One Definition to Protect Them All: Global Consensus on Child Maltreatment

Featured Article

The Lancet Regional Health - Europe | 2025, Vol. 50, 101196.

Article Title

Defining child maltreatment for research and surveillance: an international, multi-sectoral, Delphi consensus study in 34 countries in Europe and surrounding regions

Authors

Laura Elizabeth Cowley - Population Data Science, Swansea University Medical School, Swansea University, UK

Diogo Lamela - Digital Human-Environment Interaction Lab (HEI-LAB), Lusófona University, Porto, Portugal

Katarzyna Drabarek - Empowering Children Foundation, Warsaw, Poland

Leonor Bettencourt Rodrigues - ProChild CoLAB Against Child Poverty and Social Exclusion, Guimarães, Braga, Portugal

Athanasios Ntinapogias - Department of Mental Health and Social Welfare, Institute of Child Health, Athens, Greece

Aideen Naughton - Public Health Wales NHS Trust, Cardiff, UK

Geoff Debelle - Birmingham Women and Children’s Hospital, Birmingham, UK

Ravit Alfandari - School of Social Work, University of Haifa, Haifa, Israel

Andreas Jud - Clinic of Child and Adolescent Psychiatry, University Hospital Ulm, Ulm, Germany

Gabriel Otterman - Barnafrid and Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
Taina Laajasalo - Safety and Protection Unit, Finnish Institute of Health and Welfare, Helsinki, Finland

Cindy W. Christian - Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA

Vaska Stancheva-Popkostadinova - Department of Medical Social Sciences, South-West University Neofit Rilski, Blagoevgrad, Bulgaria

Luciana Caenazzo - Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy

Virginia Soldino, - University Research Institute of Criminology and Criminal Science, University of Valencia, Valencia, Spain

Rachael Vaughan - Children’s Social Care Research and Development Centre (CASCADE), Cardiff University, Cardiff, UK

Alison Kemp - Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK

Ulugbek Nurmatov - Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK

Abstract

Child maltreatment is a complex public health issue that has consequences across the life-course. Studies to quantify child maltreatment and identify interventions and services are constrained by a lack of uniform definitions. We conducted a European Delphi study to reach consensus on types and characteristics of child maltreatment for use in surveillance and research. Statements were developed following a scoping review and identification of key concepts by an international expert team (n = 19). A multidisciplinary expert panel (n = 70) from 34 countries completed three rounds of an online survey. We defined consensus as ≥70% agreement or disagreement with each statement after the final round. Consensus was reached on 26/31 statements (participant retention rate 94%). From the statements, we propose a unified definition of child maltreatment to improve measurement and surveillance in Europe. Concerted efforts are now required to test and refine the definition further prior to real-world operationalisation.

Keywords

Child maltreatment, Definitions, Delphi study, Europe, Public health surveillance

Summary of Research

“Child maltreatment has been recognised by the World Health Organization (WHO) as a major public health problem… Governments and international organizations advocate for increased action to prevent child maltreatment. However, for prevention efforts to be successful, improved measurement strategies and systematic surveillance are required. High-quality measurement and surveillance of child maltreatment, in turn, require the use of a standardized definition… Different sectors and professions involved in child protection practice and research use their own terminology and use varying definitions, and these can often be non-specific or implicit… these issues hinder attempts to quantify child maltreatment…

Several attempts have been made to standardise definitions… However, these have either focused on a broader concept of violence against children that includes collective as well as interpersonal violence…, or specific forms of child maltreatment…This evidence gap is increasingly being recognised, with recent calls for a standardised definition of child maltreatment to support global surveillance efforts… The aim of this study was to reach consensus on types and characteristics of child maltreatment for use in surveillance and multi-sectoral research… The specific objectives were to develop consensus on 1) the characteristics that distinguish child maltreatment as a subset of violence against children, 2) types and sub-types of child maltreatment, and 3) the minimum characteristics required to define an incident as child maltreatment for surveillance and research purposes” (p. 1- 2).

“This study was designed and conducted by an international, multidisciplinary expert team of 19 researchers and child protection practitioners from 11 countries involved in the Euro-CAN network… Preliminary work included a scoping review, comparative analysis of international child maltreatment classification systems, a survey of child maltreatment experts, and critical appraisal of other attempts to improve surveillance systems in this field” (p. 2- 3).

“Overall, consensus was reached for 26 statements and not reached for five… A definition of child maltreatment was formed by combining the information from the 26 statements for which consensus was reached. This is provided [below:]” (p. 4).

“Across all three rounds, there was consensus that child maltreatment should be classified as a subset of violence against children… There was also consensus that the nature of the victim-perpetrator relationship is one of the key characteristics that defines child maltreatment as a subtype of violence against children [and] consensus that perpetrators of child maltreatment can be adults or minors… (p. 4- 5).

“There was consensus that ‘neglect’ is a broad type of child maltreatment within which there are different sub-types, and that all sub-types of neglect can be characterised as a failure to provide or a failure to supervise… [consensus included] that the term “psychological” should be used as the overarching term to encompass emotional, cognitive, and behavioural maltreatment… and that psychological maltreatment should be divided into sub-types of psychological abuse and psychological neglect for research and surveillance purposes…

Participants agreed that it is essential to know that an act or omission has caused harm, or has the potential to harm a child, to define an incident as child maltreatment, and that a harmful act should be defined as child maltreatment regardless of the traditional or cultural beliefs of the perpetrator… There was also consensus that maltreatment does not require confirmation, for example, by a multidisciplinary team or statutory authority” (p. 5).

“A key strength of this study was the inclusion of 70 experts working across multiple disciplines, including child protection professionals, healthcare professionals, academics, police, legal or forensic professionals, policy makers or civil servants, as well as adults with lived experience of child maltreatment, who are frequently excluded from research in this field” (p. 12).

Translating Research into Practice

“There was a clear consensus [that] child maltreatment is a subset of violence against children… Additional work is needed to clarify the characteristics that distinguish between these concepts, as well as to identify mechanisms that can be used by professionals working in this field to identify and classify new forms of maltreatment as they come to light” (p. 7- 8).

“Neglect, as agreed by our participants, is characterized by the failure to provide essential resources or failure to supervise a child, which leads to harm or the potential for harm… The agreement that all forms of neglect can be characterized as either a failure to provide or a failure to supervise aligns with the CMS. It will be helpful to further categorise neglect within these two sub-types, because specific types of neglect (e.g., educational or medical) require different and specialized interventions and support” (p.10-11).

“Further work is needed to explore how the concept of ‘psychological maltreatment’ overlaps with the broad neglect category and to understand whether there are additional sub-types within ‘psychological maltreatment’ that could be important to distinguish (e.g., fabricated or induced illness or childhood verbal abuse)” (p.11).

Other Interesting Tidbits for Researchers and Clinicians

“It is important to recognise that this is the first step in achieving international consensus on a definition of child maltreatment that can be widely used within research and surveillance. The next step will be to test whether the consensus commands support amongst additional experts from a wider range of professions. We suspect that several aspects of the definition will be challenged. These debates are positive and necessary, and may lead to significant refinements [and] modifications prior to wider acceptance and operationalisation” (p. 6-7).

“Standardised definitional elements are a prerequisite for the ability to compare the efficacy of interventions and prevention efforts across countries and systems in empirical studies. We propose a two path roadmap towards operationalisation: first, with targeted actions to apply the consensus definitional elements within research and surveillance. The second path emphasises strategic advocacy. Equipped with the robust consensus achieved, we see the need to support professionals, advocates, and communities to push for the resources and infrastructure necessary for the empirical study of child maltreatment epidemiology, prevention, and intervention” (p. 13).

“Use of a standardized definition will improve measurement and recording of child maltreatment, and lead to the development and implementation of more effective and targeted services and interventions. This in turn has the potential to reduce inequalities and lead to improved public health outcomes for children at risk of maltreatment” (p. 13).