Via Parigi, 11 - 00185 ROMA


European report on preventing child maltreatment

child maltreatment is a leading cause of health inequality, with the socioeconomically disadvantaged more at risk. It worsens inequity and perpetuates social injustice because of its far-reaching health and development consequences. In spite of child maltreatment being a priority in most countries in the WHO European Region, few have devoted adequate resources and attention to its prevention. this report outlines the high burden of child maltreatment, its causes and consequences and the cost−effectiveness of prevention programmes. It makes compelling arguments for increased investment in prevention and for mainstreaming prevention objectives into other areas of health and social policy, reflecting the whole-of-society approach promoted by Health 2020 and the need for increased intersectoral working and coordination. the report offers policy-makers a preventive approach based on strong evidence and shared experience to support them in responding to increased demands from the public to tackle child maltreatment. Prevention programmes that stop maltreatment from occurring in the first place and reduce children’s exposure to adversity have wide-ranging public health and societal benefits.


child abuse – prevention and control Violence – prevention and control Public health

Health policy Europe


Many international experts and WHO staff members contributed to developing this publication. the conceptual foundations were outlined at an editorial meeting held at the WHO Regional Office for Europe on 20 September 2012, where the following were present: Lenneke Alink, Jürgen Barth, Mark Bellis, Manuel Eisner, Gauden Galea, Ruth Gilbert, Deepa Grover, Karin Helweg-Larsen, Karen Hughes, Staffan Janson, christopher Mikton, Francesco Mitis, Anja Neumann, Noemi Pereda, Gentiana Qirjako, Marija Raleva, Dinesh Sethi and Freja Ulvestad Kärki. Helpful information was sent by George Nikolaidis, Anne tursz and Karen Devries.

the editors − Dinesh Sethi with Mark Bellis, Karen Hughes, Ruth Gilbert, Francesco Mitis and Gauden Galea − are particularly grateful to the following WHO staff members:

  • EnriqueLoyola and Ivo Rakovac, for providing advice and data from WHO mortality and hospital admissions databases;
  • colinMathers, for providing five-years age-group mortality

data from the Global Burden of Disease study;

  • Vivian Barnekow, Alex Butchart, Aigul Kuttumuratova,

christopher Mikton, Joanna Nurse, Lars Møller and Matthijs Muijen, for providing very helpful comments; and

  • Aigul Kuttumuratova andtina Kiaer, for advice on design

and help with selecting photographs.

We are grateful to our external peer reviewers for their very helpful comments and for contributing to improving the report’s completeness and accuracy:

  • KevinLalor, Dublin Institute of technology, Ireland;
  • JamesMercy, centers for Disease control and Prevention,

United States of America; and

  • Lorraine Radford, University of central Lancashire, United

Our thanks to the health ministry focal persons for violence prevention who participated in the survey on the prevention of child maltreatment and to the heads of WHO country offices who helped coordinate national responses.

Dinesh Sethi was the lead editor. Mark Bellis, Karen Hughes, Francesco Mitis, Ruth Gilbert and Gauden Galea contributed to the editing. the authorship of the chapters is as follows:

  • chapter1: Dinesh Sethi
  • chapter 2: Dinesh Sethi, Francesco Mitis, Lenneke Alink,

Alexander Butchart, Jacqueline Wagner and Marije Stoltenborgh

  • chapter3: Karen Hughes and Mark Bellis
  • chapter4: Karen Hughes, Mark Bellis, Miriam Maclean, Sara

Wood and christopher Mikton

  • chapter 5: Dinesh Sethi, Vivian Barnekow, Francesco Mitis, Ruth Gilbert and Freja Ulvestad Kärki
  • Annexes:Francesco Mitis, Dinesh Sethi, Lenneke Alink,

Jacqueline Wagner and Peter Newell.

Unless otherwise specified, the boxes were written by the authors.

the editors are grateful to the following experts for contributing valuable case studies of child maltreatment in the European Region:

  • Box 3: Julia Schellong and Anja Neumann, University Hospital of Dresden, Germany;
  • Box 4: Jürgen Barth, University of Bern, Switzerland;
  • Box5: Noemi Pereda, University of Barcelona, Spain;
  • Box7: Karen Hughes and Mark Bellis, Liverpool John

Moores University, United Kingdom;

  • Box 8: Gentiana Qirjako, University of tirana, Albania;
  • Box 9:Miriam Maclean and Melissa O’Donnell, University

of Western Australia, and Ruth Gilbert, UcL Institute of child Health, United Kingdom;

  • Box1: Dimitrinka Jordanova-Pesevska and Marija Raleva,

University clinic of Psychiatry Skopje, the former yugoslav Republic of Macedonia;

  • Box 2: Elinor Milne and Peter Newell, Global Initiative to

End All corporal Punishment of children, United Kingdom;

  • Box4: Staffan Janson, Karlstad University, Sweden;
  • Box 6: SaraWood and Karen Hughes, Liverpool John

Moores University, United Kingdom;

  • Box 7: Karin Helweg-Larsen, National Institute of Public Health, copenhagen, Denmark; and
  • Box 8: Julia Schellong and Anja Neumann, University

Hospital of Dresden, Germany.

We are grateful to Nikesh Parekh, who conducted the preliminary data analysis, to Jacqueline Wagner who helped in selecting the photographs and to the following experts who shared the database and results of national AcE studies: Adriana Baban, Margarita Kachaeva, Robertas Povilaitis, Iveta Pudule, Gentiana Qirjako, Marija Raleva, Natasa terzic and Betul Ulukok.

the WHO Regional Office for Europe thanks the Department of Health, United Kingdom (England), the Government of the United Kingdom and the Norwegian Directorate of Health for their generous support.

Layout: Lars Møller Editing: Alex Mathieson


reducing child maltreatment is a mainstay of the actions required to reduce inequity in europe and achieve the goals of Health 2020. Child abuse and neglect are a product of social, cultural, economic and biological factors and occur in all societies and countries in the wHo european region. They are a leading cause of health inequality and social injustice, with the socioeconomically disadvantaged more at risk. estimates suggest that at least 18 million children in the region will suffer from maltreatment during their childhood. Most child abuse and neglect occurs in the community and may not come to the attention of child protection agencies. They are nevertheless grave public health and societal problems with farreaching consequences for the mental, physical and reproductive health of children and for societal development. Maltreated children are at increased risk of becoming victims or perpetrators of violence in later life and may have poorer educational attainment and employment prospects. Maltreatment is also closely linked to other adverse childhood experiences. The consequences of such adversity may affect people throughout the life-course, with high societal costs.

Child maltreatment has long been regarded as a criminal justice and social issue and has only recently been seen in a public health perspective. This report supports the view that child maltreatment is not inevitable and that it is preventable. It endorses a public health approach and argues that prevention is more cost−effective than dealing with the consequences. evidence indicates that organized responses by society can prevent child maltreatment. experience accumulated in countries across the region and worldwide shows that sustained and systematic approaches can address the underlying causes of violence and make children’s lives safer. Among these are programmes to promote positive parenting and provide welfare support to families at risk.

The report documents these evidence-informed approaches, which take a broad interdisciplinary approach that cuts across sectors. Health systems have a key role not only in providing high-quality services for children who experience violence, but also in detecting and supporting families at risk. The health sector is also best placed to advocate for preventive approaches within an evaluative framework.

Member States need to join the global effort to reduce a leading health and social problem and to create safer and more just societies for children in the region. The prevention of maltreatment in children can only be achieved by mainstreaming responses into other areas of health and social policy. Investing in nurturing relationships would reduce the cycles of violence, improve social cohesion and represent a worthwhile investment. we at the wHo regional ofce for europe hope that this report will provide policy-makers, practitioners and activists with the facts they need to integrate the agenda for preventing child maltreatment into health and other sectors.