Résumé

Objectif

Estimer la charge sanitaire et économique de la maltraitance des enfants en Chine.

Méthodes

Nous avons réalisé une revue systématique des études sur la maltraitance des enfants en Chine en utilisant les bases de données PubMed, Embase, PsycInfo, CINAHL-EBSCO, ERIC et de l'Infrastructure nationale de connaissances chinoises. Nous avons effectué les méta-analyses des études qui satisfaisaient les critères d'inclusion, afin d'estimer la prévalence de l'abandon moral des enfants et des abus physiques, psychologiques et sexuels des enfants. Nous avons utilisé les données des estimations 2010 de la charge mondiale de morbidité pour calculer l'espérance de vie corrigée de l'incapacité (EVCI) perdue du fait de la maltraitance des enfants.

Résultats

À partir de 68 études, nous avons estimé que 26,6% des enfants de moins de 18 ans ont souffert d'abus physiques, 19,6% d'abus psychologiques, 8,7% d'abus sexuels et 26,0% d'abandon moral. Nous estimons que les abus psychologiques représentent 26,3% de l'EVCI perdue à cause des troubles mentaux et 18,0% de l'EVCI perdue à cause des comportements autodestructeurs. Les abus physiques pendant l'enfance représentent 12,2% de l'EVCI perdue à cause de la dépression, 17,0% à cause de l'anxiété, 20,7% à cause des problèmes de surconsommation d'alcool, 18,8% à cause de l'usage des drogues illicites et 18,3% à cause des comportements autodestructeurs. Nous estimons que les conséquences des abus physiques sur les enfants ont coûté à la chine 0,84% de son produit intérieur brut, soit 50 milliards de dollars en 2010. Les pertes correspondantes attribuables aux abus psychologiques et sexuels pendant l'enfance s'élevaient à 0,47% et 0,39% du produit intérieur brut, respectivement.

Conclusion

En Chine, la maltraitance des enfants est courante et associée à des pertes économiques considérables, car de nombreux enfants maltraités souffrent de détresse psychologique profonde et qu'ils peuvent adopter des comportements augmentant leur risque de maladie chronique.

Resumen

Objetivo

Estimar la carga sanitaria y económica del maltrato infantil en China.

Métodos

Se realizó una revisión sistemática de los estudios sobre el maltrato infantil en China utilizando las bases de datos PubMed, Embase, PsycInfo, CINAHL-EBSCO, ERIC y Chinese National Knowledge Infrastructure. También se efectuó un metaanálisis de los estudios que cumplieron los criterios de inclusión para estimar la prevalencia del abandono infantil y del abuso infantil físico, emocional y sexual. Se emplearon datos de las estimaciones de la carga mundial de morbilidad del año 2010 para calcular los años de vida ajustados por discapacidad (AVAD) perdidos como consecuencia del maltrato infantil.

Resultados

A partir de 68 estudios se estimó que el 26,6 % de los niños menores de 18 años de edad han sufrido abuso físico, el 19,6 % abuso emocional, el 8,7 % abuso sexual y el 26,0 % abandono. Asimismo, se estimó que el abuso emocional en la infancia representa el 26,3 % de los AVAD perdidos a causa de trastornos mentales y el 18,0 % de los perdidos por autolesión. El abuso físico en la infancia representa el 12,2 % de los AVAD perdidos a causa de la depresión, el 17,0 % por ansiedad, el 20,7 % por problemas con el alcohol, el 18,8 % por uso de drogas ilícitas y el 18,3 % por autolesión. Las consecuencias del abuso físico de niños le cuestan a China aproximadamente el 0,84 % de su producto interior bruto, es decir, 50 mil millones de dólares de los Estados Unidos, en 2010. Las pérdidas correspondientes atribuibles al abuso emocional y sexual en la infancia representaron el 0,47 % y el 0,39 % del producto interior bruto, respectivamente.

Conclusión

En China, el maltrato infantil es común y está asociado con grandes pérdidas económicas, ya que muchos niños maltratados sufren trastornos psicológicos importantes y podrían adoptar conductas que aumentan su riesgo de sufrir enfermedades crónicas.

ملخص

الغرض

تقدير الأعباء الصحية والاقتصادية لإساءة معاملة الأطفال في الصين.

الطريقة

أجرينا استعراضاً منهجياً للدراسات المعنية بإساءة معاملة الأطفال في الصين باستخدام قواعد بيانات PubMed وEmbase وPsycInfo وCINAHL-EBSCO وERIC والبنية الأساسية المعرفية الوطنية الصينية. وأجرينا تحليلات أساسية للدراسات التي لبت معايير الإدراج بغية تقدير معدل انتشار إهمال الأطفال والإيذاء البدني والنفسي والجنسي للأطفال. واستخدمنا البيانات المستمدة من تقديرات العبء العالمي للمرض لعام 2010 لحساب سنوات العمر المصححة باحتساب مدد العجز الضائعة نتيجة لإساءة معاملة الأطفال.

النتائج

أشارت تقديراتنا التي استمدت من 68 دراسة أن 26.6 % من الأطفال دون سن 18 سنة عانوا من الإيذاء البدني و19.6 % من الأطفال دون سن 18 سنة عانوا من الإيذاء النفسي و8.7 % من الأطفال دون سن 18 سنة عانوا من الإيذاء الجنسي و26.0 % من الإهمال. ووفق تقديرنا، يمثل الإيذاء النفسي في الطفولة 26.3 % من سنوات العمر المصححة باحتساب مدد العجز الضائعة بسبب الاضطرابات النفسية وأن 18.0 % منها يرجع إلى إيذاء النفس. ويمثل الإيذاء البدني في الطفولة 12.2 % من سنوات العمر المصححة باحتساب مدد العجز الضائعة بسبب الاكتئاب و17.0 % بسبب القلق و20.7 % بسبب تعاطي الكحوليات الذي يمثل مشكلة و18.8 % بسبب تعاطي المخدرات غير المشروعة و18.3 % بسبب إيذاء النفس. ووفق التقديرات، بلغت التكاليف التي تكبدتها الصين من عواقب الإيذاء البدني للأطفال 0.84 % من ناتجها المحلي الإجمالي - أي 50 مليار دولار أمريكي - في عام 2010. وبلغت الخسائر المقابلة التي تعزى إلى الإيذاء النفسي والجنسي في الطفولة 0.47 % و0.39 % من الناتج المحلي الإجمالي، على التوالي.

الاستنتاج

تشيع في الصين إساءة معاملة الأطفال وترتبط إساءة معاملة الأطفال بخسائر اقتصادية كبيرة نظراً لمعاناة العديد من الأطفال الذين تعرضوا لإساءة المعاملة من ضائقة نفسية شديدة، وقد يسلكوا سلوكيات تزيد من خطورة إصابتهم بأمراض مزمنة.

摘要

目的

估计中国儿童虐待的健康和经济负担。

方法

我们使用PubMed、Embase、PsycInfo、CINAHL-EBSCO、ERIC和中国国家知识基础设施数据库（中国知网）对中国儿童虐待研究做了系统回顾。我们对符合纳入标准的研究进行荟萃分析，估计儿童忽视和儿童身体、情感以及性虐待流行率。我们使用2010年全球疾病负担估计的数据计算因儿童虐待导致的伤残调整寿命（DALY）损失。

结果

在我们估计的68份研究中，18岁以下儿童有26.6%遭受身体虐待、19.6%遭受情感虐待、8.7%遭受性虐待、26.0%遭受忽视。据我们估计，童年时期遭受情感虐待分别是26.3%因精神疾病和18.0%因自残导致的DALY损失的根源。而童年时期遭受身体虐待分别是12.2%因抑郁、17.0%因焦虑、20.7%因酗酒、18.8%因使用毒品以及18.3%因自残导致的DALY损失的根源。2010年儿童身体虐待后果令中国国内生产总值（GDP）损失0.84%（即500亿美元）。因童年情感和性虐待造成的损失分别是国内生产总值的0.47%和0.39%。

结论

中国的儿童虐待情况很常见，并伴有巨大的经济损失，这种损失是因为许多受虐儿童遭受巨大的心理压力，可能做出增加慢性病风险的行为。

Резюме

Цель

Оценить влияние бремени жестокого обращения с детьми в Китае на состояние здоровья и экономику.

Методы

С помощью сведений, полученных из баз данных PubMed, Embase, PsycInfo, CINAHL-EBSCO, ERIC и Китайской национальной инфраструктуры знаний (CNKI), был проведен систематический обзор исследований, посвященных жестокому обращению с детьми в Китае. Для оценки распространения безнадзорности детей, физического, морального и сексуального насилия над детьми был проведен мета-анализ исследований, отвечающих критериям включения в данный обзор. Для расчета количества лет жизни с поправкой на инвалидность (DALY), потерянных в результате жестокого обращения с детьми, были использованы данные оценок глобального бремени болезней за 2010 г..

Результаты

По данным 68 исследований было установлено, что 26,6% детей в возрасте до 18 лет пострадали от физического насилия, 19,6% – от эмоционального насилия, 8,7% – от сексуального насилия и 26,0% – от безнадзорности. Было установлено, что на эмоциональное насилие в детстве приходится 26,3% DALY, потерянных в результате психических расстройств и 18,0% DALY, потерянных в результате нанесения себе увечий. На физическое насилие в детстве приходится 12,2% DALY, потерянных в результате депрессии, 17,0% – из-за страха, 20,7% – из-за пьянства на почве желания уйти от ситуационного стресса, 18,8% – из-за использования запрещенных наркотиков и 18,3% – из-за нанесения себе увечий. Последствия физического насилия над детьми обошлись Китаю предположительно в 0,84% от валового внутреннего продукта, т. е. составили 50 миллиардов долларов США в 2010 году. Убытки, связанные с эмоциональным и сексуальным насилием в детстве, составляли 0,47% и 0,39% от валового внутреннего продукта соответственно.

Вывод

Жестокое обращение с детьми в Китае является распространенным явлением, которое приводит к значительным экономическим убыткам, поскольку многие дети, подвергающиеся жестокому обращению, страдают устойчивыми психологическими расстройствами и могут демонстрировать формы поведения, которые повышают риск возникновения хронических заболеваний.

Introduction

In the past decade there has been considerable growth in the analysis of the occurrence and consequences of maltreatment and other adversities in childhood.¹1 Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009 Jan 3;373(9657):68–81. doi: http://dx.doi.org/10.1016/S0140-6736(08)61706-7 PMID: 19056114
https://doi.org/10.1016/S0140-6736(08)61... ^–33 Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat. 2011 May;16(2):79–101. doi: http://dx.doi.org/10.1177/1077559511403920 PMID: 21511741
https://doi.org/10.1177/1077559511403920... The maltreatment of children has been found to impair the current and future health and well-being of the children in every country and cultural context in which it has been investigated. The morbidity, disability and mortality caused by child abuse and neglect lead to substantial human suffering, social disadvantage and economic loss.⁴4 Shonkoff JP, Boyce WT, McEwen BS. Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA. 2009 Jun 3;301(21):2252–9. doi: http://dx.doi.org/10.1001/jama.2009.754 PMID: 19491187
https://doi.org/10.1001/jama.2009.754... ^,55 Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl. 2012 Feb;36(2):156–65. doi: http://dx.doi.org/10.1016/j.chiabu.2011.10.006 PMID: 22300910
https://doi.org/10.1016/j.chiabu.2011.10...

In China, research in this field has a short history.⁶6 Dunne MP, Chen JQ, Wan Yuen Choo. The evolving evidence base for child protection in Chinese societies. Asia Pac J Public Health. 2008;20(4):267–76. doi: http://dx.doi.org/10.1177/1010539508325047 PMID: 19124321
https://doi.org/10.1177/1010539508325047... There have been no national assessments of child maltreatment and only a few comprehensive provincial studies. However, the results of early descriptive surveys of child sexual⁷7 Chen JQ, Dunne MP, Wang X. Prevalence of childhood sexual abuse among female students in a senior high school. Chin J Sch Health. 2002;23:108–10.[Chinese].^–1010 Tang CS. Childhood experience of sexual abuse among Hong Kong Chinese college students. Child Abuse Negl. 2002 Jan;26(1):23–37. doi: http://dx.doi.org/10.1016/S0145-2134(01)00306-4 PMID: 11860160
https://doi.org/10.1016/S0145-2134(01)00... and physical abuse¹¹11 Ma YX, Chen JQ, Dunne MP, Liang YH, Cheng YJ, Wu CM, et al. [The impact of childhood experience of being beaten by bare hands on adolescents’ mental health]. Chin J Sch Health. 2005;26(12):1001–3. Chinese. and some more recent relevant data¹²12 Leung PW, Wong WC, Chen WQ, Tang CS. Prevalence and determinants of child maltreatment among high school students in Southern China: a large scale school based survey. Child Adolesc Psychiatry Ment Health. 2008;2(1):27. doi: http://dx.doi.org/10.1186/1753-2000-2-27 PMID: 18823544
https://doi.org/10.1186/1753-2000-2-27... ^,1313 Chan KL. Sexual violence against women and children in Chinese societies. Trauma Violence Abuse. 2009;10(1):69–85. PMID: 19056687 have been included in global and regional reviews.²2 Pereda N, Guilera G, Forns M, Gómez-Benito J. The international epidemiology of child sexual abuse: a continuation of Finkelhor (1994). Child Abuse Negl. 2009 Jun;33(6):331–42. doi: http://dx.doi.org/10.1016/j.chiabu.2008.07.007 PMID: 19477003
https://doi.org/10.1016/j.chiabu.2008.07... ^,33 Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat. 2011 May;16(2):79–101. doi: http://dx.doi.org/10.1177/1077559511403920 PMID: 21511741
https://doi.org/10.1177/1077559511403920... ^,1414 Child maltreatment prevalence, incidence and consequences: a systematic review of research on child maltreatment in East Asia and Pacific. Bangkok: United Nations Children’s Fund East Asia and Pacific Regional Office; 2012.^,1515 Fry D, McCoy A, Swales D. The consequences of maltreatment on children’s lives: a systematic review of data from the East Asia and Pacific Region. Trauma Violence Abuse. 2012 Oct;13(4):209–33. doi: http://dx.doi.org/10.1177/1524838012455873 PMID: 22899705
https://doi.org/10.1177/1524838012455873... There has also been one systematic review that focused solely on the prevalence of child sexual abuse in China.¹⁶16 Ji K, Finkelhor D, Dunne M. Child sexual abuse in China: a meta-analysis of 27 studies. Child Abuse Negl. 2013 Sep;37(9):613–22. doi: http://dx.doi.org/10.1016/j.chiabu.2013.03.008 PMID: 23643201
https://doi.org/10.1016/j.chiabu.2013.03... There have been no comprehensive studies in China that cover all forms of child maltreatment, examine the consistency of the apparent impacts of such maltreatment on health and well-being or estimate the probable economic consequences. The paucity of official statistics on the incidence of child maltreatment reported to judicial, educational, health and social services – and on the economic costs incurred by such services as a consequence of such maltreatment – also poses a major barrier to the development of an effective and evidence-based policy for child protection in China.

The purpose of this paper was to synthesize the results of previous community-based research on child maltreatment in China. We derived summative estimates of prevalence of emotional, physical and sexual abuse and neglect of children under 18 years of age. We also calculated the magnitude of associations between child maltreatment and consequent poor mental health and health-risk behaviours. We then estimated economic impact of child maltreatment in China. Our observations indicate both the extent to which this major cause of morbidity and disability has been overlooked in China and the research that is still required.

Methods

Systematic review

We searched PubMed, Embase, PsycInfo, CINAHL-EBSCO, ERIC and the Chinese National Knowledge Infrastructure for papers published from the inception of each database to 31 December 2013 using search term combinations of China with child abuse, emotional abuse, physical abuse, sexual abuse or child neglect – and their Chinese equivalents. Languages were restricted to English and Chinese. Two reviewers identified and screened potentially relevant articles in Chinese and English and independently assessed the quality of each study that met the inclusion criteria. To identify additional relevant studies, we contacted 18 researchers and organizations involved in child protection in China and checked the reference lists of key narrative reviews on child maltreatment in or around China.⁶6 Dunne MP, Chen JQ, Wan Yuen Choo. The evolving evidence base for child protection in Chinese societies. Asia Pac J Public Health. 2008;20(4):267–76. doi: http://dx.doi.org/10.1177/1010539508325047 PMID: 19124321
https://doi.org/10.1177/1010539508325047... ^,1313 Chan KL. Sexual violence against women and children in Chinese societies. Trauma Violence Abuse. 2009;10(1):69–85. PMID: 19056687^,1414 Child maltreatment prevalence, incidence and consequences: a systematic review of research on child maltreatment in East Asia and Pacific. Bangkok: United Nations Children’s Fund East Asia and Pacific Regional Office; 2012.^,1616 Ji K, Finkelhor D, Dunne M. Child sexual abuse in China: a meta-analysis of 27 studies. Child Abuse Negl. 2013 Sep;37(9):613–22. doi: http://dx.doi.org/10.1016/j.chiabu.2013.03.008 PMID: 23643201
https://doi.org/10.1016/j.chiabu.2013.03... ^,1717 Chen JQ. [Review of prior research in China: child abuse and its impact on the victims]. Zhonghua Er Ke Za Zhi. 2006 Aug;44(8):625–8. Chinese. PMID: 17083797

Prevalence studies were included if they met the following criteria: (i) published in a peer-reviewed journal; (ii) participants recruited from a student or general population; (iii) quantitative methods were used to estimate the prevalence of the maltreatment of participants when they were younger than 18 years; (iv) reported a lifetime prevalence of child maltreatment; and (v) the recorded maltreatment had been reported directly by the victims. Studies on the possible consequences – to the victims – of child maltreatment were included if these: (i) represented primary research that had explored the relationship between at least one form of child maltreatment and its impact on employment, education, mental health, physical health, health behaviours, aggression, violence, criminality, exposure to further violence or use of health services;¹1 Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009 Jan 3;373(9657):68–81. doi: http://dx.doi.org/10.1016/S0140-6736(08)61706-7 PMID: 19056114
https://doi.org/10.1016/S0140-6736(08)61... (ii) included the calculation of odds ratios (ORs) or relative risks (RRs) disaggregated by the type of maltreatment; and (iii) had not sampled on the basis of the presence of any specified outcome – since this would have invalidated the calculation of an OR or RR for that outcome.¹⁸18 Andrews G, Corry J, Slade T, Issakadis C, Swanston H. Child sexual abuse. In: Ezzati M, Lopez AD, Rodgers A, Murray C, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization; 2004.

The abstract of each article of potential interest was screened to see if the article met our inclusion criteria. We then read the full text of each included article and extracted key variables related to study design and findings. The authors of the articles were contacted if additional information was needed.

Each article was reviewed for data quality by using the Newcastle–Ottawa Scale for case–control and cohort studies¹⁹19 Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute; 2014. and Boyle’s guidelines for evaluating prevalence studies.²⁰20 Boyle MH. Guidelines for evaluating prevalence studies. Evid Based Ment Health. 1998;1(2):37–9. doi: http://dx.doi.org/10.1136/ebmh.1.2.37
https://doi.org/10.1136/ebmh.1.2.37... The risk of bias in each included study was determined as in an earlier regional systematic review on child maltreatment.¹⁴14 Child maltreatment prevalence, incidence and consequences: a systematic review of research on child maltreatment in East Asia and Pacific. Bangkok: United Nations Children’s Fund East Asia and Pacific Regional Office; 2012.

Meta-analyses

Following the example of Andrews et al.,¹⁸18 Andrews G, Corry J, Slade T, Issakadis C, Swanston H. Child sexual abuse. In: Ezzati M, Lopez AD, Rodgers A, Murray C, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization; 2004. we conducted multiple linear regression analyses to examine the characteristics of the methods that may have influenced previous estimates of the prevalence of child maltreatment. The characteristics examined included type of sample, sample site and size, response type and rate, whether maltreatment was defined as a single or repeated act, whether validated instruments were used and whether specific behavioural questions were asked.

Based on the multiple regression analyses, the unstandardized regression coefficients for the significant predictors of child neglect, emotional abuse and physical abuse were used to adjust the corresponding prevalence. That is, the prevalence of emotional abuse was adjusted from any to repeated abuse, the prevalence of child physical abuse was adjusted to rates generated by validated instruments such as the Conflict Tactics Scale, and the prevalence of child neglect was adjusted to rates reported by studies that had used large samples and asked specific questions about neglect. The prevalence of contact sexual abuse was used as the estimate of the prevalence of any sexual abuse – because the use of any broad definition of non-contact sexual abuse may easily lead to an overestimate of the prevalence of sexual abuse.²¹21 Choo WY, Dunne MP, Marret MJ, Fleming M, Wong YL. Victimization experiences of adolescents in Malaysia. J Adolesc Health. 2011 Dec;49(6):627–34. doi: http://dx.doi.org/10.1016/j.jadohealth.2011.04.020 PMID: 22098774
https://doi.org/10.1016/j.jadohealth.201... As girls are generally more likely to suffer sexual abuse than boys,³3 Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat. 2011 May;16(2):79–101. doi: http://dx.doi.org/10.1177/1077559511403920 PMID: 21511741
https://doi.org/10.1177/1077559511403920... we made separate estimates of the prevalence of contact sexual abuse in childhood for females and males.

In seven studies, subtraction of the unstandardized coefficients from the reported prevalence produced negative values.²²22 Fuh JL, Wang SJ, Juang KD, Lu SR, Liao YC, Chen SP. Relationship between childhood physical maltreatment and migraine in adolescents. Headache. 2010 May;50(5):761–8. doi: http://dx.doi.org/10.1111/j.1526-4610.2010.01639.x PMID: 20236341
https://doi.org/10.1111/j.1526-4610.2010... ^–2828 Ma JF, Dai JH, Guan SZ, Liu W, Liu JW. [Retrospective study on the adverse childhood experience among medical college students]. Chin J Sch Health. 2012;33(12):1454–6. Chinese. These studies were excluded from the final meta-analyses.

Finally, for each of the four types of child maltreatment, a set of adjusted prevalence estimates were combined using random-effects meta-analysis. The separate rates for sexual abuse of boys and girls were combined to produce an overall rate for such abuse – assuming that the Chinese population had 106 males for every 100 females.²⁹29 The World Factbook. East & southeast Asia: China [Internet]. Washington: Central Intelligence Agency; 2014. Available from: https://www.cia.gov/library/publications/the-world-factbook/geos/ch.html [cited 2014 Nov 12].
https://www.cia.gov/library/publications... The Cochran's Q tests were conducted to assess the heterogeneity across studies.

Population attributable fractions

To calculate a population attributable fraction, it is necessary to know the prevalence of a risk factor – e.g. maltreatment in childhood – and the RR for the disease or outcome of interest – e.g. depression – given exposure to that risk factor. Since we found only a few articles that reported the effects of child maltreatment on physical health, we focused on outcomes associated with mental health and health-risk behaviours. To match the outcomes with the available global burden of disease categories,³⁰30 Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet. 2013 Jun 8;381(9882):1987–2015. doi: http://dx.doi.org/10.1016/S0140-6736(13)61097-1 PMID: 23746901
https://doi.org/10.1016/S0140-6736(13)61... the outcomes were further limited to: current smoker, problem drinking, illicit drug use, self-harm and mental disorder – including depression and anxiety. For each of these outcomes, we attempted to calculate a population attributable fraction for each type of child maltreatment that we considered.

If only the unadjusted ORs for a study were available, we produced corresponding estimates of adjusted ORs using the ratios between adjusted and unadjusted ORs reported for other studies.¹⁸18 Andrews G, Corry J, Slade T, Issakadis C, Swanston H. Child sexual abuse. In: Ezzati M, Lopez AD, Rodgers A, Murray C, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization; 2004. Similarly, as only ORs for suicide attempt – rather than self-harm – following sexual abuse were available, we produced estimates of the corresponding OR for self-harm by using the ratio between the ORs for self-harm and suicide attempt following physical abuse. As most studies included in the systematic review reported ORs but not RRs, RRs had to be estimated from the ORs.³¹31 Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998 Nov 18;280(19):1690–1. doi: http://dx.doi.org/10.1001/jama.280.19.1690 PMID: 9832001
https://doi.org/10.1001/jama.280.19.1690...

In some of our included studies, only RRs for various levels of exposure to a type of maltreatment were available. For these studies, we estimated general RRs for a type of maltreatment by calculating weighted averages – with the numbers of cases at each level of exposure used as the weights.

Finally, for each type of child maltreatment, the estimated RRs were grouped according to outcomes and then combined using random-effects meta-analysis.³²32 Borenstein M, Hedges LV, Higgins JP, Rothstein HR. Introduction to meta-analysis. Chichester: John Wiley & Sons; 2011.

Economic burden

We attempted to estimate the economic losses associated with child maltreatment in China. Following the work of the World Health Organization (WHO)³³33 Macroeconomics and Health. Investing in health for economic development. Geneva: World Health Organization; 2001. and Brown,³⁴34 Brown DW. Economic value of disability-adjusted life years lost to violence: estimates for WHO Member States. Rev Panam Salud Publica. 2008 Sep;24(3):203–9. doi: http://dx.doi.org/10.1590/S1020-49892008000900007 PMID: 19115548
https://doi.org/10.1590/S1020-4989200800... we estimated the disability-adjusted life-years (DALYs) lost – because of mental health disorders attributable to child maltreatment and health-risk behaviours – and then estimated the monetary value of those DALYs.

For each of the main types of child maltreatment that we considered, a population attributable fraction for an outcome of interest was multiplied by the estimate of the number of DALYs expected to be lost because of that outcome. Population attributable fractions of our selected health and behavioural outcomes (mental disorder, depression, anxiety, current smoker, problem drinking, illicit drug use, and self-harm) were matched to definitions of “mental disorder”, “unipolar depressive disorders”, “anxiety disorders”, “tobacco smoking”, “alcohol use”, “illicit drug use”, and “self-harm” respectively, from the 2010 global burden of disease China study.³⁰30 Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet. 2013 Jun 8;381(9882):1987–2015. doi: http://dx.doi.org/10.1016/S0140-6736(13)61097-1 PMID: 23746901
https://doi.org/10.1016/S0140-6736(13)61...

For physical abuse and also for emotional abuse, the population attributable fraction for the overall measure of mental disorders was available (Table 1). This was multiplied by an overall estimate of the DALYs lost because of any form of mental ill health. It was often impossible to compute values for individual mental health conditions since population attributable fractions for many such conditions have yet to be estimated. For sexual abuse, population attributable fractions for depression and anxiety – but not for the overall measure of mental ill health – were available (Table 1), and therefore these two individual conditions were used to estimate the DALYs lost because of mental health disorders following sexual abuse in childhood.

As in previous studies,³³33 Macroeconomics and Health. Investing in health for economic development. Geneva: World Health Organization; 2001.^,3434 Brown DW. Economic value of disability-adjusted life years lost to violence: estimates for WHO Member States. Rev Panam Salud Publica. 2008 Sep;24(3):203–9. doi: http://dx.doi.org/10.1590/S1020-49892008000900007 PMID: 19115548
https://doi.org/10.1590/S1020-4989200800... we assumed that, in monetary terms, one DALY in China was equal to the per-capita gross domestic product. Data on the size of China’s population and its per-capita gross domestic product in 2010 were obtained from the World Bank.³⁵35 World development indicator 2010 [Internet]. Washington: World Bank; 2011. Available from: http://data.worldbank.org/data-catalog/world-development-indicators/wdi-2010 [cited 2014 Nov 12].
http://data.worldbank.org/data-catalog/w...

Results

The systematic review identified 68 studies that met our inclusion criteria (Fig. 1), of which 62 reported prevalence estimates and 14 reported consequences. Eight studies were reporting both. For our prevalence estimates, we originally used data from 31 studies on child emotional abuse,²³23 Yang S, Zhang Y, Huang G, Guo G. A preliminary study on child abuse. Chin J Clin Psychol. 2004;12(2):140–1.^,2424 Lu X, Zhou M, Liang F, Ma X, Zhong Q. [An investigation on child physical and emotional abuse of Zhuang and Han nationalities in western Guangxi]. J Youjiang Med Univ Natl. 2012;34(4):453–4. Chinese.^,2626 Chen J, Ma Y, Liang Y. [A retrospective survey of childhood corporal punishment and emotional maltreatment by their parents in students]. Chin Ment Health J. 2008;22(12):922–7. Chinese.^–2828 Ma JF, Dai JH, Guan SZ, Liu W, Liu JW. [Retrospective study on the adverse childhood experience among medical college students]. Chin J Sch Health. 2012;33(12):1454–6. Chinese.^,3636 Huang G, Zhang Y, Zou S, Shen J, Xiang H, Zhao L. [Plasma Neuropeptide-Y and Cognitive function in female intimates with childhood sexual abuse]. Chin J Psychiatry. 2006;39(1):12–5. Chinese.^–6161 Chen J. [Childhood physical and emotional maltreatment and its psychological effects in 391 university students in China]. Chin J Sch Doctor. 2005;19(4):341–4. Chinese. 36 studies on physical abuse,¹¹11 Ma YX, Chen JQ, Dunne MP, Liang YH, Cheng YJ, Wu CM, et al. [The impact of childhood experience of being beaten by bare hands on adolescents’ mental health]. Chin J Sch Health. 2005;26(12):1001–3. Chinese.^,2222 Fuh JL, Wang SJ, Juang KD, Lu SR, Liao YC, Chen SP. Relationship between childhood physical maltreatment and migraine in adolescents. Headache. 2010 May;50(5):761–8. doi: http://dx.doi.org/10.1111/j.1526-4610.2010.01639.x PMID: 20236341
https://doi.org/10.1111/j.1526-4610.2010... ^–2626 Chen J, Ma Y, Liang Y. [A retrospective survey of childhood corporal punishment and emotional maltreatment by their parents in students]. Chin Ment Health J. 2008;22(12):922–7. Chinese.^,2828 Ma JF, Dai JH, Guan SZ, Liu W, Liu JW. [Retrospective study on the adverse childhood experience among medical college students]. Chin J Sch Health. 2012;33(12):1454–6. Chinese.^,3636 Huang G, Zhang Y, Zou S, Shen J, Xiang H, Zhao L. [Plasma Neuropeptide-Y and Cognitive function in female intimates with childhood sexual abuse]. Chin J Psychiatry. 2006;39(1):12–5. Chinese.^–4444 Zeng Q, Wu Z, Zhu H, Zhou W, Huang W, Qiu M, et al. [Childhood experience and romantic relationship of university students]. Chin J Sch Health. 2010;31(11):1352–5. Chinese.^,4646 Cai X. [A study of child abuse among Meng and Han Meng]. J Chifeng Univ. 2008;24(5):179–80. [Nat Sci Ed] Chinese.^,4747 Zhao X, Zhang Y, Li L. [Childhood abuse an investigation of 435 middle school students]. Chin J Clin Psychol. 2004;12(4):377–9. Chinese.^,5151 Yan QQ, Jiao WY, Lin J, Jiao FY. [Effect of childhood physical and emotional abuse on psychological health in undergraduate students]. Zhongguo Dang Dai Er Ke Za Zhi. 2009 Aug;11(8):675–8. Chinese. PMID: 19695200^–5353 Zhu X, Wang C, Zhou Q, Qiao J, Geng D, Li J. [Characteristics of big five personality in college students and its relationship with childhood abuse]. China J Health Psychol. 2012;20(7):1083–6. Chinese.^,5757 Tao FB, Huang K, Kim S, Ye Q, Sun Y, Zhang CY, et al. [Correlation between psychopathological symptoms, coping style in adolescent and childhood repeated physical, emotional maltreatment]. Zhonghua Er Ke Za Zhi. 2006 Sep;44(9):688–93. Chinese. PMID: 17217665^,5959 Xiao Q, Dong MX, Yao J, Li WX, Ye DQ. Parental alcoholism, adverse childhood experiences, and later risk of personal alcohol abuse among Chinese medical students. Biomed Environ Sci. 2008 Oct;21(5):411–9. doi: http://dx.doi.org/10.1016/S0895-3988(08)60062-8 PMID: 19133615
https://doi.org/10.1016/S0895-3988(08)60... ^–7272 Xiao Y, Tao F, Xu SJ, Su P, Huang C. [Self- injurious behaviors in adolescents with repeated childhood abuse]. Chin J Publ Health. 2008;24(9):1028–30. Chinese. 18 studies on neglect²³23 Yang S, Zhang Y, Huang G, Guo G. A preliminary study on child abuse. Chin J Clin Psychol. 2004;12(2):140–1.^,2727 Xie Z, Tang Q, Chang X, Deng Y. 457 College students’ experience of psychological abuse and neglect in childhood and mental health. Chin J Clin Psychol. 2008;16(1):62–5.^,2828 Ma JF, Dai JH, Guan SZ, Liu W, Liu JW. [Retrospective study on the adverse childhood experience among medical college students]. Chin J Sch Health. 2012;33(12):1454–6. Chinese.^,3636 Huang G, Zhang Y, Zou S, Shen J, Xiang H, Zhao L. [Plasma Neuropeptide-Y and Cognitive function in female intimates with childhood sexual abuse]. Chin J Psychiatry. 2006;39(1):12–5. Chinese.^,4343 Gao C, Dai F, Liu H. [Impact of childhood abuse experience on mental health of middle school students]. Dis Surveill. 2011;26(4):313–6. Chinese.^,4444 Zeng Q, Wu Z, Zhu H, Zhou W, Huang W, Qiu M, et al. [Childhood experience and romantic relationship of university students]. Chin J Sch Health. 2010;31(11):1352–5. Chinese.^,4646 Cai X. [A study of child abuse among Meng and Han Meng]. J Chifeng Univ. 2008;24(5):179–80. [Nat Sci Ed] Chinese.^,4747 Zhao X, Zhang Y, Li L. [Childhood abuse an investigation of 435 middle school students]. Chin J Clin Psychol. 2004;12(4):377–9. Chinese.^,4949 Zhu M, Xu X, Su S, Lin D. Moderating effects of social support on the associations between depression and psychological abuse and neglect of Chinese junior high school students. In: Proceedings of 2010 International Conference on Psychology, Psychological Sciences and Computer Science (PPSCS); 2010 Nov 27–28; Wuhan, China. Beijing: Institute of Electrical and Electronics Engineers; 2010. pp. 121-6.^,5050 Zhou S, Liu Q, Zhu H, Guo Z, Shem J. [Childhood psychological abuse and neglect: An investigation of 397 senior high school students]. Guide China Med. 2010;8(25):16–8. Chinese.^,5353 Zhu X, Wang C, Zhou Q, Qiao J, Geng D, Li J. [Characteristics of big five personality in college students and its relationship with childhood abuse]. China J Health Psychol. 2012;20(7):1083–6. Chinese.^–5656 Chang X, Wang H. [Effect of psychological abused and neglect in childhood on adult mental health]. Chin J Health Psychol. 2008;16(11):1239–41. Chinese.^,5959 Xiao Q, Dong MX, Yao J, Li WX, Ye DQ. Parental alcoholism, adverse childhood experiences, and later risk of personal alcohol abuse among Chinese medical students. Biomed Environ Sci. 2008 Oct;21(5):411–9. doi: http://dx.doi.org/10.1016/S0895-3988(08)60062-8 PMID: 19133615
https://doi.org/10.1016/S0895-3988(08)60... ^,7373 Gao Y, Pan J, Yang W, Teng H, Ying Y. [Cross sectional study on child neglect among rural children aged 9-11 years in Shanxi Province]. J Medl Theor Pract. 2013;26(20):2680–5. Chinese.^–7575 Cheng P, Cao F, Chen Q, Liu J, Li Y, Kong Z, et al. [Prevalence and influencing factors of juvenile victimization]. CJCHC. 2010;18(6):479–81. Chinese. and 16 studies on sexual abuse among females⁷7 Chen JQ, Dunne MP, Wang X. Prevalence of childhood sexual abuse among female students in a senior high school. Chin J Sch Health. 2002;23:108–10.[Chinese].^–1010 Tang CS. Childhood experience of sexual abuse among Hong Kong Chinese college students. Child Abuse Negl. 2002 Jan;26(1):23–37. doi: http://dx.doi.org/10.1016/S0145-2134(01)00306-4 PMID: 11860160
https://doi.org/10.1016/S0145-2134(01)00... ^,2525 Qiu C, Ma Y. [Sexual behavior and influence factors among 693 female technical secondary school students]. Chin J Sch Health. 2010;31(4):417–8. Chinese.^,6363 Ye Q, Tao F, Fang D, Huang K, Sun Y. [Impact of child abuses on psychology and risk behaviors regarding harmful dietary patterns in adolescents]. Chin J Epidemiol. 2006;27(4):319–23. Chinese.^,6868 Chan KL, Yan E, Brownridge DA, Ip P. Associating child sexual abuse with child victimization in China. J Pediatr. 2013 May;162(5):1028–34. doi: http://dx.doi.org/10.1016/j.jpeds.2012.10.054 PMID: 23219443
https://doi.org/10.1016/j.jpeds.2012.10.... ^,7676 Lin D, Li X, Fan X, Fang X. Child sexual abuse and its relationship with health risk behaviors among rural children and adolescents in Hunan, China. Child Abuse Negl. 2011 Sep;35(9):680–7. doi: http://dx.doi.org/10.1016/j.chiabu.2011.05.006 PMID: 21907409
https://doi.org/10.1016/j.chiabu.2011.05... ^–8484 Chen J, Dunne MP. [The impact of sexual abuse in childhood on females’ mental development]. Chin J Publ Health. 2003;19(9):1142–3. Chinese. and 12 studies of sexual abuse among males.⁹9 Chen J, Dunne MP, Han P. Child sexual abuse in China: a study of adolescents in four provinces. Child Abuse Negl. 2004 Nov;28(11):1171–86. doi: http://dx.doi.org/10.1016/j.chiabu.2004.07.003 PMID: 15567022
https://doi.org/10.1016/j.chiabu.2004.07... ^,1010 Tang CS. Childhood experience of sexual abuse among Hong Kong Chinese college students. Child Abuse Negl. 2002 Jan;26(1):23–37. doi: http://dx.doi.org/10.1016/S0145-2134(01)00306-4 PMID: 11860160
https://doi.org/10.1016/S0145-2134(01)00... ^,6363 Ye Q, Tao F, Fang D, Huang K, Sun Y. [Impact of child abuses on psychology and risk behaviors regarding harmful dietary patterns in adolescents]. Chin J Epidemiol. 2006;27(4):319–23. Chinese.^,6868 Chan KL, Yan E, Brownridge DA, Ip P. Associating child sexual abuse with child victimization in China. J Pediatr. 2013 May;162(5):1028–34. doi: http://dx.doi.org/10.1016/j.jpeds.2012.10.054 PMID: 23219443
https://doi.org/10.1016/j.jpeds.2012.10.... ^,7676 Lin D, Li X, Fan X, Fang X. Child sexual abuse and its relationship with health risk behaviors among rural children and adolescents in Hunan, China. Child Abuse Negl. 2011 Sep;35(9):680–7. doi: http://dx.doi.org/10.1016/j.chiabu.2011.05.006 PMID: 21907409
https://doi.org/10.1016/j.chiabu.2011.05... ^,7878 Gu L, Chi S, Zhang Z. [A study of child sexual abuse among college students]. Chin J Sch Health. 2005;26(4):309–10. Chinese.^–8383 Chen JQ. [A retrospective survey in child sexual abuse among 565 university students]. Zhonghua Liu Xing Bing Xue Za Zhi. 2004 Oct;25(10):873–7. Chinese. PMID: 15631745^,8585 Chen J, Wang X, Dunne MP. [Childhood sexual abuse: An investigation among 239 male high school students]. Chin Ment Health J. 2003;17(5):345–7. Chinese. (Table 2; available from: http://www.who.int/bulletin/volumes/93/3/14-140970). All of our included studies had a low or medium risk of bias. A weak sampling design, lack of statistical reporting – e.g. a lack of confidence intervals (CIs) – or the use of researcher-developed questions led to a medium risk of bias.

Three studies were excluded from the final meta-analyses for each of the three types of child maltreatment: emotional abuse,²³23 Yang S, Zhang Y, Huang G, Guo G. A preliminary study on child abuse. Chin J Clin Psychol. 2004;12(2):140–1.^,2424 Lu X, Zhou M, Liang F, Ma X, Zhong Q. [An investigation on child physical and emotional abuse of Zhuang and Han nationalities in western Guangxi]. J Youjiang Med Univ Natl. 2012;34(4):453–4. Chinese.^,2626 Chen J, Ma Y, Liang Y. [A retrospective survey of childhood corporal punishment and emotional maltreatment by their parents in students]. Chin Ment Health J. 2008;22(12):922–7. Chinese. physical abuse,²²22 Fuh JL, Wang SJ, Juang KD, Lu SR, Liao YC, Chen SP. Relationship between childhood physical maltreatment and migraine in adolescents. Headache. 2010 May;50(5):761–8. doi: http://dx.doi.org/10.1111/j.1526-4610.2010.01639.x PMID: 20236341
https://doi.org/10.1111/j.1526-4610.2010... ^,2323 Yang S, Zhang Y, Huang G, Guo G. A preliminary study on child abuse. Chin J Clin Psychol. 2004;12(2):140–1.^,2525 Qiu C, Ma Y. [Sexual behavior and influence factors among 693 female technical secondary school students]. Chin J Sch Health. 2010;31(4):417–8. Chinese. and neglect.²³23 Yang S, Zhang Y, Huang G, Guo G. A preliminary study on child abuse. Chin J Clin Psychol. 2004;12(2):140–1.^,2727 Xie Z, Tang Q, Chang X, Deng Y. 457 College students’ experience of psychological abuse and neglect in childhood and mental health. Chin J Clin Psychol. 2008;16(1):62–5.^,2828 Ma JF, Dai JH, Guan SZ, Liu W, Liu JW. [Retrospective study on the adverse childhood experience among medical college students]. Chin J Sch Health. 2012;33(12):1454–6. Chinese. In these studies, subtraction of the unstandardized coefficients from the reported prevalence estimates produced negative values. Thus, the final five meta-analyses were based on 28 studies on emotional abuse, 33 on physical abuse, 15 on neglect and 16 on sexual abuse for females and 12 studies of sexual abuse of males (Table 2).

The unadjusted and adjusted prevalence estimates from the included studies for emotional abuse, physical abuse and neglect are shown in Fig. 2 and Fig. 3. The estimates for sexual abuse have been published.¹⁶16 Ji K, Finkelhor D, Dunne M. Child sexual abuse in China: a meta-analysis of 27 studies. Child Abuse Negl. 2013 Sep;37(9):613–22. doi: http://dx.doi.org/10.1016/j.chiabu.2013.03.008 PMID: 23643201
https://doi.org/10.1016/j.chiabu.2013.03... Table 3 presents our unadjusted and adjusted estimates of the prevalence of each type of child maltreatment in China. Table 1 shows the RRs and population attributable fractions for the health and behavioural outcomes associated with each type of child maltreatment. No relevant data were available for child neglect. We estimate that for mental disorder, the population attributable fraction of emotional abuse is 26.3%, while the population attributable fraction of physical abuse is 18.8%. The population attributable fractions for physical abuse varied between 9.6% and 20.7% in the seven outcomes that we investigated. In general, the population attributable fractions for physical abuse were higher than those for sexual or emotional abuse.

The numbers and economic values of the DALYs lost because of child maltreatment are shown in Table 4. Although only a limited number of health outcomes were considered, an estimated 11 288 100 of DALYs lost in China in 2010 were attributable to child physical abuse. The estimated economic value of these lost DALYs was 50 billion United States dollars – or 0.84% of China’s gross domestic product in 2010. Even though we only considered the impacts of child emotional abuse on mental health disorders and self-harm, we estimated that such abuse caused 6 334 700 of the DALYs lost in China in 2010. The DALYs lost in 2010 because of child emotional and sexual abuse had estimated values equivalent to 0.47% and 0.39% of China’s gross domestic product in 2010, respectively.

Discussion

We estimated the general burden of child maltreatment in China. Maltreatment is a common experience for Chinese children. Despite a paucity of data on the impact of child maltreatment on child and adult health, the associations between such maltreatment and subsequent poor mental health and harmful behaviours in China are substantial and consistent with the results of research elsewhere.⁹²92 Gershoff E, Lansford J, Sexton H, Davis-Kean P, Sameroff A. Longitudinal links between spanking and children’s external behaviours in a national sample of white, black and Hispanic and Asian families. Child Dev. 2012;83:1–6. doi: http://dx.doi.org/10.1111/j.1467-8624.2011.01732.x
https://doi.org/10.1111/j.1467-8624.2011... ^,9393 Hoeve M, Dubas JS, Eichelsheim VI, van der Laan PH, Smeenk W, Gerris JR. The relationship between parenting and delinquency: a meta-analysis. J Abnorm Child Psychol. 2009 Aug;37(6):749–75. doi: http://dx.doi.org/10.1007/s10802-009-9310-8 PMID: 19263213
https://doi.org/10.1007/s10802-009-9310-... According to our calculations, 11.3 million of the DALYs lost in China in 2010 were attributable to child physical abuse. This value lies between the corresponding estimates for diabetes mellitus – 7.8 million DALYs lost – and ischaemic heart disease – 17.8 million DALYs lost.³⁰30 Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet. 2013 Jun 8;381(9882):1987–2015. doi: http://dx.doi.org/10.1016/S0140-6736(13)61097-1 PMID: 23746901
https://doi.org/10.1016/S0140-6736(13)61... The size of this burden justifies further research and increased efforts to improve child protection in China, especially since our estimates of the burdens of child maltreatment are based on the available data on a small number of health outcomes and are therefore likely to be underestimates.

There is a paucity of Chinese data on child neglect and emotional abuse and their associated consequences. If the financial burden of child maltreatment is to be accurately assessed in China, there is also a need for additional information on child-maltreatment-attributable losses in productivity and the short- and long-term medical costs of child maltreatment.⁵5 Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl. 2012 Feb;36(2):156–65. doi: http://dx.doi.org/10.1016/j.chiabu.2011.10.006 PMID: 22300910
https://doi.org/10.1016/j.chiabu.2011.10... Another considerable gap in our current understanding is that, as no community-based study on temporal changes in child maltreatment in China has been published, it remains unclear if the problem is getting better or worse or staying unchanged. Population-based research that provides estimates of the temporal changes across a broad spectrum of childhood abuse, neglect and other adversities should be a core element of any comprehensive national prevention response.

Our study had several limitations and had several major gaps in the relevant evidence base. Most of the data that we used for calculating prevalence and population attributable fractions came from studies that did not employ representative samples. Many of our included studies only investigated one type of maltreatment or – if they investigated several types – did not report disaggregated data. The high level of variation in the reported prevalence of maltreatment is worrying and possibly indicative of substantial variation in how maltreatment has been defined and evaluated and in the sampling method used. Population attributable fractions can be sensitive to small changes in prevalence and RR and this problem may be exacerbated when the fractions are based on data from multiple studies. Although we carefully reviewed all input data to select appropriate studies, our results rest squarely on the – often uncertain – quality of the available data. By using DALYs, we were only able to estimate the non-fatal health burden posed by child maltreatment. We could find no data on maltreatment-attributable child mortality in China. However, WHO recently estimated that, in China, 1266 children aged 0–14 years died from interpersonal violence in 2012 – resulting in 111 170 years of life lost.⁹⁴94 Health statistics and information systems. Estimates for 2000–2012 [Internet]. Geneva: World Health Organization; 2014. Available from: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html [cited 2014 Nov 12].
http://www.who.int/healthinfo/global_bur... It seems very likely that, in China, there are also violent deaths among adolescents aged 15–18 years and that some children commit suicide as a result of maltreatment.

As some of the health outcomes that we investigated may have overlapped, our estimates may have been affected by the double-counting of DALYs lost. However, we carefully scrutinized all study inputs and population attributable fractions to try to minimize this problem. As far as possible, we maintained one-to-one correspondence between the population attributable fractions and the burden measures from the global burden of disease 2010 study in China.

Many of the studies that we included in our review excluded many possibly important confounding factors and may therefore have overestimated the direct effects of child maltreatment. For example, it is almost impossible to know if genetic inheritance may explain some portion of the associations between maltreatment and outcomes. The accuracy of our estimates was also limited by the fact that most of the data on prevalence and outcomes that we used were self-reported in cross-sectional studies where maltreatment was measured retrospectively.

After considering all of the limitations of our study, we think that our burden estimates are probably underestimates of the true values. Many of the serious effects of child maltreatment – e.g. poor educational and employment outcomes, high levels of health-care utilization, criminal behaviour and reproductive health problems – were not included because no relevant studies have been published. In addition, no estimates are available of the costs to the Chinese police and child welfare services of child maltreatment.

Despite the gaps in the current evidence base, this study indicates the importance of prioritizing child maltreatment as a key health concern in China. It also underscores the need to steer resources towards child protection and to strengthening the knowledge base regarding the scale and consequences of child maltreatment at national level.

Acknowledgements

MPD has a dual affiliation with the Institute for Community Health Research, Hue University of Medicine and Pharmacy, Hue, Viet Nam.

References

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