Background
Child maltreatment is considered a major public health problem [
1‐
3]. The consequences of maltreatment are diverse and may affect victims throughout their whole lifespan via psychological and behavioral problems, as well as somatic disorders [
1,
4‐
11]. As a consequence, in addition to these individual consequences, maltreatment causes high financial burden for society. Previous studies estimated annual expenses caused by maltreatment between 11 to 30 billion Euros for Germany [
7] and up to 124 billion US Dollars per year in the US [
8].
Results from international studies show that child maltreatment is highly prevalent. This is also true in high income countries where prevalence rates are comparable to those of widespread diseases [
9,
10]. Meta-analyses on the prevalence of different types of maltreatment exist, and especially child sexual abuse having been reviewed repeatedly [
10‐
13]. One meta-analyses showed varying prevalence rates mostly due to varying definitions, but also due to methodological factors, like small sample sizes, geographical regions or non-random designs [
11,
13]. One review by Stoltenborgh and colleagues [
11] focused on the assessment of child sexual abuse in adult populations and included 331 independent samples with a total of almost 10 million participants. The overall prevalence for self-reported child sexual abuse was reported at around 12.7% (95% confidence interval (CI) 10.7–15.0%), 18% for women and 7.6% for men. These rates are comparable to those found in other meta-analyses [
10,
12] and also in a meta-analysis focusing on prevalence rates of sexual abuse in adolescent populations [
13]. Overall, females seem to be more often affected by sexual abuse than men.
For other types of maltreatment like neglect, the data base is less comprehensive. The so-called “neglect of neglect” is still evident in research [
3,
14,
15]. Meta-analyses on physical and emotional abuse, as well as neglect show a high variation in prevalence rates [
15‐
17]. Regarding physical abuse, prevalence rates of 22.6% (95% CI 19.6–26.1%) were reported by Stoltenborgh and colleagues [
16], similar to 22.9% by Sethi and colleagues for the European Region [
10]. Larger differences were reported for emotional abuse with a rate of 36.3% worldwide [
17] and 29.1% reported from the European Union [
10]. With regard to child neglect, Stoltenborgh and colleagues identified 19 independent samples, underlining the need for further studies on neglect. Prevalence rates were reported at 16.3% (95% CI 12.1–21.5) for physical and 18.4% (95% CI 13.0–25.4) for emotional neglect. In contrast to findings on sexual abuse, there does not seem to be a gender preponderance for the other types of maltreatment [
3,
15‐
17].
For Germany, data on the prevalence of child maltreatment in the general population is limited to three data sets: two studies, which were conducted almost 20 years apart from each other, focused on the assessment of child sexual abuse [
18‐
20]. They reported a marked decline of sexual abuse over a period of almost 20 years. Only one study reported on the prevalence of different types of maltreatment in the general population. The study was conducted in 2010 using the Childhood Trauma Questionnaire (CTQ) [
21,
22] and reported a prevalence of 1.6% for severe emotional, 2.8% for severe physical, 1.9% for severe sexual abuse, and 6.6% for severe emotional and 10.8% for severe physical neglect [
22].
In summary, data on the prevalence of different types of child maltreatment exist, however usually only general prevalence rates for different types of maltreatment and males and females are reported. On closer examination, prevalence rates vary considerably across different subgroups (e.g. age cohorts or gender) [
18,
22]. As the CTQ has been used in a range of brain imaging studies as a covariate [
23,
24] and it is a widely used screening instrument for the assessment of child maltreatment [
22,
25,
26] recent data need to be made available to set new scientific findings into context and inform the debate of societal burden by childhood maltreatment.
The aim of the present study is to provide recent and detailed prevalence rates for all types of maltreatment as assessed by the CTQ (emotional, physical, and sexual abuse, as well as physical and emotional neglect) in a representative sample of the general population in Germany.
Methods
Procedure
Data collection took place between September and November 2016. Using a random route procedure, a representative sample of the German population was obtained by a demographic consulting company (USUMA, Berlin, Germany). The sample was representative in regard to age, gender, and geographic region. Households of every third residence in a randomly chosen street were invited to participate in the study. In multi-person households, participants were randomly selected using a Kish-Selection-Grid. For inclusion, participants had to be at least 14 years of age and have sufficient German language skills. Of 4902 designated addresses, 2510 households participated in the study. The main reason for non-participation was failure to contact anyone in the residence after four attempts (14.9%), refusal by the individual who answered the door to have anyone in the household participate in the study (15.3%), failure to contact the randomly selected household member after four attempts (2.3%) and refusal by the selected member to participate (14.7%).
Individuals who agreed to participate were given information about the study and provided informed consent. Participants were told that the study was about psychological health and well-being. Responses were anonymous. In a first step, socio-demographic information was obtained in an interview-format by the research staff. Then, the researcher handed out a copy of the questionnaire and a sealable envelope. The researcher remained nearby in case the participants needed further information. The completed questionnaires were linked to the respondent’s demographic data, but did not contain name, address, or any other identifying information.
The study was conducted in accordance with the Declaration of Helsinki, and fulfilled the ethical guidelines of the International Code of Marketing and Social Research Practice of the International Chamber of Commerce and of the European Society of Opinion and Marketing Research. The study was approved by the Ethics Committee of the Medical Department of the University of Leipzig.
Measures
The sociodemographic section contained information on age, gender, citizenship, geographical area (East vs. West Germany, rural vs. urban area), educational and occupational status and partnership status. Additionally, an estimation of the equivalence income (household income divided by the square root of household size), according to OECD [
27] was calculated.
The prevalence of five types of child maltreatment was assessed using the 28 item brief version of the Childhood Trauma Questionnaire (CTQ) [
21,
28,
29]. The CTQ is a screening measure for the assessment of child maltreatment. The CTQ contains five subscales each assessed by 5 items, including sexual, emotional and physical abuse as well as emotional and physical neglect. Additionally, three items assess whether participants tend to minimize problematic experiences within their family. The psychometric properties of the German version of the CTQ have been demonstrated by Klinitzke and colleagues [
21]. The internal consistency ranged between 0.62 and 0.96 for the subscales. The intra-class coefficient for an interval of 6 weeks was 0.77 for the overall scale and for subscales between 0.58 and 0.81. Based on norm data by Häuser and colleagues [
22] severity scores for each subscale can be calculated, ranging from “none–minimal”, “minimal–moderate”, “moderate–severe”, to “severe–extreme”. For the prevalence analysis of the different types of maltreatment, a cut-off of at least “moderate–severe” was chosen.
Participants
A total of 2510 participants were included in the sample. Participants were on average 48.4 years old (SD = 18.2) and 53.3% were female. 3.2% reported a place of birth outside Germany. The sample was representative for the German population in regard to age and gender. The sociodemographic characteristics are presented in Table
1.
Age |
Mean (standard deviation) | 48.4 (18.2) | 48.9 (18.1) | 47.8 (18.4) |
Range | 14–94 | 14–94 | 14–93 |
Living with partner |
Yes | 1370 (55%) | 719 (54%) | 651 (56.2%) |
No | 1119 (45%) | 612 (46%) | 507 (43.8%) |
Citizenship |
German | 2429 (96.8%) | 1303 (97.3%) | 1126 (96.2%) |
Not German | 81 (3.2%) | 36 (2.7%) | 45 (3.8%) |
Geographical area |
Eastern Germany | 505 (20.1%) | 255 (19%) | 921 (78.7%) |
Western Germany | 2005 (79.9%) | 1084 (81%) | 250 (21.3%) |
Rural | 1026 (40.9%) | 548 (40.9) | 478 (40.8%) |
Urban | 1484 (59.1%) | 791 (59.1%) | 693 (59.2%) |
Occupational status |
Full-time | 1074 (42.8%) | 407 (30.4%) | 667 (57%) |
Part-time | 281 (11.2%) | 246 (18.4%) | 35 (3%) |
Hourly | 60 (2.4%) | 54 (4%) | 6 (0.5%) |
Federal volunteer service/parental leave | 25 (1%) | 22 (1.6%) | 3 (0.3%) |
Unemployed | 131 (5.2%) | 64 (4.8%) | 67 (5.7%) |
Retiree | 638 (25.4%) | 368 (27.5%) | 270 (23.1%) |
Homemaker | 79 (3.1%) | 77 (5.8%) | 2 (0.2%) |
In training | 42 (1.7%) | 21 (1.6%) | 21 (1.8%) |
Student | 161 (6.4%) | 70 (5.2%) | 91 (7.8%) |
Employment status |
Unemployed | 131 (5.3%) | 64 (4.8%) | 67 (5.8%) |
Employed | 2360 (94.7%) | 1265 (95.2%) | 1095 (94.2%) |
Statistical analyses
All analyses were conducted using SPSS version 21. Descriptive analyses were conducted for prevalence rates. Comparisons were conducted using χ2 tests. To assess the co-occurrence of different types of child maltreatment a configuration analysis was conducted. Binary logistic regression analyses were conducted to identify predictors of childhood maltreatment. Age and gender were entered in the analyses as potential predictors.
Conclusions
Child maltreatment, especially physical neglect, is common among the general population of Germany. Physical neglect is highly prevalent in the (post) World War II generation and steadily declines towards the youngest age group. In general, experiences of child maltreatment are associated with a lower sociodemographic status. Women are more likely to report at least moderate levels of emotional and sexual abuse than men. Different types of maltreatment, especially physical and emotional neglect, seem to co-occur frequently.
Authors’ contributions
AW and RB analyzed and interpreted the data. RB carefully read the manuscript and provided a language editing. PLP, JMF and EB were involved in planning the study, drafting the manuscript and language editing. All authors read and approved the final manuscript.
Competing interests
AW, RB, EB state that they have no competing interests.
JMF has received research funding from the EU, DFG (German Research Foundation), BMG (Federal Ministry of Health), BMBF (Federal Ministry of Education and Research), BMFSFJ (Federal Ministry of Family, Senior Citizens, Women and Youth), German armed forces, several state ministries of social affairs, State Foundation Baden-Württemberg, Volkswagen Foundation, European Academy, Pontifical Gregorian University, RAZ, CJD, Caritas, Diocese of Rottenburg-Stuttgart. Moreover, he received travel grants, honoraria and sponsoring for conferences and medical educational purposes from DFG, AACAP, NIMH/NIH, EU, Pro Helvetia, Janssen-Cilag (J&J), Shire, several universities, professional associations, political foundations, and German federal and state ministries during the last 5 years. Every grant and every honorarium has to be declared to the law office of the University Hospital Ulm. Professor Fegert holds no stocks of pharmaceutical companies.
PLP has received research funding from the Bundesinstitut für Arzneimittel und Medizinprodukte, BMBF (Federal Ministry of Education and Research), VW-Foundation, Baden-Württemberg Stiftung, Lundbeck, Servier. Professor Plener holds no stocks of pharmaceutical companies.