Global Prevalence of Past-year Violence Against Children: A Systematic Review and Minimum Estimates Susan Hillis, PhD, MSN,a James Mercy, PhD,b Adaugo Amobi, MD, MPH,c Howard Kress, PhDb

CONTEXT: Evidence confirms associations between childhood violence and major causes of abstract mortality in adulthood. A synthesis of data on past-year prevalence of violence against children will help advance the United Nations’ call to end all violence against children. OBJECTIVES: Investigators systematically reviewed population-based surveys on the prevalence of past-year violence against children and synthesized the best available evidence to generate minimum regional and global estimates. DATA SOURCES: We searched Medline, PubMed, Global Health, NBASE, CINAHL, and the World Wide Web for reports of representative surveys estimating prevalences of violence against children. STUDY SELECTION: Two investigators independently assessed surveys against inclusion criteria and rated those included on indicators of quality. DATA EXTRACTION: Investigators extracted data on past-year prevalences of violent victimization by country, age group, and type (physical, sexual, emotional, or multiple types). We used a triangulation approach which synthesized data to generate minimum regional prevalences, derived from population-weighted averages of the country-specific prevalences. RESULTS: Thirty-eight reports provided quality data for 96 countries on past-year prevalences of violence against children. Base case estimates showed a minimum of 50% or more of children in Asia, Africa, and Northern America experienced past-year violence, and that globally over half of all children—1 billion children, ages 2–17 years—experienced such violence. LIMITATIONS: Due to variations in timing and types of violence reported, triangulation could only be used to generate minimum prevalence estimates. CONCLUSIONS: Expanded population-based surveillance of violence against children is essential to target prevention and drive the urgent investment in action endorsed in the United Nations 2030 Sustainable Development Agenda.

b Division of Violence Prevention; aNational Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; and cDepartment of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Drs Hillis and Mercy conceptualized and designed the study, drafted the initial manuscript, approved the fi nal manuscript as submitted, and are accountable for representing all aspects of the work; Drs Hillis and Kress conducted the systematic review, abstracted relevant data, analyzed and/or interpreted the synthesized data, revised and approved the fi nal manuscript, and are accountable for representing all aspects of the work; and Dr Amobi contributed to acquiring, synthesizing, and interpreting the data, drafting, reviewing, and revising the manuscript, approved the fi nal manuscript as submitted, and is accountable for representing all aspects of the work.

To cite: Hillis S, Mercy J, Amobi A, et al. Global Prevalence of Past-year Violence Against Children: A Systematic Review and Minimum Estimates. Pediatrics. 2016;137(3):e20154079

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 137 , number 3 , March 2016 :e 20154079 REVIEW ARTICLE Violence against children is a public Empirical associations between abuse victimization is >30 times health, human rights, and social early exposure to violence and major higher than official reports,8 and self- problem, with potentially devastating causes of mortality in adulthood reported physical abuse victimization and costly consequences.1 Its were recognized years ago, before is >75 times higher.9 Thus, self- destructive effects harm children in elucidation of their shared biological reports are now considered an every country, impacting families, underpinnings.3,4,7 Recent evidence essential measurement tool and communities, and nations, and documents the biology of violence, will be foundational for informing reaching across generations. demonstrating that traumatic stress new investment opportunities Recognizing its pervasive and unjust experienced in response to violence associated with the SDG aims to end nature, almost all nations (196) may impair brain architecture, violence against children. These ratified the 1989 United Nations (UN) immune status, metabolic systems, self-reports should be ascertained Convention on the Rights of the Child, and inflammatory responses.4 Early after informed assent/consent is which recognizes freedom from experiences of violence may confer given and in private, where children violence as a fundamental human lasting damage at the basic levels and/or caretakers can provide right of children. Now, over 25 years of nervous, endocrine, and immune direct information about exposures later, the UN has launched a new systems, and can even influence to violent behaviors across types, Agenda for Sustainable Development genetic alteration of DNA.4,7 locations, and perpetrators. to end all forms of violence In response to increasing recognition In recent years, the number of against children.2 Documenting of the magnitude, consequences, representative surveys addressing the magnitude of violence against biology, and costs of violence prevalences of recent experiences children by synthesizing the best against children, there are growing of violence against children has available evidence will be essential commitments by UN agencies, increased. Two of these, the National for informing policy, driving action, the World Health Organization, Survey of Children’s Exposure to and monitoring progress for this bold the Centers for Disease Control Violence (NatSCEV) and Violence agenda. and Prevention, USAID, PEPFAR, Against Children Surveys (VACS), Data from surveys on violence World Bank, Together for Girls, measure the full range of types, against children in different countries governments, academic centers, locations, and perpetrators; and typically measure prevalences of and civil society organizations, several others, such as Multiple individual types of violence, such to its prevention. The converging Indicator Surveys (MICS), WorldSafe, as physical, sexual, or emotional prioritization of protecting children Health Behavior in School-Aged violence. Alternatively, estimates from violence has culminated in the Children Surveys (HBSC), and Global may focus on 1 location or class inclusion of not just 1, but 2 zero- School Health Surveys (GSHS), of perpetrator; examples include based targets—outcomes that every provide estimates of exposures to bullying victimization, which country should seek to eliminate, several types of violence, though is often only measured when it rather than merely reduce—in the these estimates are restricted to 1 occurs on school grounds, or child sustainable development goals class of perpetrator or location.10–15 maltreatment, which is limited to that (SDGs): to “end abuse, exploitation, Given the new global prioritization perpetrated by parents or caregivers. trafficking, and all forms of violence of the prevention of violence against Rarely do prevalence studies against children,” and to “eliminate children, it is important to use the measure ranges of types, locations, all forms of violence against women best available evidence to assess the and perpetrators. and girls.”2 Many countries lack the extent to which children in various data that will be needed to evaluate Although few studies assess regions of the world are exposed progress from 2016 to 2030 toward experiences of childhood violence to it. Our aims are to systematically these targets. across types, many reports suggest review the quality of population- differing types share similar After years of research addressing based evidence on prevalence of consequences.3 Such consequences magnitude, risk factors, and violence against children during are additive, increasing with consequences of violence against the past year, and then to use increases in types and severity children, a consensus is emerging a triangulation approach that of violence experience.3,4 These on how to reliably measure its synthesizes data from high quality harmful sequelae span major causes prevalence. Because violence against surveys to estimate global minimum of death in adulthood, including children does not typically come prevalences and numbers of children noncommunicable diseases, injury, to the attention of official agencies, exposed to violence during the past HIV, mental health problems, suicide, global evidence reveals that the self- year. We conclude by describing the and reproductive health problems.3–6 reported prevalence of child sexual urgent need to implement effective,

Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 HILLIS et al multisector programs and policies to prevent violence against children.

METHODS

Systematic Review: Approach, Characteristics, Quality, and Data Abstraction We used the PRISMA statement to guide our systematic review.16 Our database search, conducted in January 2014 by using Medline, PubMed, Global Health, NBASE, and CINAHL, identified 907 unduplicated peer-reviewed reports published after the year 2000, by using these search terms: [(low-income countries or middle-income countries or high- income countries or developing countries or developed countries) and (ages 1 to 18 years or children or adolescents or infants or preschool child or school child) and (national surveys or population surveillance or health survey or surveys or disease surveys or epidemiologic surveys or surveillance), and (child FIGURE 1 maltreatment or physical violence or Systematic review fl ow diagram: prevalence of violence against children. sexual violence or emotional violence or maltreatment or neglect or bully (Fig 1). The final 38 reports provided review, 2 investigators (S.H. and or bullying or bullies or bullied)] (see quantitative estimates of prevalence H.K.) independently assessed Supplemental Material). We extended of 1 or more types of violence studies against inclusion criteria our search from January 2014 to against children occurring during the and independently rated their August 2015 (see Supplemental previous year.1710–15,18–48 quality for key indicators, including Material) and identified an additional clear description of population- 22 published reports (Supplemental These 38 references met the based sampling, use of standard Material), including both peer- following criteria for inclusion: definitions of violent behaviors, reviewed papers and reports from (1) population-based survey data, preimplementation training the UNICEF MICS (reports from probabilistically drawn, using of interviewers/questionnaire 33 countries), VACS (reports for 8 national or subnational samples; (2) administrators, presentation of countries), and HBSC (reports for use of standard measures of violence weighted analyses, description of 37 countries). After screening a that assess behaviors (Supplemental whether survey was national or total of 929 unduplicated reports Table 6, Supplemental Material); subnational, and participation rates for descriptions of population-based (3) data collected by interviewer- measures of any type of past-year administered household survey, (Table 1). Finally, the investigators violence against children in the 0 to school survey, or random digit dialed (S.H. and H.K.) performed duplicate 17 year age range, we conducted a telephone survey using self-report extraction of past-year prevalence 2–16,18 full review on 54 reports. Of these, (by child and/or caregiver); (4) age data by age, country, and 16 reports were excluded due to: of target population (2–17 years); type of violent victimization as no report of past-year prevalence,6 (5) specification of country-specific defined by varying investigators, report of perpetration only,1 or area-specific estimates; and (6) including physical violence, moderate subjective definition of exposure,2 violence reported during 1 to 12 physical violence, severe physical nonprobabilistic sampling,5 and months before implementation of the violence, emotional violence, severe provision of only qualitative data2 survey. To conduct the systematic psychological (emotional) violence,

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 137 , number 3 , March 2016 3 sexual violence, bullying, and physical prevalences of physical violence, WorldSafe, and survey adaptations dating violence (Supplemental Table severe physical violence, sexual of CTS), we used prevalences for 6, Supplemental Material). Although violence, emotional violence, severe severe violence (such as kicked, our interest was experience of any psychological (emotional) violence, choked, smothered, burned, scaled, violence, which included 1 or more bullying victimization, fighting, and branded, beat repeatedly, or hit with types of victimization (physical, when reported, exposure to “any an object) in the base case analyses to sexual, or emotional) committed by violence.” Forty-three countries avoid inclusion of spanking13,25,35,39,43 a range of perpetrators (authority reported exposure to “any violence” (Supplemental Table 6, Supplemental figures, peers, romantic partners, in the past year. MICS studies33 and Material). For the sensitivity analysis, or strangers) in various locations the Canada Conflict Tactics Scale we expanded the classification of (home, school, or community), only (CTS) adaptation1 report moderate exposures to include prevalences of VACS and NatSCEV provided such physical and/or harsh physical and/ moderate physical violence or any measures.10,11,19,26–30,38,40,41,44,47 or emotional by 1 type of perpetrator violence, both of which had spanking The MICS, however, do report “any in 1 type of location; VACS studies8 as a defining indicator (Supplemental violent discipline” as the perpetration report physical, emotional, and/or Material).13,25 As expected, country- in the home by caregivers of any of sexual by multiple perpetrators and specific prevalences of violence against these categories of violent discipline: locations; NatSCEV1 reports physical children in the base case were lower moderate physical and/or severe and/or emotional, and/or sexual than those in the sensitivity analysis. physical and/or psychological and/or bullying and/or direct crime violence. For this article, we include against the child, and/or witnessing Country-specifi c Estimates of Violence MICS reports of “any violent violence by multiple perpetrators Against Children discipline” in our “any violence” and locations.10–12,19,25–30,38,40,41,44,47 We used published prevalence category.25 Though NatSCEV includes both data to generate country-specific victimization and witnessing estimates for 2 age groups (2–14 Synthesizing Estimates of Minimum violence, we include only direct and 15–17 years) of minimum Exposure to Past-year Violence victimization data. In instances prevalences of violence in the where the same survey had been The final review included data from previous 12 months. Age ranges and implemented periodically (eg, 112 studies in 96 countries. We used types of violence reported varied NatSCEV, HBSC), we used the most a triangulation approach, which across surveys, with most reporting recently published.14,47 included a critical synthesis of data only 1 or 2 types; additionally, to develop minimum estimates by many surveys only measured past- using population-weighted averages Definitions vary on the measurement month exposure. Therefore, due to of regional exposures to past- of exposure to any given type of limitations in types and timing, we 49–51 year violence. Triangulation violent victimization. Definitions can only characterize prevalence is appropriate for comparing, vary particularly in whether they of past-year violence in terms of contrasting, and synthesizing include hitting with bare hands, or minimum exposure for children research characterized by varying spanking, as a form of violence. For living in 1 of the countries with methodologies and diverse limitation example, in the WorldSafe, MICS, published data. We also excluded when the primary purpose is not and survey adaptations using CTS, children aged 0–1 years, since few to elucidate etiology, but rather “moderate physical violence” includes reports include this group. to catalyze public health action.49 “slapping, hitting with bare hands, Although previous reports have hitting with an object, shaking, or To estimate the minimum number of pooled data on a specific type of spanking”13,25,29,35,43; in contrast, the children aged 2 to 17 years exposed violence from a standardized survey NatSCEV and VACS exclude spanking to violence in each country, we used (eg, GSHS), our interest in generating from their measures.10,47 In light 2014 US Census Bureau international estimates of past-year experience of of these variations, we performed population data to create 2 any type of violence across surveys our base case analysis by using the population-at-risk age groups: 2 to 14 made triangulation more suitable, conservative definition for physical and 15 to 17 years53 (Supplemental due to variations in methods, violence which excluded spanking, Material). Then, for both base case definitions, populations, and timing although in so doing we also excluded and sensitivity analyses, to estimate of data collection.15,49,52 Using types other dimensions in the moderate numbers of children in a given of violence measured in various category for violent discipline, such as country known to be exposed, we surveys, such as NatSCEV, MICS, slapping and shaking. Thus, for survey applied the highest published age WorldSafe, VACS, GSHS, and HBSC measures based on the experiences group–specific prevalence of violence (Table 1), we abstracted past-year of violence in the home (MICS, (often only 1 type for the base case)

Downloaded from www.aappublications.org/news by guest on September 27, 2021 4 HILLIS et al samples, 14%–67% Coverage Participation NAT REG MUN Quality Analyses Weighted Sampling Training Probabilistic 8 8 8 8 8 88%–98% 21 2137 37 21 37 21 21 37 37 84% 60% 33 33 33 33 33 Not Reported Defi nition Defi Countries Standard Jordan, Lebanon, Kenya, Morocco, Namibia, Oman, Philippines, Swaziland, Tajikistan, Tanzania, Uganda, United Arab Emirates, Venezuela, Zambia, Zimbabwe Republic, Estonia, Denmark, England, Finland, France, Germany, Greece, Greenland, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxemburg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Ukraine, United States, Wales Nigeria, Cambodia & Herzegovina, Burkina Faso, Cameroon, Central Ghana, African Republic, Gambia, Georgia, Guinea-Bissau, Guyana, Iraq, Ivory Coast, Jamaica, Lao People’s Democratic Republic, Kazakhstan, Kenya, Montenegro, Macedonia, Serbia, Kyrgystan, Sierra Leone, Suriname, Syria, Tajikistan, Togo, & Tobago, Vietnam, Ukraine, Yemen Trinidad 1 Brazil1 United States3 New Zealand, Pakistan, Australia 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 45%–70% 83% 67% 1 United States3 Canada, Italy, Finland8 Swaziland, Zimbabwe, Kenya, Tanzania, Haiti, Malawi, 1 3 1 1 3 1 1 1 1 2 Variable across 50%–57% 21 Botswana, Brazil, Chile, China, Egypt, Guyana, 37 Armenia, Austria, Belgium, Canada, Croatia, Czech No. of Countries No.) 20, 22, 23) 32, 42) of School Health (PeNSE) (48) dating violence (36, 46) 34) 40, 41, 47) 43) 25–30, 31, 44) GSHS (15, 17, 19, HBSC (14, 21, National Survey YRBS, Physical Bullying (17, 33, WorldSafe (13)NatSCEV (11, 38, 6CTS (35, 37, 39, Brazil, Egypt, India, United States, Chile, Philippines 6 6 6 6 1 5 33%–99% Survey Type (Ref. Population-Based Surveys Measuring Past-year Violence Against Children: Characteristics and Survey Quality Indicators TABLE 1 Characteristics Age Group for Y Review, national; REG, regional. MUN, municipal; NAT, 15–17 VACS (10, 18, 2–14 MICS (12, 24, 45) 33 Albania, Algeria, Azerbaijan, Belarus, Belize, Bosnia

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 137 , number 3 , March 2016 5 to the corresponding 2014 reference 2 to 14 years and 15 to 17 years Latin America (Table 2). For Europe, population age group for that experiencing violence and the sum prevalences of the more severe types country: either the 2- to 14-year-old of corresponding regional 2014 of violence included in the base or the 15- to 17-year-old population. populations to estimate regional case scenario tended to be lower Disaggregated age data were and global minimum prevalences than for other regions. We largely available for 110 of 112 abstracted and numbers of children ages 2 to computed these base case minimum prevalence estimates, either through 17 years experiencing past-year estimates for 2- to 14-year-olds age-related eligibility criteria for violence. Finally, we used a similar by using country-specific highest a given survey or through age- population-weighted approach to reported prevalence for 1 type of stratified data for surveys including estimate minimum prevalences of violence (eg, severe physical violence ages 0 to 17 years (see Supplemental past-year violence against children by caregivers for most countries), Material for details). While reports based on the UN classification of because most surveys reporting measuring violent discipline (eg, developed and developing nations. exposures to any violence for this MICS) provided most country- The use of triangulation to critically age included spanking in their specific estimates for ages 2 to 14 synthesize data on past-year violent definitions. In contrast, the sensitivity years, those surveys focusing on victimization across surveys allowed analyses did include prevalence adolescents, such as VACS, GSHS, and us to combine data for children living measures of any violence; synthesis HBSC provided most data for the 15- in nearly half the countries in the of results for 2- to 14-year-olds to 17-year-old population.10,14,15,25 world; ∼42% of the world’s children showed minimum prevalences of For a given country, prevalence reside in these countries. past-year violence exceeded 60% estimates may have included only 2- in Northern America, 60% in Latin to 14-year-olds, only 15- to 17-year- America, 70% in Europe, 80% in Asia, olds, or both (Supplemental Table 7, RESULTS and 80% in Africa (Table 3). Supplemental Material). Quality of Surveys For the base case, our estimates for Regional Estimates of Minimum The majority of surveys in our the entire group of 2- to 17-year- Prevalences and Projected Numbers of review were high quality (Table 1). olds indicated that a minimum of Children Exposed to Past-year Violence We confirmed 100% (112/112) of 64% of these children in Asia, 56% For each region, we derived reports used probabilistic sampling, in Northern America, 50% in Africa, estimates of the minimum prevalence and 100% used standard definitions 34% in Latin America, and 12% of children exposed to past-year of exposures to violent behaviors. in Europe experienced past-year violence from the population- In addition, 96% (108/112) violence (Table 4). The low estimate weighted average of the country- described training of interviewers/ for Oceania is linked to the fact that specific prevalences, and then questionnaire administrators, 93% representative surveys measuring applied the known prevalences to (104/112) reported weighting prevalences of violence were only the entire region. The 96 countries findings, 100% reported whether available for ages 15 to 17 years and with population-based data included their surveys were national (102) or thus, we assumed none of the 2- to 24 in Africa, 20 in Asia, 9 in Latin/ subnational (10), and 70% (78/112) 14-year-olds experienced violence. South America, 3 in Northern reported participation rates (39%– An estimation of the total minimum America, 38 in Europe, and 2 in 99% range). Although nearly half numbers of children exposed, which Oceania. We computed estimates of the countries in the world have is a function of both prevalence and separately for 2- to 14-year-old published population-based data on size of the population-at-risk in 2014, and 15-to 17-year-old populations, at least 1 type of violence, this also shows Asia has the highest number, by using 2014 Census data53 to means that half of the countries in with over 700 million children provide minimum prevalences of the world do not have such data. exposed; Africa follows with over 200 childhood violence by age (Table 2 million children; then Latin America, and Supplemental Material). Next, Synthesized Estimates Northern America, and Europe we used the estimates of regional For the base case analysis of combined show over 100 million prevalences from abstracted data minimum prevalences of past-year children exposed. The synthesized to develop projected total minimum violence among 2- to 14-year olds findings for the base case scenario numbers of children exposed to and 15- to 17-year-olds, we found indicate that, globally, a minimum of violence in the corresponding that synthesized estimates for both over 1 billion children were exposed region by age group. We then age groups approached or exceeded to violence during 2014 (Table 4). used the sum of the minimum 50% for Africa, Asia, and Northern For the sensitivity analysis, we found regional numbers of children ages America, and exceeded 30% for that a minimum of over 1.4 billion

Downloaded from www.aappublications.org/news by guest on September 27, 2021 6 HILLIS et al of the nearly 2 billion children aged 2 to 17 years experienced physical,

640 197 emotional, and/or sexual violence in 6 967 841 8 006 772 10 943 618 36 691 983

101 949 939 the previous year (Table 4). Though j = (g/f) × (i)

Affected by VAC prevalences of violence were high in both the developing and developed world, the minimum number estimated as suffering victimization in the developing world in 2014 i Total Population at Risk

1 617 154 exceeded 1 billion children (Table 5). 32 906 540 22 775 007 71 989 161 13 699 268 212 833 830

Total N From Census Data Minimum n Imputed DISCUSSION

Our systematic review of studies used Ages 15–17 y h = g/f to derive minimum estimates of past- year VAC With Past- Minimum % year violence against children showed these population-based surveys were high quality.16 Most surveys g n Affected

399 949 40 had the following characteristics:

Reports probabilistic sampling, standard by VAC From definitions, training of interviewers/ Minimum questionnaire administrators, weighting of estimates for complex Pooled From Published Reports

f designs, and national scope. If we

Data assume our base-case scenario combining prevalences across Reports, Census Total N for Included approximately half of the countries are representative of overall minimum prevalence estimates for all countries, and thus can be projected to the by VAC

Minimum n entire population, then the number Imputed Affected of children exposed to violence in the past year exceeds 1 billion, or half the children in the world. Region-specific

Total Population at Risk estimates for children aged 2 to 17 7 090 890 Not available 1 010 283 years indicate that the Asian, African, Census Data Total N From and Northern American regions had the highest minimum prevalences. Because of the sheer size of the Asian VAC % With

Ages 2–14 y population, the minimum estimate Past-year Minimum of numbers of children experiencing past-year violence there was ∼2 times

b c = b/a d e = (b/a) × (d) greater than in the other regions combined. Even more sobering were Minimum n Not available From Reports Affected by VAC findings from the sensitivity analyses, which included moderate physical violence and showed three-fourths Pooled From Published Reports a of the world’s children experienced 16 686 939 1 359 251 8 100 964 471 8 224 160 21 542 125 6 590 651 31 71 876 435 35 958 876 50 385 921 657 193 071 746 30 848 759 15 723 230 51 57 837 970 32 175 318 56 57 860 154 32 187 659 13 696 533 8 005 173 58

393 844 643 266 954 747 68 903 793 328 612 606 832 143 742 417 68 854 329 48 violence in the previous year. Total N for Census Data

Included Reports, Whether from the base case or from the sensitivity analysis, our findings

Base Case Estimates of Past-year Violence Against Children by Age Group and Region compel urgent action. Prevalences of country-specific types America Europe Northern Oceania Africa Asia Latin America 53 738 988 18 429 032 34 138 468 115 47 485 696 13 477 938 4 482 313 33 Region TABLE 2 ned as spanked, slapped in the face, hit, or shook. physical violence, which is defi Minimum prevalences and projected minimum estimates of total numbers children affected. Excludes exposed to moderate of violence against children, such as

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 137 , number 3 , March 2016 7 TABLE 3 Sensitivity Analysis Estimates of Past-year Violence Against Children by Age Group and Region Ages 2–14 y Ages 15–17 y Pooled From Published Reports Total Population at Risk Pooled From Published Reports Total Population at Risk Total N From Pooled n Past-year Total N From n Imputed Total N From Pooled n Past-year Total N From n Imputed Census Data Affected by VAC, % Census Data Affected by Census Data Affected by VAC, % Census Data Affected by VAC From VAC VAC From VAC Reports Reports a b c = b/a d e = (b/a) f g h = g/f i j = (g/f) × (i) Region × (d) Africa 71 876 435 62 759 153 87 385 921 657 336 968 802 30 848 759 15 723 230 51 71 989 161 36 691 983 Asia 393 844 643 340 657 383 86 903 793 328 781 739 387 143 742 417 71 644 993 50 212 83 3830 106 081 967 Latin 53 738 988 34 340 020 64 138 468 115 88 483 205 13 477 938 4 482 313 33 32 906 540 10 943 618 America Europe 16 686 939 12 184 304 73 100 964 471 73 721 241 21 542 125 6 527 774 30 22 775 007 6 901 367 Northern 57 837 970 35 685 684 62 57 860 154 35 699 372 13 630 826 8 005 173 58 13 699 268 8 006 772 America Oceania Not available 7 090 890 Not available 1 010 283 40 1 617 154 Minimum prevalences and minimum estimates of total numbers of children affected. Includes children exposed to moderate physical violence, defi ned as spanked, slapped in the face, hit, or shook.

TABLE 4 Regional and Global Projections of Minimum Prevalences of Past-year Violence, and Minimum Numbers of Children Exposed to Past-year Violence Region Base Case Sensitivity Analysis Children-at-Risk: Census Past-year Projected No. of Children Ages Past-year Estimate Projected No. of Children Ages 2–17 Population Ages 2–17 y Estimate of 2–17 y Exposed to Any Violence of Any Violence, y Exposed to Any Violence, Moderate Any Violence or Severe Violence Moderate Violence, Violence, or Severe Violencea or Severe or Severe Violence, Violence, % %a Africa 457 910 818 50 229 763 729 82 373 660 785 Asia 1 116 627 158 64 714 556 771 80 887 821 353 Latin 171 374 655 34 58 429 315 58 99 426 824 America Europe 123 739 478 12 15 192 001 65 80 622 608 Northern 71 559 422 56 40 194 431 61 43 706 144 America Oceania 8 708 044 7 640 197 7 640 197 World 1 949 919 575 54 1 058 776 444 76 1 485 877 910 “Any violence” includes, depending on survey type, exposure to 1 or more of the following: physical violence, emotional violence, sexual violence, bullying, or witnessing violence. a Includes children exposed to moderate physical violence, which is defi ned as spanked, slapped in the face, hit, or shook.

TABLE 5 Global Projections of Minimum Prevalences of Past-year Violence and Minimum Numbers of Children Exposed to Past-year Violence by UN Economic Groupings Region Base Case Sensitivity Analysis Children-at-Risk: Census Past-year Estimate Projected No. of Children Ages Past-year Estimate Projected No. of Children Ages 2–17 y Population Ages 2–17 y of Any Violence or 2–17 y Exposed to Any Violence of Any Violence or Exposed to Any Violence or Moderate Severe Violence, % or Severe Violence Moderate Violence or Violence or Severe Violencea Severe Violence, %a Developing 1 730 914 508 59 1 025 119 052 78 1 347 185 177 Countries Developed 219 005 067 44 97 052 628 60 131 184 841 Countries “Any violence” includes, depending on the survey type, exposure to 1 or more of the following: physical violence, emotional violence, sexual violence, bullying, or witnessing violence. Based on UN developing countries, including least developed countries in: Africa, Asia excluding Japan, the Caribbean, Central America, South America, and Oceania excluding Australia and New Zealand; and developed countries in: Northern America, Europe, Japan, Australia, New Zealand. a Includes children exposed to moderate physical violence, which is defi ned as spanked, slapped in the face, hit, or shook.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 8 HILLIS et al that described in UNICEF’s Hidden in We considered limitations that rates were relatively constant over Plain Sight, also demonstrate an urgent may have biased our estimates of time. need to escalate global commitments past-year violence against children. Just as global recognition of the to protecting children.45 In our report, The strongest limitation is that our endemic magnitude of violence we critically synthesized population- estimates underreport prevalences against children has sped forward based measures of violence against for several reasons. First, since over the past decade, the multisector children aged 2 to 17 years that are few surveys include the range of evidence demonstrating that such recent (past-year) and more serious types, perpetrators, and locations violence is largely preventable has to provide minimum regional and of violence, base-case estimates advanced.1,65,66 The state of evidence global estimates of the public health were often computed on only 1 type demonstrates interventions to address burden of violence against children. of violence; for example, violent violence against children should cross Our interest for the base scenario discipline in the home was the strata of the socioecologic model, in more serious types of violence is predominate type reported for 2- to including the child, family, community, linked to their potential to influence a 14-year-olds, and either bullying, and society.1,67 For optimum impact, range of public health consequences fighting, or multiple exposures such policies and programs will be and to be associated with the kind (from VACS) for 15- to 17-year- multisector, spanning health, social of toxic stress that damages brain olds. However, for the sensitivity services, education, and justice architecture in children.3,4,54Thus, analyses, nearly half (n = 43) of the sectors.1 In the United States, for given our findings, we estimate that countries had data on exposure to example, although NatSCEV shows no violence may threaten the optimum multiple types of violence. We further overall reductions in recent trends development of over a billion brains underestimated prevalences by in direct victimization of children, in children, every year. Though we assuming none of the children ages 2 administrative data from child excluded moderate forms of violence, to 14 years in Oceania were exposed, protection agencies shows a 40% such as hitting a child on the buttocks because no data were available for decline in substantiated child sexual or extremities in the base analysis, we this age group. We also assumed, abuse from 1990 to 2000; this decline included these forms in the sensitivity due to lack of data, that no children may be linked to the interplay of analysis, as evidence suggests spanking under 2 years were exposed. It is programs and policies implemented is considered a form of violence, also possible that selection bias may across sectors.68 The integration of violates rights to protection, can be have influenced our imputed regional multisector approaches with ones harmful to development, and is linked estimates, if minimum prevalences that are also multi-stakeholder with externalizing and internalizing of violence differ between those should accelerate progress, behavior problems.55–63 Given that the countries with and those without engaging governments, business, published estimates, or if in the new SDG agenda proposes ending all nongovernmental, and civil society several cases with only subnational forms of violence against children, organizations in the shared goal of estimates, those differ from national our synthesized estimates help caring for the world’s children. convey the scale of this urgent global ones. There may also be differential problem. bias between regions given The World Health Organization, in variations in age distributions, types collaboration with UNICEF, UNODC, The overarching purpose of of violence reported, and proportion PEPFAR, USAID, World Bank, US population-based surveys on violence of the populations living in countries Department of State, Centers for against children is to drive national without estimates. Finally, we Disease Control and Prevention, and action plans that catalyze change.1 believe it is unlikely that our findings Together for Girls, is leading the Several surveys, including HBSC and were meaningfully biased by our development of a unified package of NatSCEV, have been implemented assumption that prevalences of these 7 evidence-based strategies to repeatedly to monitor trends. An violence were stable during the prevent violence against children: evaluation of trends in bullying time period between their teaching positive parenting skills, from 2002–2010 by using HBSC, for publication and 2014, the year of helping children develop social- example, shows no change in most of estimation of the population-at-risk. emotional skills and stay in school, the 33 countries, although reductions For over 90% of our estimates, this raising access to health, protection, were observed in one-third of lag-time was 1 to 5 years. A recent and support services, implementing countries.14 Similarly, over 3 waves report demonstrates trends in and enforcing laws that protect of NatSCEV in the United States, child maltreatment in 6 countries all children, valuing social norms from 2008–2014, there was no remained unchanged from the mid- that protect children, empowering overall reduction in past-year violent 1970s through 201064; thus, it may families economically, and sustaining victimization of children.47 be reasonable to assume violence safe environments for children. These

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 137 , number 3 , March 2016 9 strategies are in large part built as of evidence-based interventions to ABBREVIATIONS an adaptation of the CDC THRIVES reduce this high burden of violence core package and similar guidance against children.89 Improved CTS: Conflict Tactics Scale from WHO, UNICEF, PEPFAR, and surveillance of the range of types, GSHS: Global School Health USAID65–67,69–90 locations, and perpetrators of violence Surveys against children, as well as of access HBSC: Health Behavior in School- to key prevention interventions, is Aged Children Surveys CONCLUSIONS essential to target prevention, monitor MICS: Multiple Indicator Surveys NatSCEV: National Survey of Our findings using population- progress, and drive the urgent action Children's Exposure to based data from approximately endorsed in the 2030 Sustainable Violence half of the countries in the world Development Agenda.2 The time is SDG: sustainable development show that over 1 billion children ripe for the newly-established Global goals ages 2 to 17 years have experienced Partnership to End Violence Against UN: United Nations violence in the past year. These data Children to catalyze multi-stakeholder VACS: Violence Against Children demonstrate an urgent need for wider investments in expansive solutions for Surveys adoption, scaling, and sustaining a billion children.2,91–93

The fi ndings and conclusions in this paper are those of the author(s) and do not necessarily represent the offi cial position of the Centers for Disease Control and Prevention. DOI: 10.1542/peds.2015-4079 Accepted for publication Dec 7, 2015 Address correspondence to Susan Hillis, PhD, MSN, CAPT, U.S. Public Health Service, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2016 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

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