Frequency of child maltreatment in a representative sample of the German population

Child maltreatment refers to all forms of abusive and neglectful behavior involving emotional, physical and sexual transgressions, resulting in actual or potential harm to the child’s health, survival or development [1, 2]. Although child maltreatment is one of the most important social challenges worldwide and is associated with substantial impairments of social wellbeing and health [3‐6], information about the frequency of child maltreatment in high-income societies is still scarce and inconsistent.

For example, there are hardly any studies that have reported rates of child maltreatment in the German population. As an exception Wetzels [7] has included an instrument for the assessment of sexual and physical abuse in a representative survey of 3,289 subjects in the age range of 16 to 59. Sexual abuse was reported by 8.6% of the women and 2.8% of the men and prevalence rate of physical abuse was 10.6%. However, this study is limited by the fact that the assessment of child maltreatment was not comprehensive. Although consensus definitions of child maltreatment include five types, i.e. physical abuse, physical neglect, emotional abuse, emotional neglect and sexual abuse [8‐10], and the emotional types of maltreatment seem to have similar detrimental health effects as sexual and physical abuse [11], the emotional forms of maltreatment have commonly been excluded from large-scale representative surveys in different countries [12‐15]. In addition, similar to the other studies Wetzels [7] concentrated on the assessment of physical and sexual abuse using an ad-hoc developed scale that does not allow a comparison of results with other surveys or data from clinical populations that used different questionnaires.

Recently, Haeuser et al. [16] reported the frequency of child maltreatment from a representative survey in Germany. This study is outstanding since data on child maltreatment was collected using the standard and well validated child maltreatment instrument Childhood Trauma Questionnaire (CTQ) [17] that allows the assessment of all common types of child maltreatment. The strength of this instrument is that it allows a severity rating of sexual abuse, physical abuse, physical neglect, emotional abuse and emotional neglect, which reflects the fact that the different forms of child maltreatment may be continuous phenomena ranging from small to severe transgressions rather than clearly delimitable entities [18, 19]. However, a dichotomous categorization of the forms of child maltreatment using a severity cut-off is indicated to allow the comparison of rates of child maltreatment from studies that applied different instruments based on similar definition. While the authors of the CTQ do not provide thresholds to determine the presence of the different types of maltreatment on a dichotomous basis, Haeuser et al. [16] reported frequency rates based on severity ratings above the severity range labeled as 'low to moderate’. The resulting prevalence rates were as high as for emotional (49.5%) and physical neglect (48.4%), with 12% for physical abuse, 15% for emotional abuse and 12,6% for sexual abuse.

The present article presents a re-analysis of the German general survey data which had also been used by the Haeuser et al. [16] study. In contrast to the previous analysis, this analysis did not rely on cut-off scores based on the original severity ratings, but on empirically determined and validated threshold values for the different types of child maltreatment as reported by Walker et al. [20]. These cut-off criteria had been ascertained by relating CTQ subscale scores to ratings of experts blind for the CTQ scores who administered detailed clinical interviews. Based on the fulfillment of consensus child abuse and neglect criteria [20], experts determined whether participants had a history of clinically significant abuse or neglect. Walker et al. [20] used the same definitions of child abuse and neglect the items of the five subscales of the CTQ were derived from. Emotional abuse was defined as “verbal assaults on a child’s sense of worth or well-being or any humiliating or demeaning behavior directed toward a child by an adult or older person”. Emotional neglect was defined as “the failure of caretakers to meet children’s basic emotional and psychological needs, including love, belonging, nurturance, and support”. Physical abuse was defined as “bodily assaults on a child by an adult or older person that posed a risk of, or resulted in, injury”. Physical neglect was defined as “the failure of caretakers to provide for a child’s basic physical needs, including food, shelter, clothing, safety, and health care” (poor parental supervision was also included if it placed a child’s safety in jeopardy). Sexual abuse was defined as “sexual contact or conduct between a child younger than 17 years of age and an adult or older person (at least 5 years older than the child)”. Receiver operating characteristic (ROC) methods had been employed to determine threshold scores for each subscale. Resulting threshold scores showed good to excellent sensitivity and specificity. Maltreatment is assumed when threshold scores for emotional abuse (10), emotional neglect (15), physical abuse (8), physical neglect (8), and sexual abuse (8) are met. In contrast threshold scores that were established by Bernstein et al. [18] and used in the Haeuser et al. [16] study were 9 for emotional abuse, 10 for emotional neglect, 8 for physical abuse, 8 for physical neglect, and 6 for sexual abuse. With this procedure we aim to provide the first comprehensive and representative prevalence data on different types of child maltreatment based on empirically derived cut-off criteria for the German population. Empirically derived and externally validated cut-off criteria allow for a more accurate and clinically significant evaluation of the presence of a history of abuse and neglect while clinical relevance of the cut-off scores used in previous studies remain uncertain. In addition, inter-correlations and co-occurrence of different kinds of maltreatment as well as their association to age and sex were examined.

In this study, we presented prevalence rates of child abuse in a representative sample of the German population based on empirically derived cut-off scores. The frequency of emotional neglect was 13.9%, 10.2% of the subjects reported emotional abuse, 12.0% met criteria for physical abuse, 48.4% for physical neglect, and 6.2% for sexual abuse.

Unsurprisingly, as all of the cut-off values used in our analysis were lower than those applied in the previous analysis of this dataset reported by Haeuser et al. [16], frequencies reported here were lower on all subscales except for the physical abuse and the physical neglect scale (a survey of prevalence rates presented in previous studies is given in Table 5). In particular, our cut-off resulted in considerably lower frequencies for emotional neglect. Previous representative surveys in Germany [7, 25, 26] were restricted to the assessment of physical or sexual abuse. While the magnitudes of physical abuse in the studies by Wetzels [7] as well as Glaesmer et al. [25] were tentatively comparable, Hauffa et al. [26] reported an exceptionally low rate of physical violence. Since regional or temporal factors as well as the use of different assessments are not sufficient to explain these differences, the authors suggested that the answering patterns of subjects may account for the discrepancy in reported frequencies [26].

Frequencies of sexual abuse reported in previous representative surveys showed a wide range. While Wetzels [7] reported a rate that was comparable to our findings, frequencies of sexual abuse in the studies of Glaesmer et al. [25] and Hauffa et al. [26] were rather small. Comparison of prevalence rates for sexual abuse is limited by the fact that Glaesmer et al. [25] as well as Hauffa et al. [26] reported frequencies of subjects being raped. Criteria for sexual abuse used in our study embodied a wide range of sexual assaults including rape. The wide range of criteria for sexual abuse may account for higher prevalence rates for both sexes in our study compared to previous findings.

In a survey of 91 women born in the years 1895 to 1936, von Sydow [29] reported much higher prevalence rates for sexual abuse. Experiences of sexual abuse under the age of 12 were reported by 18% of the women, 21% reported sexual abuse between the age of 13 and 21.

A recent validation study of the German translation of the CTQ has indicated that the scale for physical neglect has weak psychometric properties, is highly correlated with the other subscales and presented with a weak internal consistency in comparison to the other subscales [24]. These factors may have contributed to the uncommon and possibly excessive rates of physical neglect found in this study. As a consequence, findings based on this subscale from our study as well as from other studies should be interpreted with caution.

In our study, sex differences in the frequencies of child abuse were only found for sexual abuse. Prevalence rates of physical and sexual abuse reported for both sexes were comparable to frequencies reported by Wetzels [7]. In their sample, 11.8% of the men and 9.9% of the women experienced a history of physical maltreatment in childhood. A history of sexual abuse was reported for 2.8% of the men and 8.6% of the women. In contrast to the findings of Glaesmer et al. [25], prevalence rates of physical abuse in women were higher. While Glaesmer et al. [25] reported a frequency of 5.1%, 11.5% of the women in our sample met criteria for physical abuse.

In a population-based study in the US, the CTQ short form was administered in a randomized telephone interview survey with adults aged 18 to 65 [28]. Respondents were classified as having been abused if they either explicitly labeled themselves as having been abused or rated anything other than “never” to the single item of the various CTQ subscales that explicitly used the term 'abused’. Prevalence rates for the subscales physical, emotional and sexual abuse were presented. Findings from our German sample were lower on all subscales. However, these differences might be attributed to differences in sampling as well as in the applied cut-off values. It is noteworthy that, despite the differences in measurement, the replication of the National Comorbidity Survey (NCS-R) presented prevalence rates for child adversities similar to the rates reported in our study [27].

The intercorrelations and co-occurrence of maltreatment types presented in this study were consistent with previous reports [7, 16, 20, 30]. All types of maltreatment were significantly inter-correlated. In line with findings of Haeuser et al. [16], the smallest relationship was found for emotional neglect and sexual abuse. In our study, fulfillment of multiple types of maltreatment was reported for 20.6%. In the sample of Walker et al. [20] 23% of the subjects met criteria for more than one type of abuse. Reports of Haeuser et al. [16] were even higher. In their study, 40.3% of the participants reported at least two kinds of maltreatment. When the physical neglect subscale is excluded, in our study merely 9.6% of the subjects fulfill criteria for multiple types of maltreatment. This rather small frequency suggests that high frequencies of co-occurrence in prior studies result from the inclusion of the CTQ physical neglect subscale and the use of cut-off values that were based on severity ratings.

Limitations of our study include the fact that the assessment of childhood maltreatment is based on retrospective accounts and self-report, which is subject to recall biases [16]. However, the analysis of that recall bias indicates that these distortions are not sufficiently large to invalidate retrospective reports in general [31]. In addition, the present study is limited by a response rate of 56%. Prior surveys conducting a similar technique to recruit subjects reached higher response rates (62.1%) [32]. Due to data protection, differences between responders and non-responders on clinical and socio-demographical data could not be analyzed. Therefore, frequencies may have been affected by participation bias. Particularly, assessment of trauma associated experiences might have caused avoidance and refusal to participate.

In summary, findings from our study confirmed that methodological details, in particular the definition of maltreatment types and cut-off values, have a substantial impact on the frequency rates determined in surveys. However, a validation of the cut-off scores used in the present study in a German sample would be desirable in order to achieve more accurate assessments of prevalence rates. Furthermore, the present study is to our knowledge the first to present prevalence rates for the minimization/denial scale in a representative sample. In general, our analysis based on empirically derived cut-off values resulted in lower rates of child maltreatment than in previous reports that used less well validated criteria. However, still as many as 33.9% (Table 3) reported experience of a type of maltreatment, which demonstrates that child maltreatment is a significant social problem in Germany like in other countries world-wide. Commonly, prevention efforts are restricted to targeting the reduction of sexual or physical abuse. Our findings show that emotional types of abuse and neglect are at least as common and that new and more comprehensive forms of child protection may be indicated. Prevalence rates reported in our study allow for more thorough evaluation of data found for child maltreatment in clinical samples and in future research.