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REGULAR ARTICLE Acta Pædiatrica ISSN 0803–5253 Prevalence and characteristics of child physical abuse in Sweden
REGULAR ARTICLE Acta Pædiatrica ISSN 0803–5253 Prevalence and characteristics of child physical abuse in Sweden

REGULAR ARTICLE

Acta Pædiatrica ISSN 0803–5253

Prevalence and characteristics of child physical abuse in Sweden – findings from a population-based youth survey

E-M Annerbäck (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 dose–response 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 world’s 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 difficult, however, because of different methodological approaches used in different studies (1). Sweden became in 1979 the first 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 (1,3–6). 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 first 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 first area involves factors associated with the perpetrators, factors such as parental substance or alcohol abuse, parent’s psychiatric symp- toms illness or medical problems, parental intimate-partner violence and the experience the parents themselves have of being exposed to child abuse (2,9–11). The proportions of male female perpetrators are often equal in survey studies

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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 financial factors, which are regarded as factors that place stress and strain on the family. Financial difficulties, parental edu- cational level, unemployment, low socio-economic status and family setting are all conditions that have been reported as socio-economic factors (1,9,11,12,18–20). 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 suffices 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 conflict 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 insuffi- 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

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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).

Definitions 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 (0–19 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 confidentiality 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 confidential. 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 unspecified reasons. A second chance was given for those

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Prevalence and characteristics of child physical abuse

not attending on the first day of the survey. The drop-outs

Accumulation of risk factors

of pupils absent from school for unspecified reasons may

A

score was given for each of the risk factors named above.

If

the child had answered ‘no’ to all questions dealing with

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-

Final sample

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?’.

response: the children had given answers to every ques- tion that were the worst most serious alternative choices for the questions.

The final 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%.

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% confidence 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

Ethical considerations

preted as an indication that the pupils felt comfortable with

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 conflict situations was indicated if the child reported that violence had occurred between the adults in the family (parental intimate-partner violence).

eight variables gender, parent’s employment, housing accommodation, family setting, parent foreign born, child’s disability or disease, child’s social network and finally parental intimate-partner violence were entered simulta- neously (Table 1). To compare means between groups One- way ANOVA and Tamhane’s post hoc test were used.

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-

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

2 Social and or economic stress and strain on the family – Questions concerned the parent’s employment status,

3 Insufficient social network was indicated if the child

is

to ask the children about their own (most often negative)

accommodation of the family, marital status and country of origin. Social and or economic stress was indicated if

behaviour, such as smoking, alcohol use and criminal activ- ities.

the child answered yes to at least one of the questions ‘Do you live with a single parent; is at least one parent

The study was approved by the Regional Ethical Review Board of Linko¨ ping (Dnr, M180-08).

foreign born; is at least one parent unemployed or on sick leave.’

answered ‘no’ to the question; ‘Have you got any adult person with whom you can talk about things that you are concerned about?’

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

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-Deficit 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.

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 significant 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).

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35.1 (24.26–50.83)***

3.0 (2.24–4.11)***

2.2 (1.55–3.00)***

6.9 (5.05–9.42)***

1.9 (1.35–2.80)***

1.9 (1.28–2.81)**

0.92 (0.69–1.27)

1.8 (1.09–2.95)*

2.1 (1.07–4.29)*

0.9 (0.56–1.54)

0.7 (0.54–1.04)

1.0 (0.38–2.80)

0.8 (0.66–1.04)

1.0 (0.77–1.41)

1.4 (0.65–2.92)

aOR (95% CI) all variables included in the model

49.9 (37.26–66.78)***

9.5 (7.36–12.14)***

4.0 (2.94–5.43)***

2.2 (1.78–2.77)***

4.3 (3.46–5.30)***

1.9 (1.50–2.36)***

3.1 (2.44–4.04)***

1.6 (1.27–1.93)***

2.3 (1.59–3.21)***

5.4 (3.48–8.52)***

2.6 (1.97–3.41)***

4.2 (2.50–7.08)***

3.7 (2.30–5.84)***

1.4 (1.11–1.83)**

1.1 (0.95–1.35)

Reference group

Reference group

Reference group

Reference group

Reference group

Reference group

Reference group

Reference group

cOR (95% CI)

Hit twice or more n (% of children in respective group)

115 (11.5)

136 (18.2)

112 (18.1)

164 (55.2)

130 (8.8)

104 (9.5)

285 (6.8)

404 (5.4)

368 (5.6)

400 (5,9)

430 (5.8)

227 (4.5)

414 (5.8)

257 (6.3)

260 (3.6)

58 (18.1)

97 (12.3)

27 (18.5)

68 (13.7)

19 (19.4)

23 (17.7)

41 (9.1)

94 (6.1)

1.7 (1.29–2.24)***

8.0 6.34–10.13***

7.8 5.14–11.97***

1.7 1.31–2.29***

1.7 (1.07–2.57)*

1.9 (1.07–3.48)*

1.2 (0.82–1.75)

1.1 (0.77–1.51)

1.0 (0.77–1.29)

1.1 (0.87–1.43)

1.1 (0.47–2.50)

1.2 (0.98–1.53)

0.9 (0.58–1.30)

1.0 (0.87–1.24)

0.5 (0.22–1.34)

aOR (95% CI) all variables included in the model

9.3 (7.58–11.30)***

8.1 (5.60–11.58)***

2.3 (1.65–3.12)***

1.5 (1.25–1.90)***

2.0 (1.58–2.49)***

1.9 (1.43–2.59)***

1.8 (1.39–2.26)***

1.7 (1.35–2.03)***

1.3 (1.09–1.58)***

2.8 (1.75–4.44)***

1.6 (1.30–1.91)***

1.9 (1.04–3.45)*

1.2 (1.05–1.42)*

1.2 (0.84–1.58)

1.1 (0.56–2.00)

Reference group

Reference group

Reference group

Reference group

Reference group

Reference group

Reference group

Reference group

cOR (95% CI)

a multivariate logistic regression model.

Hit once, n (% of children in respective group)

102 (13.7)

120 (12.0)

207 (33.5)

160 (10.8)

135 (12.3)

173 (11.2)

541 (8.2)

586 (8.7)

653 (8.7)

654 (8.9)

621 (8.7)

378 (7.6)

409 (9.8)

343 (8.3)

491 (6.7)

50 (15.6)

58 (12.9)

50 (16.8)

91 (11.6)

23 (15.8)

13 (13.3)

46 (9.2)

10 (7.7)

Never hit n (% of children in respective group)

the comparison in group.

cOR = crude odds ratio; aOR = adjusted odds ratio.

5759 (85.4)

6473 (86.0)

5684 (86.2)

1195 (80.5)

6124 (86.5)

6287 (85.3)

4394 (87.9)

3544 (85.6)

3468 (83.3)

6564 (89.7)

1275 (82.7)

212 (66.2)

351 (78.0)

509 (68.1)

766 (76.5)

598 (76.1)

384 (77.1)

299 (48.4)

856 (78.2)

83 (27.9)

66 (67.3)

96 (65.8)

97 (74.6)

hit as simultaneously

*p < 0.05, **p < 0.01, ***p < 0.001.

Gender § Boys Girls Parents employment¶ Both parents employed One parent unemployed on sick leave Both parents unemployed on sick leave Accommodation § Private house, apartment Rented flat Child living with § Both parents Single parents with joint custody Single parent Parent and stepparent Foster home Parent foreign born § No parent foreign born 1 parent foreign born Child with disability or disease § No disability Physical disability Psychological disability Chronic disease Child’s social network § Sufficient network Insufficient network Parental intimate-partner violence Never Yes, once or twice Yes, several times

entered

8.0%.

drop-out £ is 3.5%.

never

ratio with were

Internal drop-out

8 variables

Characteristics

§ Internal

Odds

All

Prevalence and characteristics of child physical abuse

Characteristics of child physical abuse by parents or other caretakers (n = 8494) presented results are based on bivariate (cOR) and multivariate analyses (aOR)

Table 1

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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.

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, insuffi- cient social network and parental intimate-partner violence were significant on 95% CI for being hit once. The same variables and in addition the variables living with a single parent and chronic disease were significant 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 1–2 times and those who had hit more than two times was statistically significant (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; insufficient 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 0–4. The differences between the groups were significant (p < 0.001). Also the post hoc analy- sis showed a significant difference (p < 0.001) between the

Prevalence and characteristics of child physical abuse

means in the three groups with a dose–response 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 findings.

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 fig- 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 fig- 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 confirms 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 Siblings, peers Parents Authorities* BRIS or similar

41

28

36

46

59

52

20

24

22

3

13

7

25

3

The sum is >100% because some pupils answered more than one alternative. *Authority means personnel in school, social services, police and similar. BRIS (Children’s Rights in the Society) or similar means voluntary organiza- tions, where children can get in contact with someone anonymously.

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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 finding is a confirmation 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 confirmed 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 dose–response 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 insufficient social network was associated with CPA also in the adjusted analyses as was the child’s 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 confirms 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 finding of this study and confirmed 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 finding 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

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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 sufficient. 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 confirmed 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 family’s 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 conflict 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 child’s and the family’s social network weakened and or insufficient? and (iv) In what respects could the child face obstacles that make it difficult 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 children’s 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

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difficulties 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 parent’s 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 field 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.

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