In 1883, the Spanish translation of the Étude médico-légale sur l’infanticide (“Estudio médico-legal sobre el Infanticidio”), a forensic study on infanticide by Auguste Ambroise Tardieu, was published in Spain. It was the first published work devoted to the abuse suffered by children. Later, in the mid-20th century, a theoretical framework on the subject of child abuse started to be developed. Authors like Caffey, Evans, Silverman and, most decisively, Henry Kempe established the scientific basis of a problem that had until then been perceived as concerning exclusively the family and society spheres and, in extreme cases, required the involvement of incipient welfare services. At the same time, the first efforts to protect children and adolescents started to emerge. Pioneers like Concepción Arenal in Spain, a revolutionary spirit ahead of her time, or Mary Ellen Wilson in the United States paved the way for the Convention on the Rights of the Child (CRC), an international treaty promulgated by the United Nations and ratified by Spain in 1990, in which the definition of “child” was any individual aged less than 18 years. It is based on four fundamental principles regarding the rights of minors: non-discrimination, the best interests of the child, the right to life, survival and development and respecting the views of the child in all matters affecting the child.

In 2008, the World Health Organization (WHO) declared violence a public health problem. Subsequent definitions added to the physical, psychological and social damage the violation of the human rights of the victim and the power and control exerted by the perpetrator on the victim. Violence has consequences that manifest in the short, medium and long term. It not only causes pain and injury to the individual, but also has a social impact and has substantial economic costs. Preventing violence is highly beneficial, not only from an economic standpoint, for society as a whole.1

In recent years, the scientific evidence on child abuse has continued to grow, and new and significant concepts have emerged. These include the impact of adverse as well as positive childhood experiences, trauma-informed care, allostasis and allostatic load or toxic stress, among others,2 which have contributed significantly to the development of a new comprehensive care model for abused minors.

The legislation concerning the care of minors is extensive both at the regional, national and international level. The knowledge of health care professionals on this legislation tends to be poor.3 In Spain, at the national level, the changes introduced in 2015 with Organic Law 8/2015 and Organic Law 26/2015 amending the child and adolescent protection system, constituted a significant advance in child welfare. They were followed 6 years later by the promulgation of the Organic Law on the Integral Protection of Children and Adolescents against Violence (commonly referred to as LOPIVI, its acronym in Spanish). Table 1 presents the key changes introduced by this law. Organic Law 10/2023 on the comprehensive guarantee of sexual freedom includes specific measures to guarantee the protection of children and adolescents from sexual abuse and eliminates the distinction between sexual assault and sexual abuse, so that the latter term is thereby rendered obsolete. It considers any behaviour that violates sexual freedom and without express consent from the other person as sexual assault.

At the international level, the CRC is the supreme law in regard to the recognition of the child as a holder of rights. Article 3.3 of the Treaty on European Union establishes the protection of the rights of the child as one of the aims of the union, further expanded on in the Charter of Fundamental Rights of the European Union, the European Convention on Human Rights, the Council of Europe Convention on the Protection of Children Against Sexual Exploitation and Sexual Abuse (Lanzarote Convention) and the rulings of the European Court of Human Rights.4

There are four recognised types of child abuse. The most frequent type is neglect, in which the basic needs of the child or adolescent (nutrition, clothing, hygiene, health care, protection, education, emotional needs, etc.) are not being fulfilled by their primary caregivers. In 2021, neglect accounted for 76% of reported cases of child abuse in the United States5 and 42.75% of cases recorded in the Unified Register of Child Abuse (known as RUMI) in Spain,6 which has since been replaced by the Unified Register of Welfare Services concerning Violence against Children (RUSSVI). We ought to highlight that child abuse reports are least frequently filed from health care settings, although there has been a mild increase in frequency in recent years. Of all reports recorded in RUMI, 30.75 % were for psychological or emotional abuse, which occurs when the primary caregivers of children or adolescents make them feel unloved, unheard, unappreciated, unsafe or rejected. In spite of being the most frequent forms of child abuse, neglect and psychological/emotional abuse tend to be harder to identify, address and manage, and are often the forms of abuse that generate the most uncertainty in paediatric health care professionals. Physical abuse accounted for 16.91% of cases, and it is defined as any nonaccidental behaviour of the parents or caregivers that constitutes a risk of or causes physical injury or disease in a child or adolescent. Lack of training and awareness regarding child abuse frequently leads to the misconception that physical abuse is the only type of abuse that can be exerted against minors. In most cases of physical or psychological/emotional abuse, a medical visit is not made expressly for this reason, and it is the skill, knowledge, experience and awareness of health care professionals that allows its detection. In the case of children aged less than 2 years, sentinel injuries have been described that could be associated with child abuse (Table 2).

During medical visits, providers can identify warning signs leading to suspicion of violence against children7 (Table 3). We ought to mention the improvement in the diagnosis of bone lesions with the appropriate combination of radiography, magnetic resonance and bone scintigraphy.8

Sexual violence against children (SVC), which amounts to 9.59% of child abuse cases recorded in the RUMI register, is defined on the imposition of activities of a sexual nature by an adult to a minor under 18 years through coercion, which may or may not involve physical contact. The definition also includes any activity of a sexual nature between an adult and minor aged less than 16 years even if the latter consents to it, as in Spain the law sets the minimum age for sexual consent at 16 years. It also includes sexual activity between minors if there is an obvious disparity in physical or psychological development between the victim and the perpetrator or if, in parties of similar age and maturity, force, threats or other means are used to coerce the victim. Current legislation in Spain considers lawful sexual behaviour between minors aged less than 16 years of similar age and physical and psychological development that consent freely to it. In cases of SVC, there are usually no abnormal findings in the physical examination9 and/or diagnostic tests that could be clearly associated with SVC, and it is the report of the victim or of individuals in the victim’s immediate environment that allows its suspicion and/or confirmation (Table 4). Therefore, it is important that all health care professionals know how to manage SVC correctly, with an emphasis on avoiding secondary victimization through inappropriate professional interventions that, in addition to being potentially deleterious to the protection and healthy development of the victim could also hinder the legal process.

Violence against children is not limited to the 4 classical types we have discussed above. Based on the context where it takes place, the involved parties, the use of technology or other factors, different types of violence have been emerging that need to be known and that are increasingly frequently leading to seeking paediatric care services10–18 (Table 5).

Although the immediate effects are more evident, the exposure to violence at an early age has a prolonged impact on health. Since the late 20th century, it is known that the experience during childhood of dysfunction in the family or adverse social conditions, including child abuse, is associated with the development of various diseases and risk behaviours.19 This led to the coining of the term adverse childhood experiences (ACEs), which initially included 10 categories about child and family experiences. Table 6 presents the original ACE categories proposed by Vincent Felitti. The presence of 4 or more ACEs is associated with deleterious effects on health throughout the lifespan of the individual. According to a recent meta-analysis of 37 studies including 250 000 participants in total,20 the risk of cardiovascular disease, chronic obstructive pulmonary disease or cancer is doubled in adults with a history of ACEs compared to the general population. The risk of substance use, mental illness or risk behaviours is four times greater, and the risk of violent behaviour in general (including attempted suicide, with an odds ratio of 30) is seven times greater. This association between ACEs and diseases that do not appear to be related to social determinants of health, combined with previous studies describing an increased incidence in common diseases of childhood21 (otitis media, viral infections, asthma, dermatitis, urticaria, gastrointestinal and urinary tract infections), have led to the recognition of early exposure to violence, with the resulting health sequelae, as one of the modifiable risk factors with the highest impact on public health.

The scientific literature also demonstrates that the effect of violence against children is perpetuated intergenerationally, increasing the risk of exposure to violence, mental illness, substance abuse and risk behaviours in future generations.22 The pathophysiological mechanisms that underlie the long-term consequences of ACEs remain unclear. The prenatal period and the first years of life are key for the development of the central nervous system, a process in which interaction with the environment and external stimuli play an essential role. Different pathways have been proposed to explain the association between early adverse experiences and neurocognitive and psychosocial development, among which we should highlight alterations in the stress response, remodelling of synapses in the hippocampus, amygdala and prefrontal and medial orbitofrontal cortex and immunologic and epigenetic changes in neurotransmitters with accelerated ageing.23 However, it is impossible to isolate the effects of ACEs and other social determinants of health. Factors like poverty, poor nutrition, housing insecurity, residing in marginalised areas or exposure to environmental pollutants probably have an impact on cognitive functions as well, especially executive functioning, which could result in poorer academic performance and an increased risk of mental illness, in addition to the subsequent development of chronic diseases and fewer opportunities in personal development, education and employment and lower incomes.24 Therefore, violence is a priority in global health.

The management of situations of violence against children should include a detailed history-taking and physical examination, assessing for indicators of biopsychosocial risk,25,26 observing the interactions between minors and caregivers and their behaviour and safeguarding the rights of children and adolescents. Once this initial assessment is complete, it may be useful to apply the STAR mnemonic,27 which can guide the comprehensive management of child abuse: Stop—Do you think it could be a case of child abuse?; Think—assess the certainties and uncertainties in the case; Act—contact available resources for child welfare and support; Review—Did you follow specific recommendations, protocols or algorithms for the response to suspected child abuse? This strategy fails if institutions and professionals are not genuinely invested and fully coordinated in the management of violence against children and adolescents, and to facilitate this coordination it is important to understand the difference between risk situations and situations from which the child needs to be removed.28

The severity of child abuse is determined by different factors, chiefly the age of the victim, the type and frequency of the violence experienced by the child, the emotional closeness of the perpetrator, the support available within the family, available social welfare and health care resources, socioeconomic level, etc.

In cases of mild or moderate severity in which there are physical or psychological signs or social risk factors but that allow non-urgent management, the initial intervention will be performed in the setting in which the abuse is detected and the situation will be reported to child protection services through the Risk and Abuse Report form. Child protection services will develop a family intervention plan including measures to improve the current situation, including the rest of the family in the assessment with particular emphasis on the siblings of possible victims.29 Referral to social paediatrics services or care teams specialised in the management of violence victims can be considered.

When severe child abuse is suspected, the situation is urgent, as the life and integrity of the child or adolescent are threatened. The case should be reported to law enforcement, the duty court and juvenile justice system (also when the presumed perpetrator is a minor as well) and the child protection system. The need to involve child protection services and coordination with units specialised in violence or social paediatrics should be considered. The need for hospital admission should also always be assessed.

Table 7 lists the levels of intervention and Table 8 the documentation that needs to be completed.

When children or adolescents report being a victim of violence, they often need to report their experiences several times, which contributes to secondary victimization. The Barnahus model,30 which is gradually being introduced throughout Spain and was initially developed for cases of SVC but subsequently expanded to other types of child abuse, is an approach that safeguards the rights, health and integrity of minors. To implement it, there will be a progressive integration of all the agencies and institutions with the aim of pursuing the best interests of the minor. The cornerstone of the model is that the child or adolescent should only be subjected to a single forensic interview that would later be admissible as pre-appointed evidence in court31 and remain valid for the duration of the legal process.

The LOPIVI defines good treatment of minors as respecting the fundamental rights of children and adolescents and promotes the principles of mutual respect, the dignity of human beings, democratic coexistence, peaceful conflict resolution, equal rights and protection under the law, equal opportunity and non-discrimination of children and adolescents. Another concept along the lines of good treatment is positive parenting,32 which refers to parents acting based on the best interests of the child, nurturing their development and abilities, never using violence and offering guidance, including the establishment of boundaries, to allow the full development of the child.

The prevention of violence is a key issue, given its impact on health, but it requires a multidisciplinary and comprehensive approach. For instance, the INSPIRE programme,33 developed by the WHO, proposes and elaborates on seven evidence-based strategies to reduce violence against children. Chief of them are the strategies based on norms and values, parent and caregiver support and response and support services. Its implementation requires comprehensive partnerships with coordination of health care systems, community resources, education systems, social and welfare services, the legal system and law enforcement.

Another fundamental aspect is the promotion of protective factors, both in victims and in the professionals caring for them.34 We know that there is substantial variation in individual responses to violent situations, and that this variation is related to what we know as resilience, understood as positive coping of the individual subjected to challenging and traumatic life events, overcoming adversity and transforming painful experiences into opportunities for growth and development.35 By promoting good treatment, resilience, the detection of ACEs and positive childhood experiences (PCEs), whose importance has been recently demonstrated,36 health care professionals can play a key role in the suppression of the effects of violence on the victims.37

In the present article, we have offered a succinct and up-to-date perspective on the terrible impact of violence on children. This approach supports the undertaking of a comprehensive approach to paediatric care now and in the future. The future needs a holistic perspective,38 based on the interaction between the child and the child’s family, social, cultural and environmental context. General Comment No. 26 of the Committee on the Rights of the Child considers environmental degradation, including climate change, a form of structural violence against children and adolescents.39 Knowledge of the social determinants of health and of adverse as well as positive childhood experiences will facilitate the provision of comprehensive care and the prevention of adverse experiences in early life, and therefore help children and adolescents reach their full human potential while building a more just and democratic society.

We conclude by quoting the words of psychiatrist Judith Lewis Herman about trauma, the manifestation of the damage caused by violence.40 It is a call for the professional and ethical commitment of every professional involved in the care and support of children.

“To study psychological trauma means bearing witness to horrible events […] But when the traumatic events are of human design, those who bear witness are caught in the conflict between victim and perpetrator. It is morally impossible to remain neutral in this conflict. It is very tempting to take the side of the perpetrator. All the perpetrator asks is that the bystander do nothing. He appeals to the universal desire to see, hear, and speak no evil […] After every atrocity one can expect to hear [that] it never happened; the victim lies; the victim exaggerates; the victim brought it on herself; and in any case it is time to forget the past and move on […] The victim, on the contrary, asks the bystander to share the burden of pain. The victim demands action, engagement, and remembering.”