Int. Journal on Child Malt.

(2022) 5:541–571
https://doi.org/10.1007/s42448-022-00122-z

REVIEW ARTICLE

Child Maltreatment, Adverse Childhood Experiences,

and the Public Health Approach: A Systematic Literature
Review

Selena T. Garrison1   · Martie Gillen1   · Lindsey M. King2   ·

Kennedy Cutshall1 · Alyssa Howitt3,4

Accepted: 11 July 2022 / Published online: 25 July 2022

© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022

Abstract
This study provides a systematic literature review of peer-reviewed research articles
from 2011 to 2021 that examine child maltreatment or adverse childhood experi-
ences from a public health perspective. Twelve articles met the inclusion criteria.
The evidence was synthesized and reported following the preferred reporting items
for systematic reviews and meta-analysis procedure (PRISMA). Researchers sought
to understand how current literature applies a public health approach to child mal-
treatment and adverse childhood experiences, as well as how that research addresses
primary, secondary, and tertiary prevention of child maltreatment and adverse child-
hood experiences. The articles were categorized into one of the four steps of the
commonly used public health model including surveillance; identification of risk
and protective factors; development and testing of interventions; and implementa-
tion of effective prevention and control strategies. Two articles were also catego-
rized outside of that model, with a focus on stakeholder engagement and collabora-
tion. Some of the articles were categorized into multiple steps within the model. In
addition, the articles encompass primary, secondary, and tertiary prevention strate-
gies. Recommendations for policy, practice, and future research are included.

Keywords  Child maltreatment · Adverse childhood experiences · ACEs · Public

health

* Selena T. Garrison
selenah@ufl.edu
1
Department of Family, Youth and Community Sciences, College of Agricultural and Life
Sciences, University of Florida, Gainesville, FL, USA
2
Department of Health Services Research, Management & Policy, College of Public Health
and Health Professions, University of Florida, Gainesville, FL, USA
3
Department of Psychology, College of Liberal Arts and Sciences, University of Florida,
Gainesville, FL, USA
4
Department of Political Science, College of Liberal Arts and Sciences, University of Florida,
Gainesville, FL, USA

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Vol.:(0123456789)
542 S. T. Garrison et al.

Introduction

This study centers around the key findings of a systematic literature review
focused on research articles that included a public health approach to addressing
child maltreatment (CM) and adverse childhood experiences (ACEs). According
to the World Health Organization (WHO) (2020), CM refers to a wide variety of
abuse and neglect inflicted on children under 18 years old, including all manner
of physical and emotional harm, sexual abuse, neglect, and exploitation result-
ing in harm or potential harm to the child. In 1999, the WHO identified CM as
a vitally important public health issue, citing the broad array of physical, emo-
tional, and developmental problems experienced by children who have been vic-
tims of abuse and neglect (WHO, 1999). Expanding on the traditional definition
of CM, ACEs encompass a wide variety of potentially traumatic events that occur
in childhood (Centers for Disease Control and Prevention [CDC], 2022).
In the first study of its kind linking ACEs to adult health outcomes (Felitti
et  al., 1998), the Centers for Disease Control and Prevention (CDC) and Kaiser
Permanente expanded on the traditional definition of CM and examined three
areas of ACEs: abuse, neglect, and household dysfunction, in relation to health
outcomes later in life. Of the 8056 adult participants who completed both a stand-
ardized medical evaluation and the ACE study questionnaire, over half (52%) had
exposure to at least one of the ACE indicators, while 6% indicated four or more
exposures (Felitti et  al., 1998). When these results were observed in combina-
tion with the participants’ medical evaluations, their study revealed staggering
evidence that ACEs are strongly linked to some of the most prevalent adult risk
behaviors (alcoholism, drug abuse, suicide attempts, smoking, 50 or more sexual
partners, physical inactivity) and health problems (depression, severe obesity,
sexually transmitted disease, ischemic heart disease, chronic lung disease, cancer,
liver disease, skeletal fractures) (Felitti et al., 1998). The evidence is irrefutable
that ACEs are powerful determinants of adult physical and mental health.
Since the original ACEs study (Felitti et  al., 1998), the definition of ACEs
has expanded to include other adversities such as racism, bullying, community
violence, neighborhood safety, living in foster care, economic hardship, parental
death (Pachter et al., 2017), and disasters (American Academy of Family Physi-
cians, 2019). Cronholm et  al. (2015) explored the potential for expanding upon
the original 10 ACEs (conventional ACEs), specifically in the context of an urban
environment. In addition to questions about their exposure to conventional ACEs,
1784 participants in the Philadelphia area were asked about five additional com-
munity-related experiences of adversity (expanded ACEs), including how often
they had personally witnessed violence (someone being beaten, stabbed, or shot),
how often they had been discriminated against based on their race or ethnicity,
whether or not they felt safe in their neighborhood, how often they were bul-
lied, and if they were ever in foster care (Cronholm et  al., 2015). At least one
conventional ACE had been experienced by 72.9% of the sample, at least one
expanded ACE by 63.4% of the sample, and both a conventional ACE and an
expanded ACE by 49.3% of the sample. Interestingly, 13.9% had experienced

13
Child Maltreatment, Adverse Childhood Experiences, and the… 543

only expanded ACEs. Those respondents would have gone unrecognized in an

assessment including only the conventional ACEs (Cronholm et al., 2015). Utiliz-
ing the same data to assess related health outcomes, Wade et al. (2016) found that
health risk behaviors, mental illness, and physical illness were associated with
elevated conventional ACE scores, while only substance abuse history and sexu-
ally transmitted infections were associated with elevated expanded ACE scores
(Wade et al., 2016). ACEs are a critical public health issue due to the impact they
have on long-term health outcomes, the high prevalence across the life course,
and their intergenerational effects (Lopez et  al., 2021; CDC, 2010). Preventing
CM and other ACEs, as well as mitigating their effects, could have population
level, long term-benefits across communities (Bethell et al., 2017).
Researchers have suggested a greater focus on enhancing community capacity
and building social and economic capital to prevent ACEs, including all forms of
CM (Bruner, 2017). Lopez et  al. (2021) suggest taking a social ecological, multi-
level approach to prevent ACEs and mitigate their effects by addressing social
determinants of health, including housing and food insecurity, family and com-
munity violence, and discrimination (DeCandia & Guarino, 2015; Lopez et  al.,
2021). In 2015, the United Nations adopted the Sustainable Development Goals, a
call to action for countries throughout the world to end poverty and inequalities and
improve health, which are in line with a framework to prevent and reduce ACEs
globally (Hughes et al., 2017). The U.S. Department of Health and Human Services
through the Office of Disease Prevention and Health Promotion (ODPHP, 2000) sets
national objectives to improve health over each decade called Healthy People 2030.
Healthy People 2030 includes four ACEs-driven objectives that focus on reducing
ACEs and increasing trauma-informed school settings (ODPHP, 2000).
In considering a public health approach to addressing CM and ACEs, a com-
mon way of representing such an approach is through a four step model, where the
first step is defining and monitoring the problem through surveillance; the second
step is identifying risk and protective factors; the third step is development and
testing of intervention strategies; and the fourth step is ensuring wide spread adop-
tion through effective prevention and control strategies (Putnam-Hornstein et al.,
2011; Richmond-Crum et  al., 2013). In recent years, experts have recommended
population level, public health approaches to address ACEs and generate broader
systems change by shifting the focus to prevention and implementation of trauma-
informed, resilience building programs and policies (CDC, 2010; SAMHSA,
2014; Hughes et  al., 2017). A trauma-informed approach involves cultural and
systems level changes to organizations, health care, social service agencies, and
communities through a shared understanding by all members of the system that
trauma is pervasive with a focus on preventing re-traumatization (SAMHSA,
2014). A public health, trauma-informed approach can be implemented within all
systems that work with children and families, including schools and health care
settings (Higgins et al., 2022).
A public health approach also involves utilizing the public health prevention
levels (primary, secondary, tertiary levels) (Higgins et  al., 2022). Primary pre-
vention focuses on the prevention of ACEs before they can occur through sys-
tems level changes such as implementing policies that support families, reducing

13
544 S. T. Garrison et al.

poverty, eliminating structural inequalities, improving social conditions, enhanc-

ing protective factors and social support, and implementing social emotional,
trauma-informed curriculums into schools (Oral et  al., 2016). Secondary pre-
vention focuses on intervening as soon as possible after ACEs occur to reduce
shorter term outcomes (Oral et al., 2016). These interventions focus on reducing
the impact of ACEs that have already occurred via school and healthcare screen-
ings, linking children and families to appropriate resources, improving child pro-
tection services, and implementing home visiting programs (Oral et  al., 2016).
Tertiary prevention focuses on improving quality of life among individuals who
have had prolonged exposure to ACEs to mitigate long-term health outcomes. An
example of a tertiary prevention intervention includes trauma-responsive sub-
stance abuse programs for adults who have trauma histories (Oral et  al., 2016).
Rather than focusing on children and families at high risk for ACEs, a primary
prevention, universal precautions approach involves treating every person using a
trauma-informed lens through population level, strengths-based, trauma-informed
systems (Oral et al., 2016). Critical gaps exist in primary prevention, population-
based approaches, even though these efforts would have the widest public health
impact (Oral et al., 2016).
Higgins et  al. (2022), in their chapter within the Handbook of Child Maltreat-
ment, created six Core Components of Public Health Approaches, a framework to
prevent child abuse and neglect, utilizing a child-rights and public health approach.
They argue for a public health approach that emphasizes primary prevention and
universal services (Higgins et al., 2022). Their framework calls for a shift away from
solely individual interventions by highlighting the importance of non-stigmatizing,
population level prevention and early intervention approaches (Higgins et al., 2022).
Primary prevention that focuses on improving conditions and creating safe environ-
ments within the entire community will prevent CM and other forms of ACEs from
occurring and prevent children and families from needing secondary and tertiary
prevention services (Higgins et al., 2022).
The six components of a public health approach to CM and prevention include
focusing on reducing modifiable risk factors and improving structural conditions
that promote health and safety; taking a universal prevention approach that shifts the
focus from high-risk families and youth to entire populations; implementing early
intervention strategies, thus preventing most families from needing secondary and
tertiary prevention programs; utilizing evidence-based approaches that have proven
effective; use of community-based and non-stigmatizing services; and address-
ing social and structural determinants that are universally embedded and sustain-
able (Higgins et al., 2022). A public health approach to addressing CM and ACEs
requires an upstream approach that focuses on prevention and policy changes, cross
sector collaborations, reducing poverty and unemployment, and improving educa-
tion at multiple social ecological levels (Bruner, 2017). The purpose of a system-
atic review is to identify, evaluate, and summarize findings of individual primary
research studies related to a specific health-related issue (Gopalakrishnan & Ganesh-
kumar, 2013). The purpose of this systematic review is to identify, evaluate, and
summarize findings of individual primary research studies related to ACEs and CM
from a public health perspective.

13
Child Maltreatment, Adverse Childhood Experiences, and the… 545

Methods

The researchers conducted a systematic literature review of academic and peer-

reviewed study publications that examine ACEs or CM from a public health per-
spective. Systematic literature reviews follow a protocol that is clearly defined
before the review is conducted for the purpose of answering a specific question.
In this study, two primary questions were considered:

1. How does current research apply a public health approach to CM and ACEs?
2. How does current research that utilizes a public health approach to CM and ACEs
address primary, secondary, and tertiary prevention of CM and ACEs?

For this review, the protocol included searching EBSCO host, PubMed and
Google Scholar electronic databases from 2011 to 2021 (the most recent decade
of research at the time of the review) for the following search terms: “adverse
childhood experiences,” “ACEs,” “child maltreatment,” “public health,” “public
health approach,” and “public health perspective.” To be included in this sys-
tematic review, articles had to be published between 2011 and 2021, written in
English, peer-reviewed, and had to examine ACEs or CM from a public health
perspective through a clearly defined quantitative, qualitative, or mixed methods
study.
The 44 articles identified via these search terms were imported into the Covi-
dence systematic review software (Veritas Health Innovation, 2000), a citation
management software for systematic reviews. Nine articles were rejected by the
primary researcher upon review of the title and the abstract, and 23 articles were
rejected upon full text review by three researchers due to not meeting inclusion
criteria. A shared Excel spreadsheet was utilized during the full-text review pro-
cess. If a researcher determined that an article did not meet inclusion criteria
upon full-text review, it was marked on the spreadsheet for review by the other
researchers. Articles were rejected during full-text review due to not reporting
on a qualitative, quantitative, or mixed methods study. The majority of these arti-
cles were editorials, commentaries, or reviews. There were no disagreements on
which articles to reject. With 12 articles remaining, the evidence was synthesized
and reported following the preferred reporting items for systematic reviews and
meta-analysis procedure (PRISMA) (see Fig. 1).
Each article was assigned to one of three for data extraction, with all three
researchers working together in a shared Excel spreadsheet to share and review
each other’s extracted data. All extracted data was reviewed by at least one other
researcher. Eleven categories of data were sought from each article, including clas-
sification of the study as quantitative, qualitative, or mixed methods; location of the
study; purpose of the study; any clearly identified theories used (if applicable); any
specific clearly identified public health approach used (if applicable); any interven-
tions specifically identified (if applicable); population of interest; sampling proce-
dure; sample characteristics; analytic methods utilized; and conclusions. Research-
ers also recorded their own perceived strengths and weaknesses of each study.

13
546 S. T. Garrison et al.

Fig. 1  PRISMA flow diagram for child maltreatment, adverse childhood experiences, and the public
health approach

Results

The 12 research articles included in this systematic literature review represented a

breadth of study locations, methodologies, and populations of interest. See Table 1
for an overview of all included studies. Three of the articles (Åstrøm et al., 2021;
Brattabø, et al., 2016, 2018) examined data from electronic questionnaires collected
at varying points during a five-year study among public health dental workers in
Norway. Dias et  al. (2018) utilized a mixed-method Delphi study design among
researchers and practitioners in Europe. Drury et al. (2019) utilized data from inter-
vention site logs and semi-structured interviews among outreach workers and super-
visors in the United States of America (USA). Eija et al. (2014) utilized a web-based
survey in a cross-sectional study of public health nurses in Finland. Gibbs et  al.
(2013) and Smith et  al. (2011) conducted case study assessments utilizing semi-
structured key informant interviews across three states (California, Michigan, and
Oregon) in the USA. Putnam-Hornstein et  al. (2011) utilized probabilistic linkage
strategies to match birth records and child protective service records among children
born between 1999 and 2002 in California, USA. Srivastav et  al. (2020) utilized
semi-structured, in-depth interviews among child and family-serving professionals
in South Carolina, USA. Suzuki et al. (2017) utilized a questionnaire in a cross-sec-
tional study with public health nurses working in maternal and child health care in
Finland and Japan. Finally, Tonmyr et al. (2019) utilized a web-based questionnaire
to code CM data from administrative records and case narratives in Canada.

13
 Table 1  Overview of included studies
Author/year
Åstrøm, A. N., Berg, K. G., &
Brattabø, I. V. (2021)
Brattabø, I. V., Bjørknes, R., &
Åstrøm, A. N. (2018)
13
Location Aims
Norway Examine stability and change
in mandated reporting of
suspected CM across time
(2014–2019); investigate
influences on dental health
care workers’ reporting prac-
tices across time
Norway Explore reasoning behind
public dental health profes-
sionals (PDHP) submitting
reports for suspected CM,
child welfare services (CWS)
response to those reports,
and the relationship between
reasons for reporting and
CWS response
Participants
591 dental health care workers
who participated in a baseline similar electronic question-
study in 2014 and the follow-
up study in 2019
1200 public dental health
hygienists and dentists
Method
Repeated cross-sectional study;
naires were administered at
baseline and follow-up
National cross-sectional study
utilizing an electronic ques-
tionnaire
Select results
In regard to reporting suspected CM
over a 5-year period, more than 50%
of Norwegian dental health care
workers remained stable in regard to
ever reporting and recently report-
ing suspected CM. 25% remained
stable in avoidance of reporting
suspected CM, while 57% indicated
never having avoided reporting.
Significant differences were found
in being stable ever reporters across
regions, by number of patients
treated, and by confirmation of ethi-
cal and professional obligation
From 2012 to 2014, 43% of the
respondents sent 1214 reports to
CWS, with a mean number of 2.7
reports per respondent. PDHP sent
Child Maltreatment, Adverse Childhood Experiences, and the…
the reports due to suspicion of
neglect or physical, sexual, and/
or psychological abuse. Non-
attendance at dental appointments
(67%) and grave caries (49%)
were reported most frequently.
Among the reports, 25% resulted
in measures being taken by CWS,
21% were dropped, and 30% lacked
information from CWS on the
outcome. Reports due to suspicion
of sexual abuse, grave caries, and
suspicion of neglect had the highest
association with the implementation
of measures
547
 Table 1  (continued)
Author/year
Brattabø, I. V., Iversen, A. C.,
13
Åstrøm, A. N., & Bjørknes,
R. (2016)
Dias, A., Mooren, T., and Kle-
ber, R. J. (2018)
Location Aims
Norway Assess the frequency of public
dental health personal report-
ing and failing to report
suspected CM, and identify
personal, organizational, and
external predictors of report-
ing and failing to report
Europe Investigate opinions of profes-
sionals on how to mitigate
long-term consequences of
CM from a public health
perspective
Participants
1200 public dental health
hygienists and dentists
91 professionals who either
authored articles on long-
term consequences of CM
or participated in projects
on CM
Method
National cross-sectional study
utilizing an electronic ques-
tionnaire
Delphi method in 3 rounds,
including an interview (round are needed to address CM. Prior-
1) and two questionnaires
(rounds 2 and 3)
548
Select results
The majority (60%) reported having
reported suspected CM to CWS
during their dental career, with a
mean of 3.6 reports. A third (33%)
failed to send a report, with a mean
of 2.3 failures to report. A total of
43% had submitted reports during
the period of 2012–2014, with a
mean of 2.7 reports
Most agreed that public health actions
itized strategies included increasing
community awareness and training
emotional regulation in affected
adults. Preferred methods include
increasing curricular knowledge
about CM for professionals, as
well as developing evidence-based
interventions. Additional sugges-
tions included reducing barriers for
access to interventions for adults.
A significant benefit identified by
participants was reduction of CM
consequences across generations
S. T. Garrison et al.
 Table 1  (continued)
Author/year Location Aims
Drury, I., Reese, L. S., & Allan, USA Illustrate and explore the
H. (2019) dilemma in which increasing
numbers of state and local
governments are designing
programs for preventing CM,
but a small portion of families
who are offered the programs
go on to engage in and com-
plete services
13
Participants
Data logs from 21 intervention
sites, 15 outreach workers, 8
supervisors
Method
Effort data for all 21 sites were
reviewed to explore outreach
protocols and provided con-
text for qualitative analysis.
Interviews were conducted
with outreach workers and
supervisors
Select results
Of 12,163 families eligible to receive
the prevention program, only
4988 (41%) were referred. Of the
4988, 27% accepted services, 70%
declined services, and 3% were
missing responses. The most com-
monly cited barrier to engaging
families was association of the
program with Child Protective
Services (CPS), but triangulation of
data indicated minimal differences
in decline rates between sites asso-
ciated with CPS (68%) and those
associated with community provid-
ers (70%). Embarrassment and fear
by the family were also cited as
barriers to program acceptance
Child Maltreatment, Adverse Childhood Experiences, and the…
549
 Table 1  (continued)
550

Author/year Location Aims Participants Method Select results

Eija, P., Mika, H., Aune, F., & Finland Describe how Finnish public 367 public health nurses Cross-sectional study utilizing On average, PHN indicated they could

13
Leila, L. (2014) health nurses (PHN) identify an electronic questionnaire identify CM moderately well. In
and intervene in CM and how identifying factors related to CM,
they implement the National 43% indicated the child’s behavior
Clinical Guideline in their was a factor, 37% the parents’
work behavior, 54% physical signs, and
44% psychological signs. Only
15% indicated meeting maltreated
children often. On average, PHN
indicated that it was easier for
them to intervene in CM than it
was to identify it. Only about half
felt that they helped the maltreated
child (52%) and family (50%) suf-
ficiently well. More than half (54%)
indicated having joint guidelines
for CM cases, while 65% have
clear instructions on filing a CM
report. Those with experience of
working with maltreated children
reported they identify them better,
intervene better, and implement
the guideline better than those with
no experience. This difference was
also identified for those who were
aware of the guideline, had read it,
and participated in training on CM,
as compared to those who were not
aware of the guideline, had not read
it, or had not participated in such
training
S. T. Garrison et al.
 Table 1  (continued)
Author/year
Gibbs, D., Rojas-Smith, L.,
Wetterhall, S., Farris, T.,
Schnitzer, P. G., Leeb, R. T.,
& Crosby, Alex E. (2013)
13
Location Aims
USA To present the experiences
of three states tasked with
ascertaining strategies by
which collaboration between
public health and other state-
based agencies can support
surveillance of CM fatalities
and advance understanding of
fatal CM
Participants
7–8 key informants per state
(3 states), including agency
staff members involved in
the design and implementa-
tion of the surveillance
system and stakeholders from
organizations that contributed
data (i.e., law enforcement,
judicial systems, child protec-
tive services, and advocacy
groups.)
Method
Case study assessment utilizing
semi-structured key inform-
ant interviews, each lasting
about 1 h
Select results
The three funded states took sub-
stantially different approaches to
conducting surveillance of potential
CM deaths. However, three com-
mon lessons learned were identified
through the case study assessment:
the value of using multiple data
sources to identify CM fatalities,
the challenging nature of engaging
multiple disciplines in the surveil-
lance process, and the feasibility of
incorporating the CDC definition
of CM
Child Maltreatment, Adverse Childhood Experiences, and the…
551
 Table 1  (continued)
Author/year Location Aims
Putnam-Hornstein, E., Webster, USA This article reports results from 2,112,277 children born, of
13
D., Needell, B., & Magruder, child-level matches completed
J. (2011) between California’s child
protective service records and
vital birth records as an exam-
ple of new knowledge that
can be generated through such
linkages concerning children
and families reported to child
protective services
Participants
which 293,441 were reported
for possible abuse or neglect
before age 5
Method
Probabilistic linkage strategies Of all the children born in California
(with clerical review) were
employed to link child protec-
tive service records with vital by age 5. Nearly 18% of children
birth records
552
Select results
between 1999 and 2002, 14% were
referred to child protective services
with health risk present at birth,
21% of children whose birth pay-
ment method was Medi-Cal, 30%
of children born to Black mothers,
25% of children born to teenage
mothers, 19% of children born to
mothers with only a high school
diploma, and 34% of children
with no established paternity were
referred by age 5. Of all the children
born in California between 1999
and 2002, 5.2% were identified as
substantiated victims of CM by age
5. Over 8% of children with health
risk present at birth, 9% of children
whose birth payment method was
Medi-Cal, 12% of children born
to Black mothers, 10% of children
born to teenage mothers, and 16%
of children with no established
paternity were substantiated victims
of CM by age 5
S. T. Garrison et al.
 Table 1  (continued)
Author/year
Smith, L. R., Gibbs, D., Wet-
terhall, S., Schnitzer, P. G.,
Farris, T., Crosby, A. E., &
Leeb, R. T. (2011)
Srivastav, A., Spencer, M.,
Strompolis, M., Thrasher,
J. F., Crouch, E., Palamaro-
Munsell, E., & Davis, R. E.
(2020)
13
Location Aims
USA Describe the experiences of
3 state health agencies in
building collaborations and
partnerships with multiple
stakeholders for CM surveil-
lance
USA Examine the perspectives of
child and family-serving pro-
fessionals (CFSP) and state
policymakers on protective
factors to develop policy and
program recommendations
including current and needed
approaches for addressing
ACEs
Participants
7–8 key informants per state
(3 states), including agency
staff members involved in
the design and implementa-
tion of the surveillance
system and stakeholders from
organizations that contributed
data (i.e., law enforcement,
judicial systems, child protec-
tive services, and advocacy
groups.)
23 CFSP; 24 state policymakers Semi-structured, in-depth
Method Select results
Semi-structured key informant Factors that facilitated stakeholder
interviews, each lasting engagement for CM surveil-
about 1 h lance included streamlining and
coordinating the work of Child
Death Review Teams (CDRTs);
demonstrating the value of surveil-
lance to non-public health partners;
codifying relationships with
participating agencies; and secur-
ing the commitment of decision
makers. Legislative mandates were
helpful in bringing key stakeholders
together, but insufficient to ensure
sustained engagement
CFSPs and policymakers had varying
interviews opinions on involvement of state
government in primary prevention
for ACEs. Three protective factors
Child Maltreatment, Adverse Childhood Experiences, and the…
emerged from their perspectives:
(1) loving, trusting, and nurtur-
ing relationships; (2) safe home
environments; and (3) opportunities
to thrive. For each of these protec-
tive factors, participants suggested
policy options that support existing
community efforts, attempt to
alleviate poverty, and improve child
and family serving systems
553
 Table 1  (continued)
Author/year
Suzuki, K., Paavilainen, E.,
13
Helminen, M., Flinck, A.,
Hiroyama, N., Hirose, T.,
Okubo, N., & Okamitsu, M.
(2017)
Location Aims
Finland and This study aimed to investigate
Japan how public health nurses
identify, intervene in, and
implement the guidelines on
CM in Finland and Japan and
to compare the data between
the two countries
Participants
Public health nurses working
in the area of maternal and
child health care in Finland
(n = 193) and Japan (n = 440)
554
Method Select results
Cross-sectional design using a A significantly higher percentage
questionnaire of Japanese public health nurses
identified CM compared to Finnish
public health nurses, while Finnish
nurses intervened in CM better than
their Japanese counterparts. In Fin-
land, 90% agreed that the guidelines
were important, but 76% felt that
nurses had not had enough training
on the guidelines, 50% indicated
that nurses had not familiarized
themselves with the content of the
guidelines, and 57% indicated there
were not sufficient resources to
implement the guidelines in their
office. In Japan, 55% agreed that the
guidelines were important, but 87%
felt that nurses had not had enough
training on the guidelines, 82%
indicated that nurses had not famil-
iarized themselves with the content
of the guidelines, and 91% indicated
there were not sufficient resources
to implement the guidelines in their
office. In both countries, public
health nurses who had read and
used the guidelines dealt with CM
better than those who did not
S. T. Garrison et al.
 Table 1  (continued)
Author/year
Tonmyr, L., Shields, M.,
Asokumar, A., Hovdestad,
W., Laurin, J., Mukhi, S., &
Burnside, L. (2019)
13
Location Aims
Canada Assess the feasibility of hiring
coders to abstract CM data
from administrative records
and case narratives
Participants
Convenience sample of 181
records of alleged CM cases
Method
The 2 coders completed a short
web-based questionnaire for
each case to identify which
of five types of CM had been
investigated, level of sub-
stantiation for each type, and
risk of future CM. The child
welfare worker responsible
for each case completed the
same questionnaire
Select results
The agreement between coders’ and
child welfare workers’ classifica-
tions of physical abuse, sexual
abuse, and neglect was strong, but
for exposure to intimate partner
violence, agreement was weak for
one coder
Coding of emotional maltreatment
and future risk investigations could
not be evaluated
Child Maltreatment, Adverse Childhood Experiences, and the…
555
556 S. T. Garrison et al.

Application of Public Health Approach to Child Maltreatment

and Adverse Childhood Experiences

In examining the 12 articles included in this systematic literature review, all of

the articles could be categorized into one of the four steps of the commonly used
public health model: surveillance; identification of risk and protective factors;
development and testing of interventions; and implementation of effective pre-
vention and control strategies (Putnam-Hornstein et  al., 2011; Richmond-Crum
et  al., 2013). Two articles were also categorized outside of that model, with a
focus on stakeholder engagement and collaboration. Some articles were catego-
rized into multiple steps as detailed below (see Table 2).

Surveillance

Surveillance involves defining and monitoring CM, providing an understanding

of the prevalence of and risk for CM, as well as supporting effective planning,
implementation, and evaluation of CM-centered public health programs (Cent-
ers for Disease Control and Prevention, 2001). Nine of the articles included in
this review (Åstrøm, et  al., 2021; Brattabø et  al., 2016, 2018; Eija et  al., 2014;
Gibbs et  al., 2013; Putnam-Hornstein et  al., 2011; Smith et  al., 2011; Suzuki
et  al., 2017; Tonmyr et  al., 2019) were categorized as being related to surveil-
lance. Surveillance mechanisms included reports of suspected CM by dental
health workers (Åstrøm, et al., 2021; Brattabø et al., 2016, 2018) and nurses (Eija
et  al., 2014; Suzuki et  al., 2017), as well as reviews of birth records (Putnam-
Hornstein et  al., 2011) and child welfare report data (Putnam-Hornstein et  al.,
2011; Tonmyr et  al., 2019). Utilizing data collected from public health profes-
sionals in Norway, Brattabø et al. (2016) and Brattabø et al. (2018) assessed fre-
quency of reporting and failing to report suspected CM; predictors of reporting or
failing to report; reasons for reporting suspected CM; and child welfare services’
response to reports. Of 1200 public dental health professionals included in these
studies, 43% sent reports to child welfare services in the previous 2-year period
due to suspicion of neglect or abuse, including physical, sexual, and psycho-
logical abuse, with an average of 2.7 reports submitted per respondent. Among
the 1214 reports filed, only 25% of cases resulted in child welfare services tak-
ing measures to address the CM, 21% of cases were dropped, and 30% lacked
information from child welfare services on the outcome (Brattabø et  al., 2016,
2018). In their 2021 follow-up article, Åstrøm et  al. (2021) examined stability
and change in mandated reporting of suspected CM across time with 591 public
dental health professionals who participated in the baseline study in 2014 and the
follow-up study in 2019. Findings indicated that more than 50% of respondents
had ever reported and recently reported suspected CM in both 2014 and 2019.
While 57% indicated they had never avoided reporting a suspected case of CM at
both points of study, 25% indicated that they had avoided reporting suspected CM
in both years. Significant differences were found in being stable ever reporters

13
 Table 2  Application of public health approach to child maltreatment and adverse childhood experiences
Approach category

Surveillance Identification of risk and protective Development and testing of Implementation of prevention and Stakeholder buy-in and collaboration
factors interventions control strategies

Author/year Åstrøm, A. N., Berg, K. G., & Brattabø, I. Putnam-Hornstein, E., Webster, Drury, I., Reese, L. S., & Eija, P., Mika, H., Aune, F., & Smith, L. R., Gibbs, D., Wetterhall,
V. (2021) D., Needell, B., & Magruder, J. Allan, H. (2019) Leila, L. (2014) S., Schnitzer, P. G., Farris, T.,
(2011) Crosby, A. E., & Leeb, R. T. (2011)
Brattabø, I. V., Bjørknes, R., & Åstrøm, A. Srivastav, A., Spencer, M., Strom- Dias, A., Mooren, T., and Suzuki, K., Paavilainen, E., Helm- Srivastav, A., Spencer, M., Strompo-
N. (2018) polis, M., Thrasher, J. F., Crouch, Kleber, R. J. (2018) inen, M., Flinck, A., Hiroyama, lis, M., Thrasher, J. F., Crouch, E.,
E., Palamaro-Munsell, E., & N., Hirose, T., Okubo, N., & Palamaro-Munsell, E., & Davis, R.
Davis, R. E. (2020) Okamitsu, M. (2017) E. (2020)
Brattabø, I. V., Iversen, A. C., Åstrøm, A.
N., & Bjørknes, R. (2016)
Eija, P., Mika, H., Aune, F., & Leila, L.
(2014)
Gibbs, D., Rojas-Smith, L., Wetterhall, S.,
Farris, T., Schnitzer, P. G., Leeb, R. T., &
Crosby, Alex E. (2013)
Putnam-Hornstein, E., Webster, D., Needell,
Child Maltreatment, Adverse Childhood Experiences, and the…

B., & Magruder, J. (2011)

Smith, L. R., Gibbs, D., Wetterhall, S.,
Schnitzer, P. G., Farris, T., Crosby, A. E.,
& Leeb, R. T. (2011)
Suzuki, K., Paavilainen, E., Helminen, M.,
Flinck, A., Hiroyama, N., Hirose, T.,
Okubo, N., & Okamitsu, M. (2017)
Tonmyr, L., Shields, M., Asokumar, A.,
Hovdestad, W., Laurin, J., Mukhi, S., &
Burnside, L. (2019)

13
557
558 S. T. Garrison et al.

across regions, by number of patients treated, and by confirmation of ethical and

professional obligation (Åstrøm et al, 2021).
Eija et  al. (2014) and Suzuki et  al. (2017) both addressed how public health
nurses identified and intervened in CM among their patients. Focusing specifi-
cally on public health nurses in Finland registered with the Finnish Union of Public
Health Nurses, Eija et al. (2014) utilized a Likert scale to gauge how well respond-
ents felt they could identify and intervene in CM. Of the 369 respondents, 36%
worked in family planning and maternity, 45% worked in a child welfare clinic, 30%
worked in school health, and 48% worked in other clinics. On average, public health
nurses indicated they could identify CM moderately well, but they also indicated
that it was easier for them to intervene in CM than it was for them to identify it.
When discussing factors they use in identifying CM in their patients, 43% indicated
the child’s behavior was a factor, 37% indicated the parents’ behavior was a fac-
tor, 54% indicated physical signs were a factor, and 44% indicated psychological
signs were a factor. Only 15% indicated encountering maltreated children often, and
only about half felt that they helped the maltreated child (52%) and family (50%)
sufficiently well (Eija et  al., 2014). In comparing data on identification of CM by
public health nurses working in the area of maternal and child healthcare in Finland
and Japan, Suzuki et al. (2017) found that Japanese respondents identified CM sig-
nificantly more than Finish respondents, but Finish respondents intervened in CM at
higher rates than their Japanese counterparts.
Putnam-Hornstein et al. (2011) and Tonmyr et al. (2019) both utilized or sought
to utilize available data to identify or predict CM. Putnam-Hornstein et  al. (2011)
utilized a probabilistic linking strategy with clerical review to link birth records for
the 2,112,277 children born in California, USA between 1999 and 2002 to 293,441
child protective service records of reports of possible abuse or neglect by the age of
5. Of all the children born in California between 1999 and 2002, 14% were referred
to child protective services by age 5. Those referred included nearly 18% of children
with health risk present at birth, 21% of children whose birth payment method was
Medi-Cal (a form of state-funded health insurance for low-income individuals and
families), 30% of children born to Black mothers, 25% of children born to teenage
mothers, 19% of children born to mothers with only a high school diploma, and 34%
of children with no established paternity. In terms of substantiating claims of CM,
5% of all children born in California between 1992 and 2002 were identified as sub-
stantiated victims of CM by age 5, including over 8% of children with health risk
present at birth, 9% of children whose birth payment method was Medi-Cal, 12% of
children born to Black mothers, 10% of children born to teenage mothers, and 16%
of children with no established paternity at birth (Putnam-Hornstein et  al., 2011).
Tonmyr et al. (2019) took more of an exploratory approach to assess the feasibility
of hiring coders to extract data on alleged CM from a convenience sample of 181
records in Canada. Two coders completed a short web-based questionnaire for each
case, and the child welfare worker responsible for each case did the same, with the
purpose of identifying which of five types of CM had been investigated, the level
of substantiation, and risk of future CM. The agreement between coders’ and child
welfare workers’ classifications of physical abuse, sexual abuse, and neglect was
strong, but for exposure to intimate partner violence, agreement was weak for one

13
Child Maltreatment, Adverse Childhood Experiences, and the… 559

coder. Coding of emotional maltreatment and future risk investigations could not be
evaluated (Tonmyr et al., 2019).
In their study presenting experiences of three states (Oregon, Michigan, and Cali-
fornia, USA) tasked with creating strategies for collaboration between public health
and other state-based agencies to both support surveillance of CM and advance
understanding of fatal CM, Gibbs et al. (2013) found that the three states took sub-
stantially different approaches to conducting surveillance of potential CM deaths.
Despite differences in surveillance approaches, three common lessons were identi-
fied through the case study assessment, including the value of using multiple data
sources to identify CM fatalities; the challenging nature of engaging multiple dis-
ciplines in the surveillance process; and the feasibility of incorporating the CDC
definition of CM (Gibbs et al., 2013).

Identification of Risk and Protective Factors

Building on surveillance, identification of risk, and protective factors entails focus-

ing on factors that either increase or decrease the likelihood of being a perpetrator
or victim of CM (Richmond-Crum et al., 2013). Two of the articles included in this
review (Putnam-Hornstein et al., 2011; Srivastav et al., 2020) were categorized as
being related to identification of risk and protective factors. While it was also cat-
egorized as surveillance, the outcomes of Putnam-Hornstein et  al. (2011) provide
identification of a variety of risk factors related to CM among children under 5 in
California, USA, including health risk present at birth; having Medi-Cal as the birth
payment method (Medi-Cal is a state funded health insurance for low-income indi-
viduals and was used as a proxy for socio-economic status); being born to a Black
mother; being born to a teenage mother; and having no paternity established at birth.
Higher levels of maternal education and increasing maternal age were protective
factors across all CM types (Putnam-Hornstein et al., 2011). In contrast to identify-
ing protective and risk factors via data from established reports of CM, Srivastav
et al. (2020) conducted semi-structured, in-depth interviews with state policymakers
(n = 23) and child and family-serving professionals (CFSP) (n = 24) in South Car-
olina, USA, to examine their perspectives on protective factors for the purpose of
developing policy and program recommendations. Three protective factors emerged,
including loving, trusting, and nurturing relationships; safe home environments; and
opportunities to thrive. For each perceived protective factor, participants identified
policy options that supported existing community efforts, attempted to alleviate pov-
erty, and improved systems that serve children and families (Srivastav et al., 2020).

Development and Testing of Interventions

Development and testing of interventions entails utilizing surveillance data and

the identified protective and risk factors to create individual and community-level
programs and strategies that promote protective factors, reduce risk factors, or both
(Richmond-Crum et  al., 2013). Two of the articles included in this review (Dias
et al., 2018; Drury et al., 2019) were categorized as being related to development and

13
560 S. T. Garrison et al.

testing of interventions. Utilizing a three round Delphi method, Dias et  al. (2018)
sought to investigate opinions on a public health perspective for mitigating long-
term consequences of CM from 91 professionals who had either authored articles on
long-term consequences of CM or participated in related projects. Prioritized strate-
gies included increasing community awareness about CM through increasing curric-
ular knowledge about CM for professionals, as well as training emotional regulation
in adults affected by CM through development of evidence-based interventions and
reducing barriers for access to those interventions. Participants identified reduction
of generational consequences of CM as a significant benefit (Dias et al., 2018). In
their study utilizing data logs from 21 program sites and interviews with 15 outreach
workers and eight supervisors, Drury et al. (2019) illustrated the dilemma in which
state and local governments are increasingly designing programs for preventing CM,
but, due to a potential variety of complex barriers, only small proportions of families
who are referred to the program engage in and complete services. Of 12,163 fami-
lies eligible to receive the prevention program, only 4988 (41%) were referred. Of
the 4,988 who were referred, 27% accepted services, 70% declined services, and 3%
were missing responses. The most cited barrier to engaging families was association
of the program with Child Protective Services, but triangulation of data across sites
indicated minimal differences in decline rates between sites associated with Child
Protective Services and those associated with community providers. Embarrassment
and fear by the family were also cited as barriers to program acceptance (Drury
et al., 2019).

Implementation of Effective Prevention and Control Strategies

Building on the previous three steps, implementation of effective prevention and

control strategies entails working toward widespread adoption of an evidence-based
intervention or prevention program or practice via dissemination and implemen-
tation in a variety of settings (Richmond-Crum et  al., 2013). Two of the articles
included in this study (Eija et  al., 2014; Suzuki et  al., 2017) were categorized as
being related to implementation of effective prevention and control strategies. Both
articles were also categorized as surveillance, but their results help to inform effec-
tive prevention and control strategies. In their study describing how Finish public
health nurses identify and intervene in CM, Eija et  al. (2014) also examined how
public health nurses implement the National Clinical Guideline, a policy developed
as a prevention and control strategy for CM, in their work. More than half (54%)
indicated having joint guidelines for CM cases, while 65% have clear instructions
on filing a CM report. Those with experience of working with maltreated children
reported they identified them better, intervened better, and implemented the guide-
line better than those with no experience. This difference was also identified for
those who were aware of the guideline, had read it, and participated in training on
CM, as compared to those who were not aware of the guideline, had not read it, or
had not participated in such training (Eija et al., 2014). In their similar study com-
paring implementation of CM guidelines in Finland and Japan, Suzuki et al. (2017)
found that in Finland, 90% agreed that the guidelines were important, but 76% felt

13
Child Maltreatment, Adverse Childhood Experiences, and the… 561

that nurses had not had enough training on the guidelines, 50% indicated that nurses
had not familiarized themselves with the content of the guidelines, and 57% indi-
cated there were not sufficient resources to implement the guidelines in their office.
In Japan, 55% agreed that the guidelines were important, but 87% felt that nurses
had not had enough training on the guidelines, 82% indicated that nurses had not
familiarized themselves with the content of the guidelines, and 91% indicated there
were not sufficient resources to implement the guidelines in their office. Public
health nurses in both countries who had read and used the guidelines dealt with CM
better than those who did not (Suzuki et al., 2017).

Stakeholder Buy‑In and Collaboration

Two of the articles included in this study (Smith et al., 2011; Srivastav et al., 2020)
were categorized as being related to stakeholder buy-in and collaboration. Smith
et  al. (2011), also categorized as surveillance, described the experiences of three
state health agencies in California, Michigan, and Oregon, USA, in building collab-
orations and partnerships with various stakeholders for surveillance of CM. Through
interviews with key informants in each state, several factors were identified as facili-
tating stakeholder engagement for CM surveillance. These factors included stream-
lining and coordinating the work of Child Death Review Teams; demonstrating the
value of surveillance to non-public health partners; codifying relationships with par-
ticipating agencies; and securing the commitment of decision makers. While legis-
lative mandates were helpful in initially bringing stakeholders together, they were
insufficient to ensure long-term engagement (Smith et  al., 2011). Srivastav et  al.
(2020) also categorized in identification of risk and protective factors, sought per-
spectives of child and family-serving professionals and state policymakers in South
Carolina, USA, on protective factors in relation to development of policy and pro-
gram recommendations including current and needed approaches for addressing
ACEs. Interview results show varying opinions among policymakers and CFSPs on
state government involvement in the primary prevention of ACEs, indicating a dis-
connect between the evidence demonstrating the importance of government involve-
ment in primary prevention of CM and stakeholder buy-in to the importance of such
involvement.

Primary, Secondary, and Tertiary Prevention

While public health researchers and advocates argue for a primary prevention, uni-
versal cautions approach to the prevention of ACEs and CM (Oral et al., 2016; Hig-
gins et  al., 2022), primary, secondary, and tertiary prevention all serve different
purposes in addressing this complex issue. The 12 articles included in this review
encompass primary, secondary, and tertiary prevention strategies as detailed below
(see Table 3).

13
 562

13
Table 3  Primary, secondary, and tertiary prevention
Prevention category
Primary Secondary Tertiary

Author/Year Gibbs, D., Rojas-Smith, L., Wetterhall, S., Farris, T., Schnitzer, P. G., Leeb, Åstrøm, A. N., Berg, K. G., & Brattabø, I. V. (2021) Dias, A., Mooren, T.,
R. T., & Crosby, Alex E. (2013) and Kleber, R. J.
(2018)
Putnam-Hornstein, E., Webster, D., Needell, B., & Magruder, J. (2011) Brattabø, I. V., Bjørknes, R., & Åstrøm, A. N. (2018)
Smith, L. R., Gibbs, D., Wetterhall, S., Schnitzer, P. G., Farris, T., Crosby, Brattabø, I. V., Iversen, A. C., Åstrøm, A. N., &
A. E., & Leeb, R. T. (2011) Bjørknes, R. (2016)
Srivastav, A., Spencer, M., Strompolis, M., Thrasher, J. F., Crouch, E., Drury, I., Reese, L. S., & Allan, H. (2019)
Palamaro-Munsell, E., & Davis, R. E. (2020)
Tonmyr, L., Shields, M., Asokumar, A., Hovdestad, W., Laurin, J., Mukhi, Eija, P., Mika, H., Aune, F., & Leila, L. (2014)
S., & Burnside, L. (2019)
S. T. Garrison et al.
Child Maltreatment, Adverse Childhood Experiences, and the… 563

Primary Prevention

The aim of primary prevention efforts is to prevent CM or ACEs before they ever
occur through systems level changes such as implementing policies that support
families, reducing poverty, eliminating structural inequalities, improving social con-
ditions, enhancing protective factors and social support, and implementing social
emotional, trauma-informed curriculums into schools (Oral et al., 2016). Five arti-
cles included in this review (Gibbs et  al., 2013; Putnam-Hornstein et  al., 2011;
Smith et al., 2011; Srivastav et al., 2020; Tonmyr et al., 2019) were categorized as
addressing primary prevention. Smith et  al. (2011) and Gibbs et  al. (2013) exam-
ined the adoption of evidence-based approaches to preventing fatal CM across three
states in the USA, with the purpose determining the magnitude of fatal CM in these
states, identifying those at greatest risk, assessing the impact of prevention efforts,
and monitoring changes over time. Putnam-Hornstein et  al. (2011) utilized link-
ages between birth records and CM reports to glean information on those at great-
est risk for CM in California, USA, indicating that by identifying those at great-
est risk, prevention efforts could begin at birth, thus reducing CM. Srivastav et al.
(2020) worked with state policymakers and child and family-serving professionals
to develop policy and program recommendations for addressing ACEs. While the
researchers emphasized the importance of primary prevention efforts, policymak-
ers and professionals had mixed opinions on government involvement in primary
prevention efforts (Srivastav et al., 2020). Finally, Tonmyr et al. (2019) explored a
potential option for improving surveillance efforts by hiring coders to extract man-
dated information from case reports in Canada to reduce burden on child welfare
workers, with a goal of working toward prediction of future CM.

Secondary Prevention

Secondary prevention interventions focus on reducing the impact of ACEs that have
already occurred via school and healthcare screenings and linking children and fam-
ilies to appropriate resources, improving child protection services, and implement-
ing home visiting programs (Oral et al., 2016). Six articles included in this review
(Åstrøm et al., 2021; Brattabø et al., 2016, 2018; Drury et al., 2019; Eija et al., 2014;
Suzuki et al., 2017) were categorized as addressing secondary prevention. Åstrøm
et al. (2021), Brattabø et al. (2018), and Brattabø et al. (2016) each focused on the
identification and reporting of potential CM by public dental health professionals in
Norway, indicating that 43% of those professionals had avoided reporting at least
one suspected case of CM. Brattabø et al. (2018) also reported on the response of
child welfare services to those reports, indicating that only 25% of reports resulted in
measures being taken by child welfare services, while 30% of reports had no indica-
tion as to the outcome. Similarly, Eija et al. (2014) and Suzuki et al. (2017) reported
on how public health nurses identified and intervened in CM in Finland (Eija et al.,
2014; Suzuki et al., 2017) and Japan (Suzuki et al., 2017). Results in both studies
indicated that public health nurses were more confident in their ability to intervene

13
564 S. T. Garrison et al.

in CM than they were in their ability to identify it, while Suzuki et al. (2017) found
that Japanese nurses identified CM significantly more but intervened significantly
less than their Finish counterparts. Drury et al. (2019) highlighted the gaps between
prevention program eligibility, referral, and engagement in services. Of 12,163 fami-
lies eligible to receive the prevention program, only 4,988 (41%) were referred. Of
the 4,988 who were referred, 27% accepted services, 70% declined services, and 3%
were missing responses (Drury et al., 2019).

Tertiary Prevention

Tertiary prevention focuses on improving quality of life among individuals who

have had prolonged exposure to CM or ACEs to mitigate long-term health outcomes
(Oral et al., 2016). One article included in this review (Dias, et al., 2018) was cate-
gorized as addressing tertiary prevention. In this study, Dias et al. (2018) sought the
opinions of professionals, including researchers and practitioners, on how to miti-
gate long-term consequences of CM from a public health perspective. These profes-
sionals prioritized increasing community awareness of CM among professionals, as
well as providing access to and reducing barriers to participation in evidence-based
interventions focused on emotional regulation for adult survivors of CM.

Discussion

The purpose of this systematic review was to explore current research that included
a public health approach in addressing CM and ACEs. The first research question
considered how current research applies a public health approach to CM and ACEs.
The second research question considered how current research that utilized a public
health approach to CM and ACEs addressed primary, secondary, and tertiary pre-
vention of CM and ACEs. Discussion around findings related to each research ques-
tion is detailed below.

Research Question One

All 12 of the articles included in this review were able to be categorized as related to
one of the four steps of the commonly used public health model (Putnam-Hornstein
et al., 2011; Richmond-Crum et al., 2013): surveillance; identification of risks and
protective factors; development and testing of interventions; or implementation of
effective prevention and control strategies. Some articles fit into more than one cat-
egory, and two articles were related to stakeholder buy-in and collaboration.
Nine of the twelve articles were categorized as “surveillance,” with specific
mechanisms including reports of suspected CM by various medical professionals,
CM data available via child protective services, official birth records, and CM data
extracted by coders from child welfare case reports. Findings from Åstrøm, et  al.
(2021), Brattabø et al. (2018), Brattabø et al. (2016), Eija et al. (2014), and Suzuki
et  al. (2017) provided disturbing evidence of a lack of confidence in many public

13
Child Maltreatment, Adverse Childhood Experiences, and the… 565

health professionals, including dentists, dental hygienists, and nurses, in identifying

and intervening in CM. Indeed, a large portion (43%) of the study cohort of dentists
and hygienists in Norway admitted to failing to report a least one case of suspected
CM (Åstrøm, et al., 2021; Brattabø et al., 2016). When cases of suspected CM were
reported to the appropriate child welfare authorities, only 25% resulted in measures
being taken to remedy the CM, with another 30% of reports lacking any information
on the outcome (Brattabø et al., 2016). Additionally, in both Finland and Japan, the
majority of public health nurses felt that the guidelines on identifying and report-
ing CM were an important tool, but felt that nurses had not had enough training
on the guidelines, had not familiarized themselves with the guidelines, and did not
have sufficient resources in their offices to implement the guidelines (Suzuki et al.,
2017). Taken as a whole, these findings are indicative of multiple breakdowns in the
process of utilizing healthcare screenings as surveillance of CM from lack of train-
ing on and utilization of mandated guidelines for medical professionals, failure to
report suspected CM by medical professionals, and failure to accurately report case
outcomes by child welfare agencies.
Smith et al. (2011) and Gibbs et al. (2013) indicated the importance of collabo-
ration amongst various stakeholders including law enforcement, judicial systems,
child protective services, and advocacy groups in developing effective surveillance
strategies. While the three states (California, Michigan, and Oregon, USA) in these
studies each took different approaches to conducting surveillance of potential CM
deaths, common threads were identified, including the necessity of having multiple
data sources for identification of CM fatalities; the challenges of effectively engag-
ing multiple disciplines in the surveillance process; and the feasibility of incorpo-
rating the CDC’s definition of CM in their surveillance efforts (Gibbs et al., 2013).
While legislating and mandating processes is an important part of the surveillance
process, Smith et al. (2011) found that such legislative mandates were insufficient in
ensuring sustained engagement among the various stakeholders, agencies, and dis-
ciplines. These findings are important to consider as research is translated to policy
and policy is translated to practice.
Putnam-Hornstein et  al. (2011) and Tonmyr et  al. (2019) both employed novel
and promising approaches to surveillance of CM. Through utilization of a proba-
bilistic linking strategy with state birth records and child protective service records,
Putnam-Hornstein et al. (2011) were able to match birth records with reports of sus-
pected CM and substantiated CM for all children born in California, USA between
1999 and 2002, thus providing an important picture of who is being affected by CM
in early childhood. Tonmyr et  al. (2019) showed that coders could potentially be
utilized to extract mandated data on CM from case reports, thus reducing the burden
on child welfare workers.
Two of the twelve articles included in this review were categorized as “iden-
tification of risk and protective factors,” focusing on determining factors that
increase or decrease the likelihood of CM. By linking together birth records and
reports of suspected CM, Putnam-Hornstein et  al. (2011) were able to identify
a wide variety of protective and risk factors that could help identify those chil-
dren most at risk for CM at birth, allowing for early intervention. Srivastav et al.
(2020) took a different approach by engaging two groups of stakeholders, state

13
566 S. T. Garrison et al.

policy makers and child and family-serving professionals, in conversation around

protective factors for the purpose of developing policy and program recommen-
dations. With only two articles identified as addressing identification of risk and
protective factors, implications for use of the strategies presented on a wider scale
are limited. However, since a public health approach to addressing CM and ACEs
requires an upstream approach to focus on prevention and policy changes, as well
as cross-sector collaboration (Bruner, 2017), both strategies utilized in these stud-
ies illustrate potentially valuable avenues for identification of risk and protective
factors.
Two of the articles included in this review were categorized as “development and
testing of interventions,” focusing on the creation and/or testing of individual and
community-level programs and strategies that promote protective factors, reduce
risk factors, or both. Dias et al. (2018) brought together researchers and practition-
ers to glean their opinions on strategies for mitigating long-term consequences of
CM in adults. Participants prioritized increasing awareness of adult consequences
of CM among community professionals who might serve this population, and well
as development of evidence-based interventions and reducing barriers for access
to those interventions, thus providing valuable insight on how experts in the field
would address issues related to adult outcomes of CM (Dias et  al., 2018). Drury
et al. (2019) provided a troubling illustration of how development of such interven-
tions is only the beginning. While interventions may be developed and available,
many eligible families are never referred, and even fewer accept and complete the
services offered (Drury et al., 2019). As only two articles were identified as address-
ing development and testing of interventions, limitations in drawing broad-ranging
conclusions are evident. While there is value in creating evidence-based interven-
tions for addressing CM, the interventions can only do so much if families are not
engaging in them. The two studies identified included researchers and practitioners,
but not families, who may offer a different understanding of the complex variety of
barriers and confounding variables affecting program participation and completion.
Engaging local community stakeholders, including those needing the services, in
identifying ways to overcome barriers to engagement may prove beneficial.
Two of the articles included in this review that were categorized as “surveil-
lance” were also categorized as “implementation of effective prevention and con-
trol strategies,” entailing working toward widespread adoption of an evidence-based
intervention or prevention program or practice. Both Eija et al. (2014) and Suzuki
et al. (2017) examined the use of nationally implemented clinical guidelines by pub-
lic health nurses in identifying and reporting CM. As was previously described, the
findings in both studies were indicative of a lack of training for public health nurses
on the guidelines, lack of familiarity with the content of the guidelines, and lack of
resources to implement the guidelines. While the two identified articles offer poign-
ant examples of challenges related to implementation of effective prevention and
control strategies, it would be inappropriate to draw any broad conclusions related
to such strategies, in general. However, these findings are indicative of the grow-
ing pains that go along with the implementation and widespread adoption of evi-
dence-based programs or practices. While the guidelines may be excellent in the-
ory, if nurses are not trained on them, do not understand them, and do not have the

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Child Maltreatment, Adverse Childhood Experiences, and the… 567

resources to implement them, they cannot be effective at identifying or preventing

CM on a large scale.
Finally, two of the articles included in this review directly addressed stakeholder
buy-in and collaboration. Smith et  al. (2011) and Srivastav et  al. (2020) worked
with a wide variety of stakeholders, including law enforcement, judicial systems,
child protective services, advocacy groups, child and family-service professionals,
and state policymakers. Again, with only two articles categorized as addressing
stakeholder buy-in and collaboration, the ability to draw broad conclusions on such
strategies is limited. Both studies highlighted the challenges of and great value in
working together with multiple stakeholders from different disciplines in the identi-
fication of risk and protective factors, as well as the creation and implementation of
CM prevention strategies.

Research Question Two

The 12 articles included in this review reflect application of primary, secondary, and
tertiary prevention strategies. As described by Oral et al. (2016), primary prevention
focuses on the prevention of CM or ACEs before they can occur, secondary preven-
tion focuses on intervening as soon as possible after CM or ACEs occur, and tertiary
prevention focuses on improving quality of life among individuals who have had
prolonged exposure to CM or ACEs to mitigate long term health outcomes.
Five of the articles included in this review were categorized as addressing pri-
mary prevention strategies. These strategies were reflective of a wide array of pri-
mary prevention efforts, including the adoption of evidence-based approaches to
preventing fatal CM (Gibbs et al., 2013; Smith et al., 2011); the utilization of linked
birth records and CM reports to identify those greatest at risk for CM at birth, allow-
ing for early intervention and prevention (Putnam-Hornstein et  al., 2011); work-
ing with state policymakers and child and family-serving professionals to develop
primary prevention policy and program recommendations (Srivastav et  al., 2020),
and hiring coders to extract mandated information from case reports, with a goal of
working toward prediction of future CM (Tonmyr et al., 2019). The array of primary
prevention efforts included in these studies is reflective of the many avenues for pre-
venting CM and ACEs before they ever occur. While each of these studies focused
on those at most risk for CM or ACEs, Higgins et al. (2022) argue in their six com-
ponents of a public health approach to CM that primary prevention that focuses on
improving conditions and creating safe environments within the entire community
will prevent ACEs and other forms of CM from occurring and prevent children and
families from needing secondary and tertiary prevention services. While the strate-
gies reflected in these studies are a great starting point, an upstream approach that
focuses on prevention and policy changes, cross sector collaborations, reducing pov-
erty and unemployment, and improving education at multiple social ecological lev-
els is required for widespread primary prevention of CM and ACEs (Bruner, 2017).
Six of the articles included in this review were categorized as addressing second-
ary prevention strategies. Five of those articles were reflective of strategies involving
identification and reporting of potential CM by public dental health professionals

13
568 S. T. Garrison et al.

(Åstrøm et al., 2021; Brattabø et al., 2016, 2018) and public health nurses (Eija et al.,
2014; Suzuki et  al., 2017). While secondary prevention strategies often include
school and healthcare screening and linking children and families to appropriate
resources (Oral et al., 2016), the findings of the studies in this review indicate major
challenges with this process. For this strategy to be effective, public health profes-
sionals, such as the nurses and dental health professionals included in these studies,
need to be confident in their ability to identify CM and ACEs; must not avoid report-
ing suspected CM cases; must have training on and understand the guidelines in
place for identifying and intervening in CM; and must have the resources available
to implement such guidelines. Drury et al. (2019) also provided a challenging look
at secondary prevention, highlighting the gaps between those who are eligible for
services, those who are referred to services, and those who engage in services. This
disconnect between program availability, family eligibility, referral for services, and
engagement in services is not uncommon and is a challenge deserving of great con-
sideration from the very beginning of program development if prevention efforts are
to be effective.
Finally, one of the articles included in this review was categorized as address-
ing tertiary prevention strategies. Dias et al. (2018) worked with professionals with
expertise in long-term consequences of CM on public health approaches to mitigat-
ing those long-term consequences. The main strategies identified were to increase
knowledge about the long-term consequences of CM among professionals who ser-
vice this population and develop and reduce barriers to evidence-based interventions
to train affected adults on emotional regulation. With the evidence on ACEs sug-
gesting that more than half of the adult population in the USA has had exposure to
at least one ACE indicator (Felitti et al., 1998), additional research should be con-
ducted on tertiary prevention strategies for reducing the wide variety of negative
health outcomes resulting from such exposure.

Implications and Conclusions

While limited, the body of literature focused on public health approaches to the
reduction of CM and ACEs has important implications for policymakers, research-
ers, and practitioners interested in protecting vulnerable children. Policymakers can
glean valuable information from this review on the importance of incorporating the
lenses of both research and practice when developing policies around prevention of
CM and ACEs. Policies are only as good as the evidence they are based on and the
ability of practitioners to implement them. For researchers, this review illustrates
that current research is applying a public health approach to CM and ACEs through
surveillance; identification of risk and protective factors; development and testing
of interventions; implementation of effective prevention and control strategies; and
stakeholder buy-in and collaboration, but the evidence is limited to a few studies in
industrialized countries. While public health approaches to the prevention of CM
and ACEs are widely accepted in professional discourses, the primary research is
much thinner than anticipated. With the overwhelming evidence that CM and ACEs
are a true public health crisis, more research needs to be conducted on CM and

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Child Maltreatment, Adverse Childhood Experiences, and the… 569

ACEs through a public health lens. This review also illustrates that current public
health-focused CM and ACEs research addresses primary, secondary, and tertiary
prevention of ACEs. This is encouraging, and, again, more research needs to be con-
ducted with a wider variety of populations. The findings in this review also provide
evidence that practitioners play a vital role in the identification and prevention of
CM. As such, further collaboration is needed between public health professionals
and child welfare professionals to effectively identify, prevent, and intervene in cases
of CM. More than anyone else, practitioners who work with populations at risk for
CM and ACEs are on the front lines of prevention efforts. It is vital that practitioners
are confident in their abilities to identify CM and ACEs and that they report sus-
pected cases of CM via the appropriate channel in their respective country or state.

Limitations

As with all research, this systematic review has limitations. First, only 12 arti-
cles were identified over a decade that fit the review criteria. As such, of the five
approach categories, four categories had only two studies that fit the criteria. Simi-
larly, of the three prevention categories, one category had only one study that fit the
criteria. It is possible that there are other articles that could have been included in
this review but that were not found via the electronic databases and search terms
used. Additionally, as previously mentioned, this systematic review included only
articles on efforts in industrialized countries, and it is possible that the findings
in these articles are not reflective of efforts elsewhere. As only articles written in
English were included, it is also possible that valuable research from non-English
speaking scholars was excluded. With the relatively small pool of research articles
included in this systematic review, generalizability is limited.

Declarations 

Competing Interests  The authors declare no competing interests.

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