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Violence against children and adolescents is a social, public health, and human rights problem with a high prevalence in all countries of the world (Stoltenborgh et al., 2015), affecting 1 billion children aged 2-17 years per year, according to rigorous review studies (Hillis et al., 2016).
Violence in childhood, and specifically sexual violence, has been shown to have adverse health, physical, and mental consequences (Maniglio, 2009); social consequences, with increased risk of further victimization (Walker et al., 2019), but also of antisocial and criminal behavior, adult criminality, and violent behavior (Papalia et al., 2018); as well as socioeconomic consequences, with poorer academic (Fry et al., 2018) and occupational performance, and lower levels of financial well-being (Currie & Widom, 2010), involving significant losses of human capital (Henkhaus, 2022).
Establishing the cost to a given society of violence against children and adolescents has been the subject of study in different countries for some years (Ferrara et al., 2015). From a health economics perspective, it is important to understand the costs of violence for several reasons (Gerber-Grote et al., 2015). First, knowing the costs of the problem enables better informed decisions about economic investment in its prevention and treatment, as well as raising awareness of its scale and impact. Second, it makes it easier for those who must implement public policies to place the expenditure invested in violence against children and adolescents in the context of other public health services. Attempting to estimate the cost of this problem also points to the gaps in our knowledge that we need to work on to improve the evidence in the future.
Estimates of the economic cost of violence against children and adolescents can take a prevalence-based perspective or an incidence-based approach (Haddix et al., 2003). The prevalence-based economic burden refers to the costs of violence incurred over a time period of usually one year, for all victims, regardless of when the violence began (see below, for example, the UK study by the National Society for the Prevention of Cruelty to Children, Saied-Tessier, 2014). In contrast, incidence-based economic burden represents the total lifetime costs incurred by victims of violence that occurred within a set time period, usually one year (e.g., the study in the United States by Fang et al., 2012).
Objectives of the Study
To date, there is no study that has reviewed the available literature on the costs of violence against children in western countries or, specifically, in Europe. Thus, the aim of the present narrative review (Greenhalgh et al., 2018) is to analyze the studies that have presented, using the secondary data collection method and the corresponding estimates made (Corso & Fertig, 2010), the costs of medical, physical, and mental care, productivity losses, costs to the child protection system, and costs to the criminal justice system of violence against children and adolescents, with special emphasis on sexual violence. In the present study, a broad definition of sexual violence has been used, including all sexual behaviors that victimize a person under 18 years of age. The term 'sexual violence' has been chosen instead of 'sexual abuse' since, as of October 6, 2022, the date on which Organic Law 10/2022 came into force, this crime does not exist in the Spanish Penal Code. However, given the extensive use of the term 'sexual abuse' in the literature, it may be used on occasion, especially when it is the term used in the studies reviewed. Table 1 below exemplifies these costs and the secondary data to be obtained (Sethi et al., 2013).
Table 1. Costs to be Evaluated and Possible Data Sources.
| Short-term costs | Long-term costs | Source of data to be obtained |
|---|---|---|
| Health services utilization (number of inpatients, number of outpatients, diagnostic data, medication data) | Greater frequency of health service use (due to chronic sequelae (depression, drugs/alcohol, obesity, etc.) | Public health services (primary health care centers, specialized medical services (psychiatry, pediatrics, etc.)) |
| Productivity losses (loss of school days for children, drop in grades and academic performance, loss of work days for parents) | Productivity losses (higher school dropout rates, lower frequency of higher education, higher unemployment, lower job satisfaction, more work absenteeism) | State public employment service, youth guarantee program. |
| Child protection services (costs of investigation of cases, costs of cases in kinship care, foster care, residential care) | Greater frequency of use of social services (more monetary benefits issued, more requests for support, day care, residential care) | Social services, resources dependent on the child protection system |
| Criminal justice system (police costs, court costs) | Greater victimization by violence (intimate partner violence, sexual violence) Greater perpetration of violence (arrests, prosecutions, admissions to juvenile justice centers or prison) | Public court data, national statistics institutes |
| Mortality (suicide data) | Mortality (suicide data, premature deaths) | National statistics institutes, health system data |
Note.Prepared by the authors, based on Sethi et al. (2013).
It should be noted that some of the costs analyzed in the studies are direct, i.e., they are associated with the services and resources provided to child victims, such as the costs of health care and medical services, the costs of family intervention programs or residential and/or family foster care as a result of violence. There are also indirect costs that are not applied in immediate care but derive from the negative effects of sexual violence in the long term, whether due to the involvement of victims in antisocial and criminal behavior, or the need for medical care derived from physical and psychological sequelae. The third type of costs are opportunity costs, or lost choices, as victims lose the ability to make the best decisions for their lives as a result of the emotional or physical harm resulting from the abuse. Examples of these costs are unemployment, poor job performance, and lost tax revenues (Conrad, 2006). From a human capital approach these opportunity costs reflect potential productivity losses resulting from childhood violence that must also be taken into account (Henkhaus, 2022) (Figure 1).
The purpose of this paper is not to attempt to capture how and in what ways violence, and specifically sexual violence, affects each individual victim. There are important systematic reviews that have addressed this topic, including the harm caused by bullying victimization (Montes et al., 2022; Moore et al., 2017) and by cyberbullying (John et al., 2018), online victimization (Gardella et al., 2017), child abuse and neglect by primary caregivers (Leeb et al., 2011; Norman et al., 2012), sexual abuse (Irish et al., 2010; Maniglio, 2009), exposure to violence between parents (Wood & Sommers, 2011), and exposure to community violence (Lynch, 2003). The aim of the present study is to use the existing academic literature to present an approximate figure of how much childhood violence costs victims, and society as a whole, bringing the psychology professional closer to this reality that has implications for the clinical and health psychologist, but also for the educational and developmental, forensic, occupational, and social psychologist.
Results
The Costs of Violence Against Children and Adolescents
One of the first and most rigorous papers to analyze the costs of violence against children was Fang et al. (2012). According to this study, the lifetime economic burden of violence against children and adolescents resulting from 579,000 new cases of nonfatal violence and 1,740 cases of violence resulting in death in the United States in 2008 is approximately 124 billion dollars. On average, the lifetime cost is estimated at more than $210,000 per victim of nonfatal violence and $1.3 million per victim resulting in death. The costs included medical, short- and long-term care, productivity and child welfare losses, criminal justice, and special education costs. The authors conclude that, even from a very conservative perspective, when compared to other health problems, the economic burden of violence against children is substantial, requiring resources for prevention and specialized treatment.
Using a systematic review study with North American and European samples, De Bellis et al. (2019) found that the annual financial and health costs attributable to adverse childhood experiences (ACEs) were estimated at $581 billion in Europe and $748 billion in North America. The term ACE refers to several emotionally intense factors that can affect children's development such as victimization experiences (child maltreatment, exposure to family and community violence) or stressful family situations, such as substance abuse by parents or primary caregivers (Anda et al., 2010). Exposure to these factors can influence a child's neurological, biological, and social development and increase the risk for social difficulties (e.g., low educational attainment), health-damaging behaviors (such as smoking), and diagnoses of mental and physical illnesses across the lifespan (Hughes et al., 2017).
Recently, Hughes et al. (2021) have estimated the annual economic burden linked to these adverse childhood experiences for 28 European countries, including Spain. The annual health costs associated with ACEs range from $0.1 billion in Montenegro to $129 billion in Germany. According to this review, for Spain, the costs associated with adverse childhood experiences account for 1.2% of the country's gross domestic product or about $17 billion. Similarly, in Germany, the study by Habetha et al. (2012) showed that trauma resulting from violence against children and adolescents is a relevant economic problem, estimating its annual costs at between €11 billion and €30 billion for the German population. In Italy, a study published by l'Autorità Garante per l'Infanzia e l' Adolescenza, CISMAI and Fondazione Terre des Hommes Italia (2015), based on the official report of data reported in 2010 by the Italian Ministry of Health, reported a total of 100,231 maltreated children in Italy in one year and €13 billion of costs related to maltreatment, including direct and indirect costs. Direct costs referred to hospitalization (€50 million), mental health care (€21 million), protective and residential services (€164 million), foster care (€13 million), professional social work (€38 million), and juvenile justice (€53 million). Indirect costs included children's special education (€210 million), juvenile and adult delinquency (€690 million), adult medical care (€326 million), and lost productivity (€6.6 billion).
The Costs of Sexual Violence Against Children and Adolescents
Sexual violence is a specific form of violence against children with particularities and differential characteristics that justify an analysis of its costs. There are five publications to date that have analyzed the specific socioeconomic impact of sexual violence against children and adolescents in the United States, Canada, the United Kingdom, and Spain.
One of the few studies focusing on the economic costs associated with the experience of childhood sexual abuse is that of Miller et al. (1996) for the National Institute of Justice in the United States. The authors estimated the costs of this experience at $125,000 per victim. Annual costs associated with sexual abuse were placed at $23 billion, and were linked to productivity losses, medical care/ambulance, mental health, police/fire services, social/victim services, as well as loss of quality of life.
Letourneau et al. (2018), also in the United States, estimated the average cost of childhood sexual abuse from a societal perspective based on secondary data obtained from health care services (including physical and mental health), productivity losses, child welfare system costs, violence/crime costs, special education costs, and suicide death costs, as well as, loss of quality of life. The authors estimated 20 new cases of fatal child sexual abuse, resulting in the death of the child, and 40,387 new confirmed nonfatal cases in 2015, placing the lifetime economic burden of sexual abuse at approximately $9.3 billion. The cost to victims of fatal sexual abuse was $1.1 million for females and $1.5 million for males, approximately. In turn, for female victims of nonfatal child sexual abuse, an average lifetime cost of about $300,000 per victim was estimated. For male victims of nonfatal child sexual abuse, there was insufficient information on productivity losses, contributing to a lower average estimated lifetime cost of about $75,000. The authors attribute divergences with the results of previous studies with U.S. samples to the use of different methodologies that made comparison impossible. The findings of Letourneau et al. (2018) provide a more contemporary assessment of the cost of sexual violence that incorporates both a comprehensive assessment of productivity losses as well as a more conservative estimate of new cases.
Another study also focused on sexual violence is Hankivsky and Draker (2003) in Canada. The authors estimated the monetary burden resulting from current or previous experiences of child sexual abuse in the fiscal year 1997-1998. They analyzed the direct costs, linked to health ($1.72 billion), public and social services ($914 million), justice ($472 million), and education/research and employment ($13 million), and the indirect costs, morbidity ($476 million), and mortality ($100 million), of child sexual abuse, estimating that these exceeded $3.6 billion annually. The authors, however, caution that these estimates can only be considered the minimum annual costs of child sexual abuse in Canada. At the same time, the study also underscores the need to include the voice of victims in any policy aimed at improving prevention and intervention and reducing the social costs associated with the problem.
In Europe, the study Saied-Tessier, 2014 in the United Kingdom reported the total cost of child sexual abuse for all victims, current and past, in one year, placing it between £1.6 billion and £3.2 billion in 2012-2013. The costs included were selected based on a review of the literature on the short- and long-term effects of child sexual abuse. This includes criminal justice system costs linked to the involvement of the police, courts, and correctional services for perpetrators of child sexual abuse, and also some victims of child sexual abuse who commit offenses (£149 million); child protective services, which include the costs of case assessment, as well as those arising from care in foster families or residential facilities (£124 million); mental health services, focusing on the treatment of childhood depression (£1.6 million); hospital costs arising from admissions for child suicide and self-harm (£1.9 million); adult mental health services, focused on depression and post-traumatic stress disorder, and adult physical health services, focused on alcohol and drug abuse (£178 million); and lost productivity, related to the fact that victims of child sexual abuse are less likely to be working and are likely to be earning lower wages than if they had not had this experience, either because of lower academic performance and/or mental health problems, or due to interpersonal difficulties linked to forming and maintaining relationships (£2.7 billion).
Finally, in Spain, the EDUCO Foundation (2018) carried out an analysis whose objective was to make a first approximation to estimate the economic impact of violence against children and adolescents, identify information gaps, and highlight a possible quantification of these costs based on currently available data. The authors advocate focusing only on sexual violence since, although it is not the most frequent form of violence in childhood, it is the one that is most repeated over time. Thus, from a prevalence approach, they determined, firstly, the costs in 2015 as a direct response to reported cases of sexual abuse and, secondly, the costs in the same year corresponding to people estimated to have suffered sexual abuse previously. Included in the report, therefore, are 3,919 reported cases and 97,415 estimated unreported cases. Bearing in mind that a minimum figure is presented, following the literature on the subject, the costs of violence have been classified into four major groups: healthcare costs (€850 million), relating to hospital admissions, costs arising from the physical consequences of sexual abuse, emergency room visits, and costs related to chronic health problems, among others; educational costs (€4 million), including the costs of school absenteeism, repetition of academic years, the need for special services in the classroom, low performance, and school failure; judicial costs (€70 million), relating to court proceedings and prison services for perpetrators; and, finally, the costs of social services and benefits (€56 million), including residential and family foster care services. It is estimated that sexual violence against children in Spain costs society €979 million per year, bearing in mind that this is only the cost of sexual violence and that it is only the cost of the measurable consequences for which data are available.
Table 2 shows a summary of the results of the different studies on the costs of sexual violence.
Table 2. Summary of the Results Obtained in the Different Studies on the Costs of Child Sexual Abuse.
| Study | Country | Estimated cost |
|---|---|---|
| Miller et al. (1996) | USA | $23 billion |
| Letourneau et al. (2018) | USA | $9.3 billion |
| Hankivsky & Draker (2003) | Canada | $3.6 billion |
| Saied-Tessier (2014) | United Kingdom | £3.2 billion |
| EDUCO (2018) | Spain | €979 million |
Discussion
This review summarizes the main studies published in Europe and North America on the economic impact of violence against children and adolescents and, specifically, it analyzes the few studies available on the costs of sexual violence. All of the studies confirm that violence in early stages of development is associated with increased use of health services and other resources, which represent an important public investment to be taken into account. Estimates of the economic costs of violence against children and adolescents help to draw attention to this important public health problem based on its impact on the individual and on society and, therefore, warn of the need to invest in its prevention, given that it affects even those who do not feel directly affected by the problem (Corso & Fertig, 2010).
It is essential to know the socioeconomic costs of violence against children and adolescents if adequate economic models aimed at improving children's health are to be developed, within the framework of the rights to protection, prevention, provision, promotion, and participation emphasized by the Council of Europe (Gerber-Grote et al., 2015). Despite the complexity of developing these estimates, and the limitations found in different studies, economic analyses are invaluable for highlighting the impact of violence against children and adolescents on society and guiding policies to improve their prevention (Corso & Fertig, 2010). More scientific studies are needed on the burden and costs of violence against children and adolescents, as well as on the benefits of preventing this violence if a country's priority is to implement evidence-based public policies (Sethi et al., 2013).
There is a moral imperative for society to do all it can to prevent and address violence against children and the economic argument only seeks to complement this strong imperative (Saied-Tessier, 2014) and urge governments to invest in preventive interventions. Even given how high these economic costs are, it is critical to recognize that these are conservative estimates and that it is impossible to calculate the impact of the pain, suffering, and reduced quality of life experienced by victims of violence against children. These intangible losses, while difficult to quantify in monetary terms, are real and should not be overlooked. We can never know the loss involved of children not developing fully and not reaching their full potential. Intangible losses, in fact, may represent the largest component of the cost of violence against children and should also be taken into account when allocating resources (Wang & Holton, 2007).
In turn, the impact of violence in childhood, and specifically sexual violence, is much greater than its initial consequences and the resulting costs. The fact that the effects of sexual violence endure over time (Pereda, 2010) means that there are ongoing costs to the individual, throughout his or her life, as well as to society. It is important to note that what we value in terms of quality of life, health, and well-being often defies economic value and calculations. This makes capturing all of the true costs of childhood sexual abuse very difficult, if not impossible.
Identifying the most effective and efficient means of providing prevention and intervention programs and resources in the area of violence against children would lead to significant cost savings to society in terms of health care, social services, and justice costs (Hankivsky & Draker, 2003). But the benefits of preventive interventions for child and youth victims, adult survivors, families, and society at large are beyond any financial savings.
In summary, the economic costs presented in this review are only a partial and conservative accounting of this complex and multidimensional social, healthcare, and violation of rights problem. Even these preliminary estimates show that violence against children and adolescents carries enormous costs to victims, their families, and society. Therefore, this review is a valuable resource to be used by those who must influence public policies and respond to social demand in the face of violence against children.
Limitations of the Studies
The reviewed studies present important limitations that derive, mainly, from the incomplete or unreliable data included regarding mortality and morbidity linked to violence against children and that involve variable estimates of their costs, which range in Spain from approximately €17 billion for adverse childhood experiences to about €1 billion for sexual violence.
First, there is an urgent need for reliable and valid data from annual community surveys to establish the real dimension of violence against children and adolescents in a given country, using standardized tools that facilitate international comparison (Sethi et al., 2013). In Spain, we currently have one single nationwide study of child sexual abuse (López et al., 1995) and other isolated studies whose results allow us to know the prevalence of different forms of violence against children (Indias & de Paúl, 2017; Játiva & Cerezo, 2014; Pereda et al., 2014). Carrying out a national survey, repeated over time, allowing us to establish the annual incidence of violence, as well as to observe possible variations depending on the implementation of prevention programs in certain regions, is a first step to be taken into account in public policies in our country.
It is also possible to use cases officially known to child protection services or reports of violence against children reported to law enforcement to establish a baseline from which to estimate the consequences of violence against children, from a conservative perspective and at the lower limit of the actual total economic burden. However, this may be problematic given that in many countries there is no mechanism for identifying and recording cases of violence against children and adolescents in protective services or law enforcement, and, moreover, many cases go undetected and unreported to authorities (Pereda et al., 2016) which underestimates the reality of the problem.
Likewise, there is an urgent need for rigorous data from the various systems that work with children and adolescents and from services that care for victims of violence, such as the educational system and physical and mental health services, the child protection system and social services, or the criminal justice system. These data can be obtained from the cases known to the services whose costs are to be estimated. In Spain, again, this may be problematic given that the different services do not collect information on the victimization experiences of the person who comes to them and it is impossible to know how many people who commit suicide were victims of violence in their childhood, or how many people in prison suffered this experience.
It should be added that establishing causal links between violence in childhood and certain long-term harmful effects, such as increased risk behaviors, criminal activity, or chronic victimization and perpetration of violence, is even more problematic and only rough estimates can be made, such as those presented in this review, which do not claim to be exhaustive but rather aim to show the seriousness of a problem, with important economic effects for society, beyond the harm caused to the victims.
The approval of Organic Law 8/2021, of June 4, on the comprehensive protection of children and adolescents against violence constitutes a regulatory advance that may contribute to responding to some of these limitations, through the involvement of Spanish universities in carrying out studies on this problem (art. 36 and 37), or the creation of a Registro Unificado de Servicios Sociales sobre Violencia contra la Infancia [Unified registry of social services on violence against children] (RUSSVI, art. 44), among others.
Conclusions
The prevention of child maltreatment must become a priority within educational, health, and child protection programs worldwide (Ferrara et al., 2015). The frequency and severity of the consequences of violence against children and adolescents, which includes a significant economic cost, not only for direct victims, but for society as a whole, justify greater investment in evidence-based preventive and therapeutic measures (Gilbert et al., 2009).
