al., 2016Footnote 58 Violence Against Children Survey, 2012 Face-to-face interview 2916 youths age 13–24 Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A P/Y Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A Provided respondents with information of appropriate support services; alerted appropriate authorities. N/A Table 3 footnote N/A N/A N/A
Iceland Asgeirsdottir et al., 2011Footnote 2 2004 Self-administered questionnaire 9085 students age 16–19 Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A Y N/A Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote Provided respondents with information of support services. Table 3 footnote N/A N/A N/A Table 3 footnote
India Patel & Andrew, 2001Footnote 59 General Health Questionnaire (GHQ), 2000 Self-administered questionnaire 811 students grade 11 Table 3 footnote Table 3 footnote Table 3 footnote 90 min Table 3 footnote N/A N/A N/A N/A Table 3 footnote Table 3 footnote N/A N/A Provided respondents with information of support services. Table 3 footnote N/A N/A N/A N/A
Iran Mahram et al., 2013Footnote 60 2011 Self-administered questionnaire 1028 students age 9–13 α 0.83–0.98 Table 3 footnote Gift Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote N/A N/A N/A N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A
Kenya Seedat et al., 2004Footnote 35 2000 Self-administered questionnaire 901 students grade 10 LEQAV Table 3 footnote Table 3 footnote 45–60 min Table 3 footnote P N/A N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote
Okech, 2012Footnote 61 2009-2010 Self-administered questionnaire 430 students age 10–16 My Worst Experiences Scale Student: 71.6% Table 3 footnote Table 3 footnote Table 3 footnote Y P N/A N/A N/A Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Mexico Borges et al., 2008Footnote 25 Mexican Adolescent Mental Health Survey, 2005 Face-to-face interview 3005 youths age 12–17 Table 3 footnote Youth: 71% Table 3 footnote 150 min Table 3 footnote Y P N/A N/A N/A N/A N/A N/A Provided respondents with information of support services. Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote
Pineda-Lucatero et al., 2009Footnote 27 2002 Self-administered questionnaire 1067 students age 11–20 Table 3 footnote Student: 89.1% Table 3 footnote Table 3 footnote Table 3 footnote N/A Y,P,T,S Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A Alerted appropriate authorities. Table 3 footnote N/A N/A N/A N/A
Frias & Erviti, 2014Footnote 62 National Survey on Exclusion, Intolerance and Violence in Public High School Level Education, 2007 Self-administered questionnaire 13 440 students age 15–18 Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A N/A N/A N/A N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote
Malaysia Ahmad et al., 2014Footnote 63 Malaysia Global School-Based Student Health Survey-2012 Self-administered questionnaire 25 174 students age 12–17 N/A Student: 99.1% Table 3 footnote Table 3 footnote Table 3 footnote N/A P/Y N/A N/A Table 3 footnote N/A N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A
Ahmed et al., 2015Footnote 64 2011 Self-administered questionnaire 3509 students age 10–12 ICAST-CH: Child Exposure to Domestic Violence Scale Student: 88.9% Table 3 footnote Table 3 footnote Table 3 footnote N/A S/P Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A Provided respondents with information of support services. N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
Netherlands Klein et al., 2013Footnote 65 Questionnaire on experience and events in high school students in Curaçao Self-administered questionnaire 545 students age 11–17 Table 3 footnote Table 3 footnote Table 3 footnote 45 min N/A N/A P Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A
New Zealand Denny et al., 2011Footnote 66
Fleming et al., 2007Footnote 67
Adolescent Health Research Group, 2008Footnote 68
Youth'01 and Youth'07 Self-administered questionnaire 2001: 9699 students age 13–17

2007: 9107 students age 13–18
Table 3 footnote School:
2001: 86.0%
2007: 84.0%

Student:
2001: 64.0%
2007: 62.0%
Table 3 footnote Table 3 footnote Table 3 footnote N/A S/P/Y Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A Table 3 footnote
Peru Fry et al., 2016Footnote 69 National Survey on Social Relations, 2013 Face-to-face interview 1498 youths age 12–17 Table 3 footnote Youth: 99.9% Table 3 footnote Table 3 footnote Table 3 footnote N/A Y Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote Alerted appropriate authorities; gave sensitivity training to interviewers; provided respondents with information of support services. Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote
Saudi Arabia Al-Quaiz & Raheel, 2009Footnote 70 2008 Self-administered questionnaire 419 female students age 11–21 Table 3 footnote Student
80.0–90.0%
Table 3 footnote 15 min Table 3 footnote N/A N/A Table 3 footnote N/A N/A Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Al-Eissa et al., 2016Footnote 71
ISPCAN, no dateFootnote 72
2012 Self-administered questionnaire 16 939 students age 15–19 ICAST-CH
α 0.69–0.86
Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Y P Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote Gave sensitivity training to interviewers; provided respondents with information of support services. Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
Sri Lanka Rajindrajith et al., 2014Footnote 73 N/A Self-administered questionnaire 1792 youths age 13–18 Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A P/Y N/A N/A Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A
South Africa Seedat et al., 2004Footnote 35 2000 Self-administered questionnaire 1140 students grade 10 LEQAV Table 3 footnote Table 3 footnote 45–60 min Table 3 footnote P N/A N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote
Andersson & Ho-Foster, 2008Footnote 74 2002 Self-administered questionnaire 126 696 male students age 10–19 Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Pettifor et al., 2005Footnote 30 National Household Survey, 2003 Face-to-face interview 11 904 youths age 15–24 Table 3 footnote Youth: 77.2% Table 3 footnote Table 3 footnote Table 3 footnote N/A P/Y N/A Table 3 footnote N/A N/A N/A N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Waller et al., 2014Footnote 75
Young Carers Project South Africa, 2016Footnote 76
Teen Talk 2010-2011 Self-administered questionnaire 3515 youths age 10–17 UNICEF Scales for Sub-Saharan Africa: Child Exposure to Community Violence Checklist Youth: 97.2% Refreshment 40–60 min Table 3 footnote N/A P/Y Table 3 footnote ,Table 3 footnote a Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote Alerted appropriate authorities. Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote
Swaziland Breiding et al., 2013Footnote 36 2007 Face-to-face interview 1292 females age 13–24 Table 3 footnote Youth: 96.3% Table 3 footnote Table 3 footnote Table 3 footnote N/A P/Y Table 3 footnote Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote Provided respondents with information of support services; gave sensitivity training to interviewers. Table 3 footnote Table 3 footnote N/A N/A N/A
Sweden Priebe & Svedin, 2012Footnote 26
Mossige et al., 2007Footnote 77
2009 Self-administered questionnaire 3432 students age 18 Table 3 footnote School: 60.5% School compensated Table 3 footnote Table 3 footnote N/A Y N/A N/A Table 3 footnote N/A Table 3 footnote N/A Provided respondents with information of support services. Table 3 footnote N/A N/A N/A N/A
Taiwan Yen et al., 2008Footnote 78 Project for Health of Adolescents, 2003 Self-administered questionnaire 1684 students age 13–18 Abuse Assessment Screen Questionnaire Student: 81.0% Gift Table 3 footnote Table 3 footnote N/A Y N/A Table 3 footnote N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A
Turkey Sofuglu et al., 2014Footnote 79 2012 Self-administered questionnaire 7540 students age 11, 13 and 16 ICAST-CH
EM: α 0.86; PA: 0.86; NG: 0.81
Student: 85.3% Table 3 footnote 45 min Table 3 footnote N/A N/A N/A Table 3 footnote Table 3 footnote N/A N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
UK Jackson et al., 2016Footnote 80 N/A Self-administered questionnaire 730 students age 13-16 Modified JVQ
α 0.51

JVQ correlated to TSC
r = 0.29–0.37, p < 0.01
School: 22.0%
Student: 52.0%
Table 3 footnote Table 3 footnote Table 3 footnote N/A P/Y N/A Table 3 footnote N/A N/A N/A N/A Alerted appropriate authorities; followed up with respondents who disclosed sensitive information. Table 3 footnote N/A N/A N/A N/A
Radford et al., 2013Footnote 81 2009 Self-administered questionnaire 2275 youths age 11–17 Modified JVQ Youth: 64% Table 3 footnote Table 3 footnote Table 3 footnote N/A P/Y Table 3 footnote ,Table 3 footnote a Table 3 footnote Table 3 footnote N/A N/A N/A Provided respondents with information of support services; alerted appropriate authorities.
Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
United States Finkelhor, Ormrod et al., 2005Footnote 12 Developmental Victimization Survey, 2002-2003 Telephone interview 1000 youths age 10–17 JVQ Youth: 79.5% 10 $ Table 3 footnote Table 3 footnote N/A P/Y Table 3 footnote Table 3 footnote N/A N/A N/A N/A Followed up with respondents who disclosed threatening situations. Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
Finkelhor et al., 2011Footnote 82
Finkelhor et al., 2009Footnote 28
Mitchell et al., 2011Footnote 83
Finkelhor et al., 2005Footnote 84
Hamby et al., 2013Footnote 85
National Survey of Children's Exposure to Violence (NatSCEV), 2008 Telephone interview 2095 youths age 10–17 JVQ
CM: α 0.39;
SA: α 0.35–0.51

Test-retest
CM: К 0.52; 91% agreement (3–4 weeks after);
EIPV: К 1.0; 100% agreement (3–4 weeks after)

JVQ correlated to TSC
CM: r = 0.14–0.35, p < 0.01;
SA: r = 0.11–0.34, p < 0.01
Youth: 54% 20 $ 45 min Table 3 footnote N/A P/Y Table 3 footnote N/A N/A N/A N/A N/A Followed up with respondents who disclosed threatening situations; gave sensitivity training to interviewers; alerted appropriate authorities. Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
Finkelhor et al., 2013Footnote 13
Hamby et al., 2005Footnote 86
Finkelhor et al., 2014Footnote 87
NatSCEV II, 2011 Telephone interview N not provided
youths age 14–17
Validity: JVQ
compared with other CM data
Youth: 40.4% 20 $ 55 min Table 3 footnote N/A N/A N/A N/A N/A N/A N/A N/A Followed up with respondents who disclosed threatening situations; provided respondents with information of support services. Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
Finkelhor et al., 2015Footnote 88,
Finkelhor et al., 2015Footnote 89
National Survey of Children's Exposure to Violence, 2014 Telephone interview N not provided
youths age 14–17

1949 youths age 10–17
JVQ Varied by recruitment 15.1%–67.0%
Youth: 14.2%–67.0%
5 $,
20 $
Table 3 footnote Table 3 footnote N/A P/Y Table 3 footnote N/A N/A N/A N/A N/A Followed up with respondents who disclosed threatening situations. Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
McLaughlin et al., 2012Footnote 40,  Strauss, 1979Footnote 90
McLaughlin et al., 2013Footnote 91
McChesney et al., 2015Footnote 92
Merikangas et al., 2009Footnote 93
National Comorbidity Survey – Adolescent Supplement, 2001-2004 Face-to-face interview 6483 youths age 13–17 CTS (modified), Composite International Diagnostic Interview (modified) and Child Welfare Questionnaire School: 86.8% Student: 82.6% 50 $ ≈ 2h30 Table 3 footnote Y P N/A N/A N/A N/A N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote
Begle et al., 2011Footnote 4
Danielson et al., 2010Footnote 94
Hawkins et al., 2010Footnote 95
McCauley et al., 2010Footnote 96
McCart et al., 2011Footnote 97
Andrews et al., 2015Footnote 98
National Survey of Adolescents Replication, 2005 Telephone interview 3614 youths age 12–17
SA: α 0.99; PA: α 0.72; EIPV: α 0.64Footnote 73
Youth: 52.2% 10 $ Table 3 footnote Table 3 footnote Y P Table 3 footnote N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Provided respondents with information of support services; followed up with respondents who disclosed threatening situations; alerted appropriate authorities. Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote
Haley et al., 2010Footnote 99
Oregon Teen Survey, 2005Footnote 270
Oregon Healthy Teen Survey, 2005 Self-administered questionnaire 16 289 students age 13–17 Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote N/A N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Alriksson-Schmidt et al., 2010Footnote 101
Eaton et al., 2006Footnote 102
National Youth Risk Behavior Survey (YRBS), 2005 Self-administered questionnaire 7181 female students age 15–18 Table 3 footnote Student: 52.2% Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Basile et al., 2006Footnote 3
Brener et al., 2004Footnote 103
YRBS, 2003 Self-administered questionnaire 13 080 grade 9–12 students Table 3 footnote School: 67.0–100.0% Student: 60.0–94.0% Table 3 footnote Table 3 footnote Table 3 footnote N/A P N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Howard & Wang, 2005Footnote 104 YRBS, 2001 Self-administered questionnaire 13 601 students age 14–18 Table 3 footnote School: 75.0%
Student: 83.0%
Table 3 footnote Table 3 footnote Table 3 footnote N/A P N/A N/A Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Lippe et al., 2008Footnote 105 YRBS, 2007 Self-administered questionnaire Samoa: 3625
Northern Mariana Islands: 2292
Marshall Islands: 1522
Guam: 1716
Palau: 732 students age 14–18
Table 3 footnote School: 100.0% Student:
78.0%–90.0%
Table 3 footnote Table 3 footnote Table 3 footnote N/A P N/A N/A Table 3 footnote N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Peleg-Oren et al., 2013Footnote 106 Florida YRBS, 2005 Self-administered questionnaire 4564 students grade 9–12 Table 3 footnote School x Student: 66.0% Table 3 footnote 50 min Table 3 footnote Y P N/A Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A N/A
Namibia, Swaziland, Uganda, Zambia, Zimbabwe Brown et al., 2009Footnote 107
WHO, 2017Footnote 56
GSHS, 2003-2004 Self-administered questionnaire 22 656 students age 13–15 Table 3 footnote School: 90.0–100.0% Student: 75.0–99.0% Table 3 footnote Table 3 footnote Table 3 footnote N/A N/A N/A Table 3 footnote N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote N/A N/A N/A N/A
European Union Kassis et al., 2013Footnote 41
Kassis & Puhe, 2009Footnote 108
Germany, Austria, Slovenia, Spain, 2009 Self-administered questionnaire 5149 students age 13–15 Family Violence Inventory
EIPV: α 0.88;
EIPV (EM): α 0.85;
PA: α 0.83
Table 3 footnote Table 3 footnote Table 3 footnote Table 3 footnote N/A S/P/Y N/A N/A Table 3 footnote N/A Table 3 footnote Table 3 footnote Provided respondents with information of support services. N/A Table 3 footnote N/A N/A Table 3 footnote

Abbreviations: CM, child maltreatment; CTS, Conflict Tactics Scale; CTSPC, Parent Child Conflict Tactics Scale; EIPV, exposure to intimate partner violence; EM, emotional maltreatment; ICAST-CH, ISPCAN child abuse screening tool-child; ISPCAN, International Society for the Prevention of Child Abuse and Neglect; JVQ, Juvenile Victimization Questionnaire; LEQAV, Life Event Questionnaire – adolescent version; NG, neglect; P, parent; PA, physical abuse; S, school; SA, sexual abuse; T, teacher; TSC, Trauma Symptoms Checklist for Children; Y, youth.

The most commonly mentioned procedures in place for reducing or dealing with participant distress were as follows: (1) providing respondents with information and telephone numbers of appropriate support services; (2) following up with respondents who disclosed threatening situations; (3) giving focused, sensitivity training to interviewers; (4) alerting appropriate authorities when intervention was deemed necessary. Of course, disclosure to participants of the possibility of alerting authorities could negatively influence participation.

Of the maltreatment types, sexual abuse was captured most frequently in the survey questions (see Table 3). The majority of maltreatment measures specified behaviours, rather than being self-defined; sexual abuse was stipulated with the most detail. Child maltreatment prevalence estimates varied by measure and were not always reported. The heterogeneity of measures and variation in time periods covered precluded meaningful comparisons of prevalence estimates. Summary estimates for lifetime prevalence ranged from 0.3% to 44.3% for sexual abuse, 4.2% to 58.3% for physical abuse, 3.1% to 78.3% for emotional maltreatment, 0.9% to 38.3% for neglect, and 0.6% to 30.9% for exposure to intimate partner violence.

Discussion

The findings of this systematic review reflect the extensive effort that has been made to measure child maltreatment at the population level and thus the perceived importance of this problem across the world. The review identified a variety of strategies employed to enhance data accuracy and mitigate participants' distress. Our findings were similar to those found in the review from 2000.Footnote 17 However, both our findings and theirs demonstrate that information on child maltreatment can be collected, albeit the issue of inconsistent definitions remains.

Identifying surveys and factors influencing prevalence estimates

Prevalence estimates of child maltreatment varied widely among the studies examined. In assessing findings across surveys, it is important to consider factors intrinsic to self-reporting that can compromise comparability.Footnote 24 Barriers include self-blame, cognitive development and age, stigma, fear of retaliation by the perpetrator, and failure to recognize behaviour as abusive.Footnote 16 Regarding the latter, differing perceptions of what constitutes discipline versus abuse can contribute to inconsistencies in response.Footnote 8 In some cultures, the use of physical punishment is commonplace and even legally accepted,Footnote 31,Footnote 39 while in others it is considered to be abuse.Footnote 109 In some studies, behaviours related to sexual abuse were not assessed because the topic was deemed too culturally sensitive.Footnote 50,Footnote 60

Variations in prevalence estimates of child maltreatment across studies might also be attributable to differences in measures. For example, with the objective of encouraging disclosure of sexual abuse, some surveys stipulate specific behaviours,Footnote 3 while others use more generally-worded questions.Footnote 101 Some measures of maltreatment are dichotomous (yes-no), in contrast to others that ask for details on severity and frequency.

Dissimilarities in conceptual scope can also influence prevalence estimates. For example, some but not all surveys explicitly include online victimization as a component of sexual abuse. Finally, the particular vocabulary used to describe specific behaviours may also impact comparability. For example, the expression, "forced sex without consent," might be interpreted more broadly than "rape," and thus be more apt to elicit a positive response (and increase apparent prevalence). Neglect was measured in only a few surveys—perhaps reflecting the challenges inherent to capturing it in population surveys. In some communities, relatively lower estimates of neglect were attributable to close social networks and living arrangements.Footnote 65 Efforts to improve the collection of data on neglect in population-based surveys and from young respondents are currently under way.Footnote 110,Footnote 111

Quality of data

The majority of the articles examined provided no detailed information on the reliability or validity of measures used within surveys. Statements such as "the reliability of the scale has been well-documented," or indicating that validity had been determined by the authors, were common but not fully informative. Unfortunately, only three articles reported validity.Footnote 80,Footnote 84,Footnote 87 In terms of reliability, internal consistency assessed by Cronbach alpha was documented most often followed by inter-rater reliability assessed as percentage agreement.

Internal consistency may have limited use given that some maltreatment behaviours may not be related. For example, some forms of neglect may not relate to other forms of neglect nor with other types of child maltreatment. Due to these complexities of internal consistency, this measure must be interpreted with caution.Footnote 84,Footnote 112 In general, surveying youth yields data that are only minimally affected by recall bias.Footnote 113 Of course, validity may still be compromised by social desirability bias, due to the delicate nature of maltreatment questions. However, research revealed few difficulties arising from the sensitivity of the questions.Footnote 24,Footnote 53,Footnote 61 The different developmental stage of the reviewed measures may partially explain why few psychometric properties of child maltreatment measures were reported. Newer measures were often adjusted for cultural and language adaptations; continued testing should lead to improvements in data accuracy.

Data quality and response rate are also affected by technical aspects of data collection and the setting in which it takes place. Most of the studies reviewed were based on surveys conducted within schools—where all students were responding to the same survey at the same time—and thus obtained high response rates. However, willingness to participate was not universal among schools, for reasons unrelated to child maltreatment questions.Footnote 33,Footnote 53,Footnote 57 Research suggests that among students, maximizing privacy and guaranteeing anonymity are effective in ensuring high response rates.Footnote 45 The importance of privacy was also underscored in a study in which younger participants (age 10 years) found responding to a survey more upsetting in the presence of the caregiver than when they were alone.Footnote 114

The means by which consent for survey participation is obtained can also affect the response rate; the requirement for consent from parents may discourage participation, especially among youth who have experienced child maltreatment.Footnote 47,Footnote 51,Footnote 115 Parental passive consent was used in multiple surveys to increase response rate and avoid sampling bias potentially related to active parental consent.Footnote 65,Footnote 80,Footnote 106 In one study, researchers designed and used a modified consent procedure in case any of the participants were being maltreated by a primary caregiver.Footnote 58

Ethical considerations

Eliciting information about experience with child maltreatment is a delicate matter; the manner in which questions are worded is an important consideration. Even a survey's name can potentially evoke anxiety and may lead to unwillingness to participate (e.g. stronger emotions may be triggered by reference to a survey on "child maltreatment" than to one on "child health"). Similarly, the language used in questions about experience with child maltreatment can affect the respondent. Sensitivity to the potential for adverse reactions is critical, as is a clear statement assuring the anonymity and confidentiality of the survey. However, the review found that some researchers included a confidentiality breach procedure in the consent form if a youth was in need of protection, which allowed automatic referral of participants to appropriate authorities.Footnote 50,Footnote 75,Footnote 81 This strategy did not negatively affect response rate.Footnote 75,Footnote 81

This review suggests that youth are generally comfortable in answering questions about their experience with child maltreatment.Footnote 12,Footnote 14,Footnote 71,Footnote 116 One study showed that 4.6% of youth reported being upset when answering a child maltreatment survey, but of these, 95.3% said they would nonetheless participate in a similar survey.Footnote 116 Interestingly, from the 17.3% of participants who had reported experiences classified as high-risk, only 2% were referred for counselling services.Footnote 116 In addition, one article mentioned that sexual abuse questions were not answered by 11% of respondents, but did not offer adequate information to assess if non-responses were higher for sexual abuse questions than for others.Footnote 2 However, several researchers concluded that the potential benefits from the information obtained from child maltreatment questions exceed the potential respondent distress.Footnote 7,Footnote 116,Footnote 117 An earlier study in adolescents comparing stress produced by child maltreatment questions with that arising from questions about school marks found no differences.Footnote 118

Limitations

Several limitations affect this review. First, inconsistencies in child maltreatment measures across surveys—and sometimes even within different cycles of the same survey—made classification challenging. Second, some articles that otherwise met the criteria for inclusion in the review were excluded on the basis of insufficient methodological information. For instance, papers failing to identify the relationship of the perpetrator to the victim or to distinguish between exposure to family violence and community violence were not included. Third, prevalence estimates were not provided in a standardised way. Fourth, steps taken to increase the response rate could often not be distinguished from those taken to increase the comfort of the respondent, so they were considered in combination. Fifth, measures had often been modified from their original version, and results of validity and reliability testing of the modified versions were not usually provided. Sixth, certain segments of the population were excluded either because they do not attend school or were absent the day of data collection. Seventh, the exclusion of articles in languages other than English limited the international scope of the review. Eighth, only peer-reviewed articles have been included in the review, which may introduce publication bias. Finally, limiting the review to the articles without examining the underlying surveys likely resulted in the exclusion of some relevant information.

Implications

This review shows that child maltreatment is a common concern across a range of societies and cultures although Canadian national data were missing. As evidenced by the large number of self-report surveys and studies asking youth about their level of comfort, data on child maltreatment can be collected responsibly and ethically from youth in a way that protects their health and well-being.Footnote 14,Footnote 116 Surveillance and research on child maltreatment would benefit greatly from the routine inclusion of questions on the subject in population-based self-report health surveys. Hovdestad and TonmyrFootnote 119 stressed the importance of setting the stage for inclusion of child maltreatment questions in surveys by a) preparing for early resistance, b) building a broad base of support, c) having knowledge of the current literature (including issues addressed in this article), and d) being willing to compromise and showing determination. Data collected on a regular basis would provide the opportunity for enhancing our understanding of the burden and the factors that are correlated with child maltreatment.Footnote 120 Schools could be an excellent venue for data collection due to high participation in these surveys and high enrolment among youth. After required discussions and agreements with the appropriate school authorities, it is easy to have procedures in place to obtain youth consent to participate and parents/caregivers passive consent. To maximize the quality of the data, measures used in collection should undergo reliability and validity testing, and all aspects of the survey methodology should be sound. Behaviour-based questions with response options capturing severity and frequency are also recommended.

Protocols to address potential participant distress should be established, and interviewers should be trained to conduct research sensitively and appropriately. Effective means of evaluating participant distress should be refined and applied, and the results of such evaluations should inform questionnaire design and language. Surveys should be conducted according to a strict code of ethics, the overarching goals of which should be the protection of privacy and confidentiality, and respect for respondents.

Acknowledgements

The authors gratefully acknowledge assistance with the preparation of this manuscript from Kathryn Wilkins, Tanya Pires, Tanya Lary and Jaskiran Kaur, who provided useful comments on earlier drafts.

Conflicts of interest

There is no conflict to declare.

Authors' contributions and statement

L.T. conceived and designed the study. C.W., L.T., and J.L. wrote the paper: L.T. wrote the protocol, with input from the others. J.L., L.T., C.W., J.D., and S.A. extracted and categorized the data. L.T. led the evaluative component.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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