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.

bDivision 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 final 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 final 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 final 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

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PEDIATRICS Volume 137, number 3, March 2016:e20154079 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,

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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 flow 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
full review on 54 reports. Of these, (by child and/or caregiver); (4) age data by age,2–16,18 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,

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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-specific 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
Synthesizing Estimates of Minimum estimates for 2 age groups (2–14
violence, we include only direct
Exposure to Past-year Violence and 15–17 years) of minimum
victimization data. In instances
prevalences of violence in the
The final review included data from where the same survey had been
previous 12 months. Age ranges and
112 studies in 96 countries. We used implemented periodically (eg,
types of violence reported varied
a triangulation approach, which NatSCEV, HBSC), we used the most
across surveys, with most reporting
included a critical synthesis of data recently published.14,47
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
year violence.49–51 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)

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4 HILLIS et al
 TABLE 1 Population-Based Surveys Measuring Past-year Violence Against Children: Characteristics and Survey Quality Indicators
Characteristics Quality
Age Group for Survey Type (Ref. No. of Countries Standard Training Probabilistic Weighted Coverage Participation
Review, Y No.) Countries Definition Sampling Analyses
NAT REG MUN
2–14 MICS (12, 24, 45) 33 Albania, Algeria, Azerbaijan, Belarus, Belize, Bosnia 33 33 33 33 33 Not Reported
& Herzegovina, Burkina Faso, Cameroon, Central
African Republic, Gambia, Georgia, Ghana,
Guinea-Bissau, Guyana, Iraq, Ivory Coast, Jamaica,
Lao People’s Democratic Republic, Kazakhstan,
Kyrgystan, Kenya, Montenegro, Macedonia, Serbia,
Sierra Leone, Suriname, Syria, Tajikistan, Togo,

PEDIATRICS Volume 137, number 3, March 2016

Trinidad & Tobago, Vietnam, Ukraine, Yemen
WorldSafe (13) 6 Brazil, Egypt, India, United States, Chile, Philippines 6 6 6 6 1 5 33%–99%
NatSCEV (11, 38, 1 United States 1 1 1 1 1 Variable across
40, 41, 47) samples,
14%–67%
CTS (35, 37, 39, 3 Canada, Italy, Finland 3 3 1 1 2 50%–57%
43)
15–17 VACS (10, 18, 8 Swaziland, Zimbabwe, Kenya, Tanzania, Haiti, Malawi, 8 8 8 8 8 88%–98%
25–30, 31, 44) Nigeria, Cambodia
GSHS (15, 17, 19, 21 Botswana, Brazil, Chile, China, Egypt, Guyana, 21 21 21 21 21 84%
20, 22, 23) Jordan, Lebanon, Kenya, Morocco, Namibia, Oman,
Philippines, Swaziland, Tajikistan, Tanzania, Uganda,
United Arab Emirates, Venezuela, Zambia, Zimbabwe
HBSC (14, 21, 37 Armenia, Austria, Belgium, Canada, Croatia, Czech 37 37 37 37 37 60%
32, 42) 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
National Survey 1 Brazil 1 1 1 1 1 83%
of School
Health
(PeNSE) (48)
YRBS, Physical 1 United States 1 1 1 1 1 67%
dating

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violence (36,
46)
Bullying (17, 33, 3 New Zealand, Pakistan, Australia 1 2 1 1 2 45%–70%
34)
MUN, municipal; NAT, national; REG, regional.

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

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6 HILLIS et al
 Total N for Included Minimum n Affected Minimum % Total N From Census Data Minimum n Imputed
of the nearly 2 billion children aged

Affected by VAC

j = (g/f) × (i)
36 691 983
101 949 939
10 943 618
6 967 841
8 006 772

640 197
2 to 17 years experienced physical,
emotional, and/or sexual violence in
the previous year (Table 4). Though
Total Population at Risk

prevalences of violence were high in

both the developing and developed
world, the minimum number

Minimum prevalences and projected minimum estimates of total numbers of children affected. Excludes children exposed to moderate physical violence, which is defined as spanked, slapped in the face, hit, or shook.
estimated as suffering victimization
71 989 161
212 833 830
32 906 540
22 775 007
13 699 268

1 617 154
in the developing world in 2014
i

exceeded 1 billion children (Table 5).

DISCUSSION
Ages 15–17 y

With Past-
year VAC

h = g/f

Our systematic review of studies used

51
48
33
31
58

40

to derive minimum estimates of past-

year violence against children showed
Pooled From Published Reports

these population-based surveys

by VAC From

15 723 230
68 854 329
4 482 313
6 590 651
8 005 173

399 949

were high quality.16 Most surveys

Reports

had the following characteristics:

probabilistic sampling, standard
definitions, training of interviewers/
questionnaire administrators,
Reports, Census

weighting of estimates for complex

30 848 759
143 742 417
13 477 938
21 542 125
13 696 533

1 010 283

designs, and national scope. If we

Data

assume our base-case scenario

combining prevalences across
approximately half of the countries
Imputed Affected

are representative of overall minimum

e = (b/a) × (d)

Not available
193 071 746
612 606 832
47 485 696
8 224 160
32 187 659
Minimum n

prevalence estimates for all countries,

by VAC
TABLE 2 Base Case Estimates of Past-year Violence Against Children by Age Group and Region

Total Population at Risk

and thus can be projected to the

entire population, then the number
of children exposed to violence in the
past year exceeds 1 billion, or half the
Total N From

385 921 657

903 793 328
138 468 115
100 964 471
57 860 154

7 090 890
Census Data

children in the world. Region-specific

estimates for children aged 2 to 17
d

years indicate that the Asian, African,

and Northern American regions had
Ages 2–14 y

the highest minimum prevalences.

Minimum

Past-year

c = b/a
% With

Because of the sheer size of the Asian

VAC

50
68
34
8
56

population, the minimum estimate

Pooled From Published Reports

of numbers of children experiencing

Affected by VAC

Not available
From Reports

past-year violence there was ∼2 times

266 954 747
Minimum n

35 958 876

18 429 032

32 175 318
1 359 251

greater than in the other regions

b

combined. Even more sobering were

findings from the sensitivity analyses,
which included moderate physical
Included Reports,

71 876 435
393 844 643
53 738 988
16 686 939
57 837 970
Census Data

violence and showed three-fourths

Total N for

of the world’s children experienced

a

violence in the previous year.

Whether from the base case or from
the sensitivity analysis, our findings
Latin America

compel urgent action.

America
Northern

Oceania
Europe
Region

Prevalences of country-specific types

Africa
Asia

of violence against children, such as

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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, defined 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 defined 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 defined as spanked, slapped in the face, hit, or shook.

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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,
new SDG agenda proposes ending all published estimates, or if in the
nongovernmental, and civil society
forms of violence against children, several cases with only subnational
organizations in the shared goal of
our synthesized estimates help estimates, those differ from national
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

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PEDIATRICS Volume 137, number 3, March 2016 9
strategies are in large part built as of evidence-based interventions to
an adaptation of the CDC THRIVES
ABBREVIATIONS
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
progress, and drive the urgent action NatSCEV: National Survey of
Our findings using population-
endorsed in the 2030 Sustainable Children's Exposure to
based data from approximately
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 findings and conclusions in this paper are those of the author(s) and do not necessarily represent the official 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 financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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PEDIATRICS Volume 137, number 3, March 2016 13
Global Prevalence of Past-year Violence Against Children: A Systematic Review
and Minimum Estimates
Susan Hillis, James Mercy, Adaugo Amobi and Howard Kress
Pediatrics originally published online January 25, 2016;

Updated Information & including high resolution figures, can be found at:
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015-4079
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Global Prevalence of Past-year Violence Against Children: A Systematic Review
and Minimum Estimates
Susan Hillis, James Mercy, Adaugo Amobi and Howard Kress
Pediatrics originally published online January 25, 2016;

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Data Supplement at:

http://pediatrics.aappublications.org/content/suppl/2016/02/08/peds.2015-4079.DCSupplemental

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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