Safeguarding children: a call to action.

Since Kempe’s description, almost 50 years ago, of the “battered baby”, we have become all too familiar with sexual and emotional abuse of children, neglect, fabricated illness, bullying, and exposure to domestic violence. In many countries the catalogue of abuse and exploitation also includes female genital mutilation, child traffi cking and prostitution, sweatshop labour, and coercive enrolment into military service. The Lancet‘s Series on child maltreatment describes the progress that has been made in recognising maltreatment and its eff ects in the short and long term, and in evaluating interventions once abuse has occurred. However, mental-health professionals and social services too often lack the resources to apply this knowledge. Sadly, we are far from understanding why mal treat ment is so common and how to stop it. Child maltreatment occurs in all societies and all socioeconomic groups but poverty, unemployment, and overcrowding—which might lead to, or be associated with, parental mentalhealth problems and drug or alcohol abuse—all predispose to abuse. Often parents’ life circumstances help to explain why children are neglected or abused, but there are also many people who cynically exploit children for self-gratifi cation or personal gain. Prevention of child maltreatment can be approached at the level of the individual child or family, the local area or school, or the community as a whole. In the Series, Harriet MacMillan and colleagues explore the immense diffi culties in researching these approaches. Some interventions focus on one issue—eg, those designed to reduce the risk of sexual abuse. Others seek to address problems of early parent–infant attachment and parenting skills. Involving fathers is important—yet in the Series fathers seem to be perceived as perpetrators of abuse rather than key fi gures in a child’s life. Many of the children at high risk of maltreatment grow up with multiple disadvantages: lack of vital preschool learning opportunities, behavioural problems, harsh inconsistent parenting, poor schools, food insecurity, unhealthy diet causing undernutrition or obesity and dental disease, and an increased risk of illness and death from sudden infant death syndrome, infections, substance abuse, suicide, and violent crime. The apparent success of the Nurse Family Partnership (currently undergoing a replication trial in the UK) suggests that for many families a focus only on preventing maltreatment is less eff ective than a positive approach of building child-care skills, self-esteem, and fi nancial independence. However, such programmes are expensive, need scarce human resources, and must be targeted to those most likely to benefi t. The ecological approach to child maltreatment emph asises neighbourhood risk: inadequate or decaying infrastructure, endemic community violence, and social impoverishment. This approach applies equally to the decrepit featureless estates and ghettos of the industrialised nations and the slums and shanty towns of the developing world, all of which present overwhelming challenges to governments. Reducing neighbourhood risk by developing and strengthening local communities is an attractive option, although such programmes are complex to plan and expensive to implement. Child maltreatment, like many other manifestations of violence, is the end result of interaction between genetic and temperamental factors (eg, escalating aggressive behaviour in childhood or the callous–unemotional personality type), the socio economic environment, and societal attitudes. A UN report reviewed violence against children in the light of the Convention on the Rights of the Child and, in the Series, a human-rights approach is proposed by Richard Reading Co bi s Published Online December 3, 2008 DOI:10.1016/S01406736(08)61705-5