REGULAR ARTI CLE

Prevalence and characteristics of child physical abuse in Sweden ndings

from a population-based youth survey
E-M Annerbck (eva-maria.annerback@dll.se)
1,2
, G Wingren
3
, CG Svedin
1
, PA Gustafsson
1
1.Child and Adolescent Psychiatry, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linko ping University, Linko ping, Sweden
2.Research and Development Center, So rmlands County Council, Eskilstuna, Sweden
3.Occupational and Environmental Medicine, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linko ping University, Linko ping, Sweden
Keywords
Child physical abuse, Prevalence, Risk factors,
Parental intimate-partner violence, Sweden
Correspondence
E-M Annerba ck, Child and Adolescent
Psychiatry, University Hospital,
S-581 85 Linko ping, Sweden.
Tel: +46-13-224211 |
Fax: +46-13-224234 |
Email: eva-maria.annerback@dll.se
Received
2 Decemebr 2009; revised 20 February 2010;
accepted 2 March 2010.
DOI:10.1111/j.1651-2227.2010.01792.x
ABSTRACT
Aim: To examine prevalence rates of child physical abuse perpetrated by a parent
caretaker, abuse characteristics and the extent of disclosures.
Methods: A population-based survey was carried out in 2008 amongst all the pupils
in three different grades (n = 8494) in schools in So dermanland County, Sweden. The
pupils were asked about their exposure to violence and their experiences of parental inti-
mate-partner violence. Data were analysed with bi- and multivariate models and a compari-
son between means of accumulating risk factors between three groups were performed.
Results: A total of 15.2% of the children reported that they had been hit. There were
strong associations between abuse and risk factors and there was a doseresponse rela-
tionship between risks and reported abuse. It was shown that children who reported paren-
tal intimate-partner violence were at a considerably higher risk for abuse than other children
and that only 7% of the children exposed to violence had disclosed this to authorities.
Conclusion: Even though child abuse in Sweden has decreased markedly during the last
40 years, violence against children is still a considerable problem. It is a challenge to develop
methods of assessment and interventions that will ensure that the violence and its underlying
causes are directly addressed.
INTRODUCTION
Child physical abuse (CPA) committed by parents or other
caretakers is a major public-health and social-welfare prob-
lem all around the world and is a serious violation of the
human rights of children (1,2). Many severe acute and long-
term consequences are associated with violence against
children; for example, physical injuries that can lead to
long-term physical illness, psychiatric symptoms and illness
as well as psycho-social problems (1).
The extent of the problem may differ between various
countries and parts of the world. A report from United
Nations states that only 2.4% of the worlds children are leg-
ally protected from corporal punishment in all settings,
including schools and homes (2). In comparison with inter-
national studies the prevalence rate of CPA in Sweden is
relatively low (3). Comparing prevalence rates between
countries can be difcult, however, because of different
methodological approaches used in different studies (1).
Sweden became in 1979 the rst country in the world to
prohibit corporal punishment and all violence against chil-
dren has been prohibited since then. Attitudes towards
physical punishment and the use of violence in bringing up
children have changed markedly in Sweden during the last
50 years and especially since the law was passed (1,3). In
1960, almost all children in Sweden were subjected to cor-
poral punishment, in 1980 half of the children and in 2000
only 14% according to studies using interviews with par-
ents. In surveys using young people as informants, 30%
reported that they had been spanked in 1995 and approxi-
mately 13% in studies from 2000 to 2006 (1,36). The more
severe forms of CPA have not shown a decrease corre-
sponding with the decrease of milder CPA (3,5,6).
In contrast with the decrease in prevalence rates, the
number of reports to the police about physical abuse of chil-
dren in Sweden quadrupled between the beginning of the
1980s and the end of the 1990s and has continued to
increase during the rst decade of the 2000s (7,8). This
trend has been interpreted as a result of increased vigilance
and decreased tolerance towards child abuse resulting in an
increased willingness to report to the authorities (8), but it
is not currently known if this is a true increase of CPA or is
as a result of a higher reporting frequency.
Risk factors
Numerous studies have found risk factors in different areas
that are associated with CPA. The rst area involves factors
associated with the perpetrators, factors such as parental
substance or alcohol abuse, parents psychiatric symp-
toms illness or medical problems, parental intimate-partner
violence and the experience the parents themselves have of
being exposed to child abuse (2,911). The proportions of
male female perpetrators are often equal in survey studies
Acta Pdiatrica ISSN 08035253
2010 The Author(s)/Journal Compilation 2010 Foundation Acta Pdiatrica/Acta Pdiatrica 2010 99, pp. 12291236 1229
irrespective of whether children or parents were used as
informants (4,12,13). When studies show differences
between genders, there is a distinct predominance of
women as abusers especially in cases of minor abuse (14
17). In the second area, there are social and nancial
factors, which are regarded as factors that place stress
and strain on the family. Financial difculties, parental edu-
cational level, unemployment, low socio-economic status
and family setting are all conditions that have been reported
as socio-economic factors (1,9,11,12,1820). In Sweden,
parents born abroad have been shown to constitute a
risk group in the same way as minority groups in other
countries have been shown to be associated with CPA
(1,12,16,18,19). However, signs of good integration and less
socio-economic problems seem to be more important than
land of origin (4). In the third area, characteristics of the
social network of each family that might contribute to social
isolation of the entire family and or the child and to lack of
extended family support are important (2). The fourth area
comprises child-related factors, such as age (younger chil-
dren are more subject to abuse) and gender. An important
child-related factor is the presence of some kind of disabil-
ity, and children with disabilities constitute a risk group as
do children who suffer from a long-term illness, have
behavioural problems or were born premature (2,21,22).
No single factor sufces to explain why people hit and hurt
their children; the phenomenon can only be understood on
the basis of multifactorial models that integrate social,
sociological and psychological explanations (14).
Theoretical model hypothesis
Child physical abuse arises when an accumulation of risk
factors on four different levels are present and presupposes
the existence of (i) a person with a tendency to use violence
in conict situations; (ii) a strong level of stress on the per-
petrator and the family that removes those barriers that
otherwise are present to prevent violence; (iii) an insuf-
cient social network that does not manage to protect the
child; (iv) a child who does not manage to protect him or
herself depending on factors such as, young age, disabil-
ity chronic disease or strong hierarchy in the family (23).
AIM
The objective of this study was to determine the prevalence
and the characteristics of CPA perpetrated by parents or
other caretakers and to examine the association with risk
factors. The theoretical model of accumulating risk factors
on different levels outlined above was tested with respect to
applicable aspects. Finally, the study examined to what
extent the children have told others about their exposure to
violence.
MATERIAL AND METHOD
This cross-sectional study based on the total number of
pupils in three different grades (n = 10 619) was conducted
in So dermanland County in Sweden in February and March
2008 by the Centre of Public Health in cooperation with
Centre for Clinical Research, County Council in So derman-
land. All the schools in the county with pupils in grades 7
(ca. 13 years old) and 9 (ca. 15 years old) in compulsory
school and grade 2 (ca. 17 years old) in upper secondary
school were invited to participate in the surveys. The pupils
were asked about their physical and mental health, lifestyle
and life experiences. The response rate was 83.7%
(n = 8891).
Denitions
Child abuse
Physical violence against a child executed by a parent or a
caretaker.
Caretaker
A parent or a person who, instead of the parent, had the
responsibility for the child at the time of the abuse.
Child
A person younger than 18 years.
The County of So dermanland
The County of So dermanland had a population of 267 500
in 2008. The percentage of young people (019 years old)
was the same in So dermanland as in Sweden as a whole
(24% in both) as was the percentage of foreign born people
(17% in both). The unemployment rate was slightly higher
in So dermanland (3.0%) than in Sweden as a whole (2.5%
the mean values for a twelve months period). The percent-
age of children living in low income households was 14% in
So dermanland and 12% in Sweden as a whole (24).
Data collection
Contact persons in the schools (school nurses and teachers)
were responsible for distribution and collection of the ques-
tionnaires. These were completed in classrooms and were
collected anonymously. To secure the condentiality the
children left their questionnaires in sealed envelopes. The
children were informed orally and in writing about the pur-
pose of the study and were told that all the collected infor-
mation would be strictly condential. The parents of the
children in grade seven and nine were informed by the
schools. The parents of the children in grade two in upper
secondary school were not informed because children
>15 years of age in Sweden have the right to make their
own decisions in such matters.
Study-population
There were three small schools (in all 130 pupils) and one
individualized learner programme in an upper secondary
school (n = 50) that declined to participate in the study.
The survey was sent to the schools for an estimated number
of 10 619 pupils. The drop-outs (1728) consisted mainly of
children absent from school on the days the questionnaires
were given out. These children were absent because of ill-
ness, required work at locations away from school or for
unspecied reasons. A second chance was given for those
Prevalence and characteristics of child physical abuse Annerba ck et al.
1230 2010 The Author(s)/Journal Compilation 2010 Foundation Acta Pdiatrica/Acta Pdiatrica 2010 99, pp. 12291236
not attending on the rst day of the survey. The drop-outs
of pupils absent from school for unspecied reasons may
distort the results as their absence could depend on for
example truancy and they might be a group less well-of.
Exclusions
From the survey, 385 8891 (4.3%) answers were excluded
from further analyses because the reported perpetrators of
CPA were other than caretakers. Answers from 12 indi-
viduals were rejected as they showed signs of hyper-
response: the children had given answers to every ques-
tion that were the worst most serious alternative choices
for the questions.
Final sample
The nal sample became 8494 pupils of which 2858 pupils
in grade 7, 2982 in grade 9 and 2654 in grade 2. The internal
drop-out of the questions used in this study was 3.5%
except for parental occupation where it was 8%.
The questionnaires
In the questionnaire there were 68 items for grade seven, 87
for grade nine in compulsory school and 98 items for grade
two in upper secondary school. There were three questions
about violence against the child and one about intimate-
partner violence; these questions were identical for all three
grades. The questions about violence were based on previ-
ous national Swedish studies (3,6).
Variables
1 The presence of a person with a tendency to use violence
in conict situations was indicated if the child reported
that violence had occurred between the adults in the
family (parental intimate-partner violence).
2 Social and or economic stress and strain on the family
Questions concerned the parents employment status,
accommodation of the family, marital status and country
of origin. Social and or economic stress was indicated if
the child answered yes to at least one of the questions
Do you live with a single parent; is at least one parent
foreign born; is at least one parent unemployed or on
sick leave.
3 Insufcient social network was indicated if the child
answered no to the question; Have you got any adult
person with whom you can talk about things that you are
concerned about?
4 Child-related factors Physical disability was indicated if
the child answered yes severe to one or more of the
questions asking if the child had impaired hearing,
impaired vision or impaired motion function. Psycholog-
ical disability was indicated if the child answered yes
severe to the question on dyslexia and yes minor or yes
severe to the question on Attention-Decit Hyperactiv-
ity Disorder. Child with chronic disease was indicated if
the child answered yes severe to one or more of the
questions on asthma, allergy, diabetes, epilepsy and
intestinal disease.
Accumulation of risk factors
A score was given for each of the risk factors named above.
If the child had answered no to all questions dealing with
that factor the value 0 was recorded, otherwise the value 1
was recorded for each factor. Thus, a variable accumulated
risk was created with a score that could theoretically range
from 0 to 4.
Hit was indicated if the child answered yes once or yes
several times to the question Have you been boxed on the
ear been hit by an adult?.
Statistical analysis
Data were analysed using the Statistical package for Social
Sciences, SPSS (versions 14.5 and 17.0). To estimate factors
associated with the occurrence of CPA we used logistic
regression to calculate odds ratios and 95% condence
intervals (CI) and both crude (cOR) and adjusted odds
(aOR) ratios were estimated. In the adjusted analysis we
used a multivariate logistic regression model where the
eight variables gender, parents employment, housing
accommodation, family setting, parent foreign born, childs
disability or disease, childs social network and nally
parental intimate-partner violence were entered simulta-
neously (Table 1). To compare means between groups One-
way ANOVA and Tamhanes post hoc test were used.
Ethical considerations
Questions about violence could be sensitive to deal with.
The pupils got information in the questionnaires about
where they could get counselling if participation had
caused feelings of distress. The fact that there was low
internal drop-out of the questions of violence was inter-
preted as an indication that the pupils felt comfortable with
answering them and that it might even have been seen as
positive to answer questions about their own exposure. In
Sweden, youth surveys are common but their purpose often
is to ask the children about their own (most often negative)
behaviour, such as smoking, alcohol use and criminal activ-
ities.
The study was approved by the Regional Ethical Review
Board of Linko ping (Dnr, M180-08).
RESULTS
Of the total sample of 8494 children, 1294 (15.2%) reported
that they had been hit by a parent or a caretaker and 542
(6.4% of all children) reported that they had been hit more
than once. In grade 7, 12.1% of the children reported that
they had been hit, in grade 9 18.6% and in grade 2, in upper
secondary school 16%. The girls reported slightly more
often that they had been hit than the boys did, but the differ-
ence was not signicant in the adjusted analysis (Table 1).
Biological parents were the most frequent perpetrators of
physical violence. Some children reported that they had
been hit by more than one person (n = 556). The distribu-
tion according to gender amongst the perpetrators was
almost equal even though there was a greater percentage of
men who had hit more than once (Table 2).
Annerba ck et al. Prevalence and characteristics of child physical abuse
2010 The Author(s)/Journal Compilation 2010 Foundation Acta Pdiatrica/Acta Pdiatrica 2010 99, pp. 12291236 1231
T
a
b
l
e
1
C
h
a
r
a
c
t
e
r
i
s
t
i
c
s
o
f
c
h
i
l
d
p
h
y
s
i
c
a
l
a
b
u
s
e
b
y
p
a
r
e
n
t
s
o
r
o
t
h
e
r
c
a
r
e
t
a
k
e
r
s
(
n
=
8
4
9
4
)
p
r
e
s
e
n
t
e
d
r
e
s
u
l
t
s
a
r
e
b
a
s
e
d
o
n
b
i
v
a
r
i
a
t
e
(
c
O
R
)
a
n
d
m
u
l
t
i
v
a
r
i
a
t
e
a
n
a
l
y
s
e
s
(
a
O
R
)
C
h
a
r
a
c
t
e
r
i
s
t
i
c
s
N
e
v
e
r
h
i
t
n
(
%
o
f
c
h
i
l
d
r
e
n
i
n
r
e
s
p
e
c
t
i
v
e
g
r
o
u
p
)
H
i
t
o
n
c
e
,
n
(
%
o
f
c
h
i
l
d
r
e
n
i
n
r
e
s
p
e
c
t
i
v
e
g
r
o
u
p
)
c
O
R

(
9
5
%
C
I
)
a
O
R
(
9
5
%
C
I
)
a
l
l
v
a
r
i
a
b
l
e
s
i
n
c
l
u
d
e
d
i
n
t
h
e
m
o
d
e
l

H
i
t
t
w
i
c
e
o
r
m
o
r
e
n
(
%
o
f
c
h
i
l
d
r
e
n
i
n
r
e
s
p
e
c
t
i
v
e
g
r
o
u
p
)
c
O
R

(
9
5
%
C
I
)
a
O
R
(
9
5
%
C
I
)
a
l
l
v
a
r
i
a
b
l
e
s
i
n
c
l
u
d
e
d
i
n
t
h
e
m
o
d
e
l

G
e
n
d
e
r

B
o
y
s
3
5
4
4
(
8
5
.
6
)
3
4
3
(
8
.
3
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
2
5
7
(
6
.
3
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
G
i
r
l
s
3
4
6
8
(
8
3
.
3
)
4
0
9
(
9
.
8
)
1
.
2
(
1
.
0
5

1
.
4
2
)
*
1
.
0
(
0
.
8
7

1
.
2
4
)
2
8
5
(
6
.
8
)
1
.
1
(
0
.
9
5

1
.
3
5
)
0
.
8
(
0
.
6
6

1
.
0
4
)
P
a
r
e
n
t
s
e
m
p
l
o
y
m
e
n
t

B
o
t
h
p
a
r
e
n
t
s
e
m
p
l
o
y
e
d
5
6
8
4
(
8
6
.
2
)
5
4
1
(
8
.
2
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
3
6
8
(
5
.
6
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
O
n
e
p
a
r
e
n
t
u
n
e
m
p
l
o
y
e
d

o
n
s
i
c
k
l
e
a
v
e
8
5
6
(
7
8
.
2
)
1
3
5
(
1
2
.
3
)
1
.
7
(
1
.
3
5

2
.
0
3
)
*
*
*
1
.
1
(
0
.
8
7

1
.
4
3
)
1
0
4
(
9
.
5
)
1
.
9
(
1
.
5
0

2
.
3
6
)
*
*
*
0
.
9
2
(
0
.
6
9

1
.
2
7
)
B
o
t
h
p
a
r
e
n
t
s
u
n
e
m
p
l
o
y
e
d

o
n
s
i
c
k
l
e
a
v
e
9
7
(
7
4
.
6
)
1
0
(
7
.
7
)
1
.
1
(
0
.
5
6

2
.
0
0
)
0
.
5
(
0
.
2
2

1
.
3
4
)
2
3
(
1
7
.
7
)
3
.
7
(
2
.
3
0

5
.
8
4
)
*
*
*
1
.
4
(
0
.
6
5

2
.
9
2
)
A
c
c
o
m
m
o
d
a
t
i
o
n

P
r
i
v
a
t
e
h
o
u
s
e
,
a
p
a
r
t
m
e
n
t
5
7
5
9
(
8
5
.
4
)
5
8
6
(
8
.
7
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
4
0
0
(
5
,
9
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
R
e
n
t
e
d

a
t
1
1
9
5
(
8
0
.
5
)
1
6
0
(
1
0
.
8
)
1
.
3
(
1
.
0
9

1
.
5
8
)
*
*
*
1
.
0
(
0
.
7
7

1
.
2
9
)
1
3
0
(
8
.
8
)
1
.
6
(
1
.
2
7

1
.
9
3
)
*
*
*
0
.
7
(
0
.
5
4

1
.
0
4
)
C
h
i
l
d
l
i
v
i
n
g
w
i
t
h

B
o
t
h
p
a
r
e
n
t
s
4
3
9
4
(
8
7
.
9
)
3
7
8
(
7
.
6
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
2
2
7
(
4
.
5
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
S
i
n
g
l
e
p
a
r
e
n
t
s
w
i
t
h
j
o
i
n
t
c
u
s
t
o
d
y
1
2
7
5
(
8
2
.
7
)
1
7
3
(
1
1
.
2
)
1
.
6
(
1
.
3
0

1
.
9
1
)
*
*
*
1
.
2
(
0
.
9
8

1
.
5
3
)
9
4
(
6
.
1
)
1
.
4
(
1
.
1
1

1
.
8
3
)
*
*
1
.
0
(
0
.
7
7

1
.
4
1
)
S
i
n
g
l
e
p
a
r
e
n
t
5
9
8
(
7
6
.
1
)
9
1
(
1
1
.
6
)
1
.
8
(
1
.
3
9

2
.
2
6
)
*
*
*
1
.
1
(
0
.
7
7

1
.
5
1
)
9
7
(
1
2
.
3
)
3
.
1
(
2
.
4
4

4
.
0
4
)
*
*
*
1
.
9
(
1
.
3
5

2
.
8
0
)
*
*
*
P
a
r
e
n
t
a
n
d
s
t
e
p
p
a
r
e
n
t
3
5
1
(
7
8
.
0
)
5
8
(
1
2
.
9
)
1
.
9
(
1
.
4
3

2
.
5
9
)
*
*
*
1
.
2
(
0
.
8
2

1
.
7
5
)
4
1
(
9
.
1
)
2
.
3
(
1
.
5
9

3
.
2
1
)
*
*
*
0
.
9
(
0
.
5
6

1
.
5
4
)
F
o
s
t
e
r
h
o
m
e
9
6
(
6
5
.
8
)
2
3
(
1
5
.
8
)
2
.
8
(
1
.
7
5

4
.
4
4
)
*
*
*
1
.
9
(
1
.
0
7

3
.
4
8
)
*
2
7
(
1
8
.
5
)
5
.
4
(
3
.
4
8

8
.
5
2
)
*
*
*
2
.
1
(
1
.
0
7

4
.
2
9
)
*
P
a
r
e
n
t
f
o
r
e
i
g
n
b
o
r
n

N
o
p
a
r
e
n
t
f
o
r
e
i
g
n
b
o
r
n
6
1
2
4
(
8
6
.
5
)
6
2
1
(
8
.
7
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
4
1
4
(
5
.
8
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p

1
p
a
r
e
n
t
f
o
r
e
i
g
n
b
o
r
n
7
6
6
(
7
6
.
5
)
1
2
0
(
1
2
.
0
)
1
.
5
(
1
.
2
5

1
.
9
0
)
*
*
*
1
.
7
(
1
.
2
9

2
.
2
4
)
*
*
*
1
1
5
(
1
1
.
5
)
2
.
2
(
1
.
7
8

2
.
7
7
)
*
*
*
2
.
2
(
1
.
5
5

3
.
0
0
)
*
*
*
C
h
i
l
d
w
i
t
h
d
i
s
a
b
i
l
i
t
y
o
r
d
i
s
e
a
s
e

N
o
d
i
s
a
b
i
l
i
t
y
6
2
8
7
(
8
5
.
3
)
6
5
4
(
8
.
9
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
4
3
0
(
5
.
8
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
P
h
y
s
i
c
a
l
d
i
s
a
b
i
l
i
t
y
6
6
(
6
7
.
3
)
1
3
(
1
3
.
3
)
1
.
9
(
1
.
0
4

3
.
4
5
)
*
1
.
1
(
0
.
4
7

2
.
5
0
)
1
9
(
1
9
.
4
)
4
.
2
(
2
.
5
0

7
.
0
8
)
*
*
*
1
.
0
(
0
.
3
8

2
.
8
0
)
P
s
y
c
h
o
l
o
g
i
c
a
l
d
i
s
a
b
i
l
i
t
y
2
1
2
(
6
6
.
2
)
5
0
(
1
5
.
6
)
2
.
3
(
1
.
6
5

3
.
1
2
)
*
*
*
1
.
7
(
1
.
0
7

2
.
5
7
)
*
5
8
(
1
8
.
1
)
4
.
0
(
2
.
9
4

5
.
4
3
)
*
*
*
1
.
8
(
1
.
0
9

2
.
9
5
)
*
C
h
r
o
n
i
c
d
i
s
e
a
s
e
3
8
4
(
7
7
.
1
)
4
6
(
9
.
2
)
1
.
2
(
0
.
8
4

1
.
5
8
)
0
.
9
(
0
.
5
8

1
.
3
0
)
6
8
(
1
3
.
7
)
2
.
6
(
1
.
9
7

3
.
4
1
)
*
*
*
1
.
9
(
1
.
2
8

2
.
8
1
)
*
*
C
h
i
l
d

s
s
o
c
i
a
l
n
e
t
w
o
r
k

S
u
f

c
i
e
n
t
n
e
t
w
o
r
k
6
4
7
3
(
8
6
.
0
)
6
5
3
(
8
.
7
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
4
0
4
(
5
.
4
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
I
n
s
u
f

c
i
e
n
t
n
e
t
w
o
r
k
5
0
9
(
6
8
.
1
)
1
0
2
(
1
3
.
7
)
2
.
0
(
1
.
5
8

2
.
4
9
)
*
*
*
1
.
7
1
.
3
1

2
.
2
9
*
*
*
1
3
6
(
1
8
.
2
)
4
.
3
(
3
.
4
6

5
.
3
0
)
*
*
*
3
.
0
(
2
.
2
4

4
.
1
1
)
*
*
*
P
a
r
e
n
t
a
l
i
n
t
i
m
a
t
e
-
p
a
r
t
n
e
r
v
i
o
l
e
n
c
e

N
e
v
e
r
6
5
6
4
(
8
9
.
7
)
4
9
1
(
6
.
7
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
2
6
0
(
3
.
6
)
R
e
f
e
r
e
n
c
e
g
r
o
u
p
Y
e
s
,
o
n
c
e
o
r
t
w
i
c
e
2
9
9
(
4
8
.
4
)
2
0
7
(
3
3
.
5
)
9
.
3
(
7
.
5
8

1
1
.
3
0
)
*
*
*
8
.
0
6
.
3
4

1
0
.
1
3
*
*
*
1
1
2
(
1
8
.
1
)
9
.
5
(
7
.
3
6

1
2
.
1
4
)
*
*
*
6
.
9
(
5
.
0
5

9
.
4
2
)
*
*
*
Y
e
s
,
s
e
v
e
r
a
l
t
i
m
e
s
8
3
(
2
7
.
9
)
5
0
(
1
6
.
8
)
8
.
1
(
5
.
6
0

1
1
.
5
8
)
*
*
*
7
.
8
5
.
1
4

1
1
.
9
7
*
*
*
1
6
4
(
5
5
.
2
)
4
9
.
9
(
3
7
.
2
6

6
6
.
7
8
)
*
*
*
3
5
.
1
(
2
4
.
2
6

5
0
.
8
3
)
*
*
*
c
O
R
=
c
r
u
d
e
o
d
d
s
r
a
t
i
o
;
a
O
R
=
a
d
j
u
s
t
e
d
o
d
d
s
r
a
t
i
o
.

O
d
d
s
r
a
t
i
o
w
i
t
h

n
e
v
e
r
h
i
t

a
s
t
h
e
c
o
m
p
a
r
i
s
o
n
g
r
o
u
p
.

A
l
l
8
v
a
r
i
a
b
l
e
s
w
e
r
e
e
n
t
e
r
e
d
s
i
m
u
l
t
a
n
e
o
u
s
l
y
i
n
a
m
u
l
t
i
v
a
r
i
a
t
e
l
o
g
i
s
t
i
c
r
e
g
r
e
s
s
i
o
n
m
o
d
e
l
.

I
n
t
e
r
n
a
l
d
r
o
p
-
o
u
t

3
.
5
%
.

I
n
t
e
r
n
a
l
d
r
o
p
-
o
u
t
i
s
8
.
0
%
.
*
p
<
0
.
0
5
,
*
*
p
<
0
.
0
1
,
*
*
*
p
<
0
.
0
0
1
.
Prevalence and characteristics of child physical abuse Annerba ck et al.
1232 2010 The Author(s)/Journal Compilation 2010 Foundation Acta Pdiatrica/Acta Pdiatrica 2010 99, pp. 12291236
Characteristics
The association between risk factors on different levels and
the prevalence of CPA are shown in Table 1. In summary,
most of the known risk factors that were asked for in the
survey had a univariate association with physical abuse. In
the multivariate logistic regression model, living in foster
home, parent foreign born, psychological disability, insuf-
cient social network and parental intimate-partner violence
were signicant on 95% CI for being hit once. The same
variables and in addition the variables living with a single
parent and chronic disease were signicant for being hit
twice or more.
Parental intimate-partner violence
Of the total group, 915 (10.8%) children reported that vio-
lence had occurred between the adults in their families. Of
these 533 (58%) reported that they themselves had been hit
once or more. The perpetrators of violence against the child
in this group were men (fathers or and mothers partner) in
386 (55%) cases and women (mothers or and fathers part-
ner) in 318 cases (45%) (n.s.). (Some children reported
more than one perpetrator.) The proportion of male and
female perpetrators when the children had reported that
they had been hit once or twice was 51% and 49%, respec-
tively and, when they reported that they have been hit more
than twice, the proportions male and female were 61% and
39%, respectively. The difference between gender of perpe-
trators who had hit 12 times and those who had hit more
than two times was statistically signicant (p = 0.004).
Accumulation of risk factors
We determined the number of risk areas according to the
four categories (occurrence of parental intimate-partner
violence; socio-economic stress on the family; insufcient
social network; child with disability and or chronic disease)
for every single child and calculated mean values. The num-
ber of children who did not report any risk was 4590, 2840
reported one risk, 785 two risks, 78 three and 25 reported
four risks. The mean value for the whole group was 0.57.
Children who reported that they never had been hit had a
mean value of 0.47 risks per person. Those who had been
hit once had 0.94 risks per person and those who had been
hit twice or more had 1.33 risks per person. In all four
groups, the range was 04. The differences between the
groups were signicant (p < 0.001). Also the post hoc analy-
sis showed a signicant difference (p < 0.001) between the
means in the three groups with a doseresponse relation-
ship between risk and reported CPA.
Who knows about the violence against the child?
Only 32% of all the children who reported that they had
been exposed to CPA had told an adult person about this.
More than one third of the children had not told anyone.
(Table 3).
DISCUSSION
In this cross-sectional study, we examined prevalence rates
of CPA, abuse characteristics and tested a hypothesis of
accumulative risk factors. The results can be summarized in
seven main ndings.
Prevalence rates
It was found that 15% of all children had been exposed to
violence by parents or caretakers during their childhood.
The youngest children in grade 7 in compulsory school
reported CPA to a lesser degree than the older did. The g-
ure of prevalence in this study is somewhat higher in com-
parison with two other studies performed in Sweden during
the last decade (3,4). One possible explanation of this might
be that there are slightly worse socio-economic conditions
in this particular county than in Sweden as a whole (24).
However, there was no continued decrease of prevalence
between the 2000 and 2006 surveys as there had been
between 2000 and the study in 1994 (6). Whether there is a
trend of increasing prevalence of CPA in Sweden or not is
an important issue for future research to follow up. The
prevalence rate of CPA is lower in this study as well as in
previous Swedish studies compared with the rate reported
in studies from other western European countries; for
example in Denmark and England, the corresponding g-
ures for prevalence were 24% and 25%, respectively (25,26).
Contribution of gender amongst the perpetrators
In this study, the percentage of female perpetrators was
almost the same as for male perpetrators of CPA. This result
conrms what other studies have revealed (4,12,13) but
forms a sharp contrast to the proportions in the crime-sta-
tistics of Sweden where men are strongly over-represented
(7).
Table 3 Disclosures of child physical abuse
Have you told anyone
that you have been hit?
Hit once
(n = 752), %
Hit twice or
more (n = 542), %
Ever hit
(n = 1294), %
Not told 41 28 36
Siblings, peers 46 59 52
Parents 20 24 22
Authorities* 3 13 7
BRIS or similar

2 5 3
The sum is >100% because some pupils answered more than one alternative.
*Authority means personnel in school, social services, police and similar.

BRIS (Childrens Rights in the Society) or similar means voluntary organiza-

tions, where children can get in contact with someone anonymously.
Table 2 Perpetrators of violence against the child
By whom have you
been hit? Hit once, n (%)*
Hit twice or
more, n (%)* Total, n (%)*
Mother 551 (30.6) 195 (10.8) 746 (41.4)
Father 522 (29) 251 (13.9) 773 (42.9)
Mothers partner 103 (5.7) 90 (5) 193 (10.7)
Fathers partner 36 (2) 54 (3) 90 (5)
Total 1212 (67.3) 590 (32.7) 1802

*Percent of the children who reported that they had been hit.

Five hundred and eight children answered more than one alternative.
Annerba ck et al. Prevalence and characteristics of child physical abuse
2010 The Author(s)/Journal Compilation 2010 Foundation Acta Pdiatrica/Acta Pdiatrica 2010 99, pp. 12291236 1233
Disclosures of child physical abuse
Our results showed, that the experiences children have of
being exposed to violence are hidden to a high degree from
the adult society. This nding is a conrmation of what an
earlier Swedish study had found about disclosures of child
sexual abuse (27). That only 7% had told personnel from
authorities indicates that the increase of police-reports in
Sweden still only represents a fraction of the real numbers
of CPA.
Risk factors
The results from this study conrmed that CPA is associated
with several risk factors on different levels which can indi-
cate stress and strain on the family (2,9). There seemed to
be a doseresponse effect insofar as that the children report-
ing that they had been hit more than once generally
reported higher numbers of risk factors. In the crude analy-
ses, there were strong correlations between almost all of the
risk factors asked for in this survey and exposure of CPA.
When controlling for confounding, we found that many of
the social and economic factors were associated with each
other. There was strong association between living in foster
homes and CPA and also with living with a single parent
and CPA. In both these cases, there are at least two possible
interpretations. One explanation is that the children are
exposed to violence by foster parents or by the single parent
and another is that the children had been exposed at an ear-
lier stage of their lives or to a perpetrator outside the actual
family setting. Having an insufcient social network was
associated with CPA also in the adjusted analyses as was
the childs psychological disability. Having a chronic dis-
ease was correlated with being hit twice or more. The result
that children with diseases or disabilities are at higher risk
for abuse conrms other studies (22,28) and it is important
to acknowledge that these children might place increased
demands on adults and indicate a situation of strain in the
family.
Parental intimate-partner violence
The strong association between CPA and parental intimate-
partner violence was an important nding of this study and
conrmed prior studies (10,11,23,29). Our results revealed
that the children had not only been witnessing and been
aware of the violence between the adults in the family, but
had also to a great extent themselves been exposed to vio-
lence. Another important nding was that the proportion of
male perpetrators was almost the same as the proportion of
female perpetrators but men were overrepresented in cases
when children had been hit several times. Men in cases
where parental intimate-partner violence was reported were
in this respect responsible for more severe abuse. The rela-
tion between parental intimate-partner violence and CPA
needs to be studied in a comprehensive way and from more
perspectives than the general perspective that men are abus-
ing women and children. Researchers have most often
focused on either CPA or intimate-partner violence and
then overlooked the overlap between these two aspects of
violence in families. This has led to a fragmentation both of
the understanding of this phenomenon and of the societal
responses to it (30).
Parent foreign born
There was a strong association in this study, as in prior stud-
ies, between foreign born parents and CPA (18,19) and the
association remained after adjusting for other variables
including socio-economic variables as parental employment
and housing. The results showed that the explanation that
this group is living under poorer social conditions than
Swedish-born people is relevant but not sufcient. A differ-
ent view of child rearing, where violence is more generally
accepted could also be a partial explanation. In addition, we
have to acknowledge that families in which one or both par-
ents were born outside of Sweden constitute a group faced
with a high frequency of problems also on the individual
level. These problems could derive from experiences both
from their country of origin and from their stranger-position
in Sweden (23).
Accumulation of risk factors
Our results conrmed the hypothesis of accumulation of
risk factors on different levels as a condition for CPA even
though there are several variables of importance that we
could not ask for in this survey, variables such as, for exam-
ple, parental psychiatric illness, addiction, socio-economic
status and characteristics of the familys social network.
This model implies that risk assessment as well as preven-
tive and treatment interventions should be carried out on all
four levels: (i) Is there an adult person in the family with a
tendency to use violence in conict situations? (ii) To what
extent is the family exposed to stress and strain and what
interventions can be carried out to reduce these conditions?
(iii) Is the childs and the familys social network weakened
and or insufcient? and (iv) In what respects could the
child face obstacles that make it difcult to protect him- or
herself?
Strengths and limitations
This study is the largest study in Sweden of prevalence and
characteristics of CPA. The statistical power is very high
and the overall response rate is high. The large sample
enables us to determine associations between different vari-
ables and CPA also in relatively small subgroups. The results
of this study may be generalized to other children in Sweden
because there are only marginal differences between the
socio-demographical conditions in So dermanland County
as in Sweden as a whole.
Still there is a risk that the validity of the childrens
answers could be reduced by recall biases especially as ques-
tions about violence may be sensitive to deal with, which
could lead to an underestimation of the prevalence rate.
This is, however, not shown in the response-rates, as there
was a low internal drop-out of the questions about violence.
The lower rate of reported CPA amongst the youngest chil-
dren could yet be an example of recall bias as these probably
are more loyal to and dependent on their families than the
older are and therefore less willing to recall or report
Prevalence and characteristics of child physical abuse Annerba ck et al.
1234 2010 The Author(s)/Journal Compilation 2010 Foundation Acta Pdiatrica/Acta Pdiatrica 2010 99, pp. 12291236
difculties in their homes. Another problem with the design
is that it is not possible to ask children about certain kinds
of information about family conditions, as they do not have
the knowledge of them. One example is that we asked for
the parents education level but the internal drop-out of this
question was more than 30%, and therefore, we have not
been able to use that information. This limits the quantity of
information about various relevant back-ground factors.
Finally, one limitation in this survey is that it only asked for
life-time experiences of CPA. Questions about experiences
from for example the past year would have made it possible
to determine at what age the children had been exposed to
violence.
In conclusion, this study shows that violence against chil-
dren still may be considered widespread in Sweden because
almost every sixth child is exposed to a behaviour that has
been prohibited in this country for more than 30 years. It is
still a considerable problem, which needs to be taken care
of by politicians and authorities who are responsible for the
welfare of children. Methods of assessment and interven-
tions need to be improved. It is a challenge for the interdis-
ciplinary eld working with CPA to develop methods that
will ensure that the violence and its underlying causes are
directly addressed.
ACKNOWLEDGEMENTS
The study was made possible by grants from Centre for
Research and Development Centre for Clinical Research,
So dermanland County council, Sweden. Valuable statistical
support has been given from Statisticians at Centre for
Research and Development, So rmland County council,
Sweden.
References
1. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson
S. Burden and consequences of child maltreatment in high-
income countries. Lancet 2009; 373: 6881.
2. Pinheiro PS. World report on violence against children.
Geneva: United Nation, 2006.
3. Statens offentliga utredningar. Barn och misshandel: en rapport
om kroppslig bestraffning och annan misshandel i Sverige vid
slutet av 1900-talet.(Children and abuse a report of physical
punishment and other types of abuse in Sweden). (In Swedish).
Stockholm, 2001: 18.
4. Stiftelsen Allma nna Barnhuset. Va ld mot barn 2006-2007 en
nationell kartla ggning. (Violence against children a national
survey 2006-2007). (In Swedish). Stockholm, 2007: 4.
5. Gelles RJ, Edfeldt AW. Violence towards children in the United
States and Sweden. Child Abuse Negl 1986; 10: 50110.
6. Statistiska centralbyra n. Barn och aga : en underso kning om
vuxnas och ho gstadieelevers insta llning, erfarenheter och kuns-
kap. (Children and physical punishment. A survey of adultsand
pupilsattitudes, experiences and knowledge). Stockholm,
1996: 1.1.
7. Brottsfo rebyggande ra det. A

rsstatistik 2008. (Crime Statistics

for 2008) (In Swedish). [cited November 18, 2009]. Available
from: http://www.bra.se/extra/pod/?action=pod_show&
module_instance=21&id=488&statsType=200&stats
County=La&Year=2008&type=1&statsPopulation=all.
8. Statens offentliga utredningar. Barnmisshandel att fo rebygga
och a tga rda. (Child abuse Prevention and protection).
(In Swedish with an English summary). Stockholm, 2001: 72.
9. Hornor G. Physical abuse: recognition and reporting. J Pediatr
Health Care 2005; 19: 411.
10. Hornor G. Domestic violence and children. J Pediatr Health
Care 2005; 19: 20612.
11. Straus MA, Gelles RJ, Smith C. Physical violence in American
families : risk factors and adaptations to violence in 8,145
families. New Brunswick, N.J.: Transaction Publishers, 1990;
Chapter 14
12. Sariola H, Uutela A. The prevalence and context of family
violence against children in Finland. Child Abuse Negl 1992;
16: 82332.
13. Straus MA, Stewart JH. Corporal punishment by American
parents: national data on prevalence, chronicity, severity, and
duration, in relation to child and family characteristics. Clin
Child Fam Psychol Rev 1999; 2: 5570.
14. Bardi M, Borgognini-Tarli SM. A survey on parent-child
conict resolution: intrafamily violence in Italy. Child
Abuse Negl 2001; 25: 83953.
15. Figueiredo B, Bifulco A, Paiva C, Maia A

, Fernandes E, Matos
R. History of childhood abuse in Portuguese parents. Child
Abuse Negl 2004; 28: 67184.
16. Maker AH, Shah PV, Agha Z. Child Physical abuse: prevalence,
characteristics, predictors, and beliefs about parent-child vio-
lence in South Asian, Middle Eastern, East Asian, and Latina
Women in the United States. J Interpers Violence 2005; 20:
140628.
17. Tang CS-k. Corporal punishment and physical maltreatment
against children: a community study on Chinese parents in
Hong Kong. Child Abuse Negl 2006; 30: 893907.
18. Annerback EM, Lindell C, Svedin CG, Gustafsson PA. Severe
child abuse: a study of cases reported to the police. Acta
Paediatr 2007; 96: 17604.
19. Lindell C, Svedin CG. Physical child abuse in Sweden: a study
of police reports between 1986 and 1996. Soc Psychiatry
Psychiatr Epidemiol 2001; 36: 1507.
20. Youssef RM, Attia MS-E-D, Kamel MI. Children experiencing
violence I: parental use of corporal punishment. Child Abuse
Negl 1998; 22: 95973.
21. Olivan Gonzalvo G. Maltreatment of children with disabilities:
characteristics and risk factors. An Esp Pediatr 2002; 56:
21923.
22. Sullivan PM, Knutson JF. The prevalence of disabilities and
maltreatment among runaway children. Child Abuse Negl
2000; 24: 127588.
23. Annerback EM, Svedin CG, Gustafsson PA Characteristic
features of severe child physical abuse a multi-informant
approach. J Fam Violence. 2009. DOI 10.1007/s10896-
009-9280-1.
24. Statistiska centralbyra n. Befolkningsstatistik. (Statistics of
Sweden. Population statistics). (In Swedish). [Cited November
18, 2009] Available from: http://www.scb.se/Pages/list____
250612.aspx.
25. Statens institut for Folkesundhed. Unges trivsel A

r 2008 En
underso gelse med fokus pa seksuelle overgreb og vold i barn-
dom og tidlig ungdom. (Youthswell- being 2008 A survey
with focus on sexual abuse and violence in childhood and early
youth). (In Danish). Ko penhamn, 2009.
26. May-Chahal C, Cawson P. Measuring child maltreatment in the
United Kingdom: a study of the prevalence of child abuse and
neglect. Child Abuse Negl 2005; 29: 96984.
27. Priebe G, Svedin CG. Child sexual abuse is largely hidden
from the adult society: an epidemiological study of adolescents
disclosures. Child Abuse Negl 2008; 32: 1095108.
Annerba ck et al. Prevalence and characteristics of child physical abuse
2010 The Author(s)/Journal Compilation 2010 Foundation Acta Pdiatrica/Acta Pdiatrica 2010 99, pp. 12291236 1235
28. Jaudes PK, Mackey-Bilaver L. Do chronic conditions increase
young childrens risk of being maltreated? Child Abuse Negl
2008; 32: 67181.
29. Almqvist K, Broberg A. Barn som bevittnat va ld mot mamma
en studie om kvinnor och barn som vistas pa kvinnojourer i
Go teborg. (Children who have stayed in womens crisis center
in Go tebrog) (In Swedish). Go teborgs stad, 2003.
30. Edleson JL. The overlap between child maltreatment and
woman battering. Violence Against Women. 1999;5:134. DOI:
101177 107780129952003.
Prevalence and characteristics of child physical abuse Annerba ck et al.
1236 2010 The Author(s)/Journal Compilation 2010 Foundation Acta Pdiatrica/Acta Pdiatrica 2010 99, pp. 12291236