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INTRODUCTION
Child maltreatment is characterized by the use of physical force or power by a parent or caregiver against a child. It constitutes the abuse of power and neglect of the duty to protect by the adult, as well as the delegitimization of the rights of the child, who becomes an object in the hands of those who should provide care and protection1.
What makes violence against children a delicate situation is the fact that children are vulnerable, having limited capacity to defend themselves and a high level of emotional and physical dependence on adults2, 3. Violence against children is widespread, affecting the lives of millions of children all over the world, regardless of socioeconomic status3. According to data from the United Nations Children\'s Fund (UNICEF)4, up to one billion children around the world aged 2-14 years are victims of violence, with long-lasting consequences. In Brazil, in 2019, the human rights abuse hotline, Disque 1005, received 86,837 reports of child abuse involving neglect (38%), psychological violence (23%), and physical violence (21%).
These figures are of grave concern, given that exposure to violence has an array of harmful physical and psychological consequences that can endure into adulthood, including depression, aggressivity, anxiety, and social interaction and learning difficulties6. Hillis et al.7 point out that experiencing violence during childhood can impair brain architecture, metabolic systems, immune status, and inflammatory responses.
Brazil’s Federal Constitution8 became an instrument of child protection by recognizing children as subjects of rights9. In the same vein, the Child and Adolescent Statute10 provides for the development of a network dedicated to the comprehensive protection of children11 and makes it mandatory for health and education professionals to report maltreatment to child protection services.
The work of professionals who are trained and sensitized to identify and intervene in situations of violence against children is therefore essential to guarantee comprehensive protection and minimize suffering12,13. However, research shows that the everyday practice of professionals involved in the care and education of children are not always geared towards protection and the prevention of child maltreatment6, 13, 14.
Practice is understood as a processual concept whereby an individual actively transforms or reproduces an existing standard. A practice is the expression of a network formed of the individual’s own actions, motivations, desires, resistance, discourse, and meanings15. Hence, the study of practice provides important insights into how professionals recognize, produce, and formulate the scenes and regulations of everyday work16.
Most studies of child maltreatment in Brazil focus on the categorization and description of types of violence, procedures, and the institutions responsible for child protection. Qualitative research addressing intervention practices to prevent and respond to child violence is therefore scarce1, 14. Nunes et al. 3 undertook a study to characterize child violence in Brazil according to type, victim, perpetrator, and place of occurrence.
However, there is a lack of literature in Brazil on professional practices and child maltreatment. Maia et al. 17 carried out an integrative review of the practices of in-home caregivers of children, older people, and women in situations of violence, while Rosa et al.18 investigated the conduct of dental surgeons in the face of child abuse, identifying a lack of guidelines for dealing with such situations. In the same vein, Wyzykowski et al.19 concluded that weaknesses in nurse training result in deficiencies in dealing with violence against children.
Given the complex nature of child maltreatment, interventions to address this problem require coordination and cooperation between the different institutions and practitioners who are working to strengthen a network capable of protecting children’s rights2, 6. This article seeks to contribute to understanding practices across different professions by answering the following question: “How are professional practices in situations of child maltreatment addressed in Brazil?”. The aim of this study was to identify and analyze the main results of articles published in Brazil addressing the practices adopted across different professions for dealing with situations of child maltreatment.
METHOD
STUDY TYPE
An integrative review is a method that draws together empirical or theoretical studies to gain a more comprehensive understanding of and indicating new directions for future research17, 20.
DATA COLLECTION
The study was conducted following a protocol describing the different a particular phenomenon by analyzing existing knowledge on the topic stages of an integrative review20. First, we defined the topic and then formulated the problem, which guided the other stages.
The second stage of the review was conducted in accordance with the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, comprising a 27-item checklist and stages to be followed in systematic reviews21.
We then searched for health science descriptors (DeCS/MeSH) on the website https://decs.bvsalud.org/ to identify suitable keywords for the review. Keywords are useful research tools as they permit the identification of terms used to index articles and perform database searches22.
The following keywords were used in combination with the Boolean operators AND and OR: Child maltreatment; Intervention; Prevention; Professional practices. First, we performed a search using the term Child maltreatment combined with the Boolean operator OR and Child abuse to increase the breadth of the search, followed by a search using the keyword Child maltreatment combined with the Boolean operator AND and the other terms.
We searched for articles in multidisciplinary databases (Google Scholar, SciELO, and the periodicals database of the Agency for the Improvement of Higher Education Personnel - CAPES), and health and medical databases (MEDLINE, the Virtual Health Library - VHS, and Electronic Psychology Journals - PePSIC). The searches were performed between August 2021 and October 2022.
In the first stage of the article selection process, we screened the article titles. We then screened the article abstracts to assess whether the publications met the following inclusion criteria: a) studies whose central theme was child maltreatment associated with some type of professional practice (identification, reporting, referrals, care, interventions); b) studies conducted in Brazil; c) target population were children aged 0-12 years; d) full-text version of the article written in any language available online or for download; e) peer-reviewed articles; and f) articles published in the last six years (2017 to 2022). Studies conducted outside Brazil, involving both children and adolescents, and focusing on child-on-child violence or the consequences of child maltreatment in adulthood were excluded. Duplicate articles were then excluded.
The following data were extracted from the abstracts: title, author(s), year of publication, periodical, type of article, and study region in Brazil.


DATA PROCESSING AND ANALYSIS
The studies were characterized after reading the full-text version of the selected articles, focusing on the following aspects: study objective, sample, main results, and themes related to the role played by professionals in situations of child maltreatment. The reading of the full-text versions of the articles allowed us to extract relevant information and create categories, comparing studies to identify similarities and differences23 using Microsoft Excel and ATLAS.ti version 7.3.
RESULTS
The database searches identified 40.146 records: Google Scholar (n = 34.919), SciELO Brasil (n = 66), CAPES periodical database (n = 3.034), MEDLINE (n = 1.571), VHL (n = 523), and PePSIC (n = 33). A total of 254 articles were selected for screening of the titles. Of these, 71 were duplicates, 21 addressed non-relevant topics, and 58 were not freely accessible, resulting in 104 publications.
The abstracts of the selected articles were screened to assess whether they met the inclusion criteria, resulting in the selection of 24 articles for reading of the full-text version. The article selection process is summarized in Figure 1:
Figure 1: Flowchart of the article selection process
1. CHARACTERIZATION OF THE ARTICLES
The main study characteristics are shown in Box 1. With regard to year of publication, the years that accounted for the most and least articles were 2019 (6 articles) and 2022 (with only 2 articles), respectively.
Box 1: Characterization of the articles
The articles were published in different national and international journals, with the Revista Ciência & Saúde Coletiva publishing 5 articles 24, 25, 26, 27, 28 and Revista da Abeno (journal published by the Brazilian Association of Dental Education) publishing 3 articles29, 30, 31. Three of the studies published by the Revista Ciência & Saúde Coletiva were conducted with health professionals working with children 24, 27, 28, while the Revista da Abeno published 2 studies with dental graduates29, 30 and 1 with dental surgeons31.
Brazil’s South region accounted for the largest number of publications (9 articles25, 31, 32, 33, 34, 35, 36, 37, 38 plus 2 studies in the South and Southeast29, 39). The North region accounted for only 2 articles 40, 41.
The studies encompassed the areas of education, health, public security, social services, and child protection networks. The area of health accounted for the largest number of studies, with 12 articles 24, 27, 28, 29, 30, 31, 39, 41, 42, 43, 44, 45 plus 2 articles involving both health and social services32, 35. The areas of education36 and public security38 accounted only for 1 article each.
2. THEMATIC CATEGORIES
The similarities between the studies are presented in the following categories: a) factors associated with the identification and reporting of child maltreatment; b) work-related difficulties; and c) deficiencies in professional training.
2.1. FACTORS ASSOCIATED WITH THE IDENTIFICATION AND REPORTING OF CHILD MALTREATMENT
The identification and reporting of suspected or confirmed child maltreatment was one of the central themes of articles. The studies27, 28, 30, 39, 42, 43, 46 reveal that most professionals are not adequately trained to identify violence against children, showing difficulties diagnosing child maltreatment due to lack of theoretical information on the theme and poor knowledge of the child, his/her history, and family relations. Two studies41, 43 reported that professionals diagnose predominantly physical and sexual violence.
Once abuse has been identified, professionals face difficulties in filing a mandated report (MR) of violence to the child protection services. Most professionals showed that they were either unaware of the requirement or did not know how to fill in the form correctly or possible types of referral for victims25, 28, 31, 42, 43. In addition, one of the studies45 found that professionals were unaware of which institution they could refer cases of child maltreatment to.
Some studies24, 29, 44 reveal that when child maltreatment is diagnosed, professionals file a MR, recognizing the importance of this process for protecting the child and resolving the situation. In contrast, other studies show that many professionals undervalue the importance of MR, being skeptical that this type of intervention would help the victim30, 34, 35.
Sometimes professionals failed to file a MR for fear of retaliation by family members, the perpetrator, or the community, or because they were afraid that it would harm the victim given that the child may remain with the perpetrator even after filing a MR due to lack of intervention36, 43, 46.
2.2. WORK-RELATED DIFFICULTIES
Caring for victims of child maltreatment is a complex process. A number of obstacles arise in practice, such as lack of communication between professionals34 and scarce human and material resources, hampering the provision of adequate care. An example is the lack of a computerized system in child protection services, which slows down the intervention process and restricts follow-up, compromising effectiveness40.
Caring for victims of child maltreatment can have an impact on professionals. The studies show that professionals often felt irritable, powerless, sick, and pressured when dealing with cases32, 38, 40, seeing themselves as unable to care for and protect the victim34. In this respect, the existence of professional support networks was seen as a positive factor that can improve interventions to address child abuse46.
Moreover, professional practice is often based on power relations, with some professionals not seeing themselves as responsible for intervening or filing a MR32, 36 and simply passing on the responsibility to colleagues, leading to fragmented and ineffective interventions32.
2.3. DEFICIENCIES IN PROFESSIONAL TRAINING
Twenty of the 24 articles analyzed by this study mentioned deficiencies in professional training and lack of continuous training on child maltreatment. Shortcomings in professional training begin to emerge at degree level, where the topic of child maltreatment is undervalued and often not included in course curriculums28, 29, 31, 33, 42, 45.
Two studies30, 31 show that despite receiving training on child maltreatment during their degree, some professionals do not see themselves as responsible for identifying and reporting the problem. Furthermore, the inclusion of child abuse on undergraduate and postgraduate course curriculums does not necessarily guarantee the adoption of best practices as professionals may feel capable of recognizing violence against children but do not know what to do or how to act31, 45.
Three studies25, 28, 34 highlighted the need for continuous training due to the complex nature of working with victims of child violence, one of which28 mentioned that childcare training and experience with caring for children were factors that facilitated the identification and reporting of violence. Most studies concluded that professional training should encompass protocols for service providers to recognize types of violence and make sure that professionals are prepared to communicate violence and refer cases through the correct channels to protect the victim24, 25, 26, 27, 28, 34, 36, 38, 39, 42, 44, 46, 47.
Professional training is also weak when it comes to network and multidisciplinary approaches. Studies24, 26, 27, 33, 34, 40 show that victim protection is provided by a network of professionals but that actions are fragmented. This hinders the continuity of interventions and solutions, indicating an urgent need to strengthen interdisciplinary working. Studies28 also highlight the need to incorporate a broader and integrative approach to health into professional training to help promote the development of actions in coordination with other assistance services and institutions.
The lack of a protocol of actions or guidelines for the flow of victim assistance also emerged as a weakness in everyday practice35, 44, 46, 47. However, even when guidelines did exist, professionals often failed to follow the guidance24 and observe relevant legal provisions31, 37, creating their own flow within their respective organizations.
DISCUSSION
The analysis of the selected articles shows that professional practices for dealing with violence against children were investigated mainly from a health perspective, with this area accounting for the largest number of publications.
The Child and Adolescent Statute10 provides for mandated reporting of cases of child maltreatment by health and education professionals. The larger number of publications in the area of health demonstrates that health professionals seek a broader understanding of child maltreatment and the intervention process, while the scarcity of studies in the area of education may indicate that professionals in this field pay less attention to this issue.
Dornelles et al.48 highlight that although hospitals and primary care facilities account for the largest number of reports of child maltreatment, many care providers do not know what procedures to follow in cases of maltreatment and fail to file MR, compounding underreporting6, 14, 18.
Most of the selected articles address child abuse in a general manner24, 26, 29, 30, 31, 32, 34, 35, 36, 39, 40, 41, 42, 43, 44, 45, 46, 47 without specifying the type of violence. In the studies that reported type of violence, the most common types were physical27, 28, 37 and sexual25, 33, 38 violence. The literature shows that while there are various types of maltreatment (physical, psychological, sexual, institutional violence, and neglect14, 49), professionals tend to be more aware of physical violence and view it differently as it leaves visible marks on the victim’s body or triggers feelings of disgust, especially in cases of sexual violence, which can have an even greater emotional impact on professionals2.
Research highlights that the victims of sexual violence are predominantly girls2, which is confirmed by some of the studies in our sample25, 33. Researchers stress that while physical violence is more easily recognizable, it is seen as a way of disciplining children, making it a socially acceptable, and often underreported, practice2,50.
With regard to neglect, professionals are largely unaware or fail to identify this type of violence. This is shown by one of the studies29, in which professionals recognized only physical, psychological, sexual violence, and abandonment. In this regard, the literature shows that neglect is the type of maltreatment that professionals find hardest to recognize and value least2, 48.
Some of the studies show that deficiencies in professional training and continuous professional development are a weakness in efforts to combat child maltreatment, highlighting that most professionals did not receive training or information on child maltreatment during their degree29, 31, 42, 45. In this regard, Nilchian et al.51 presented data from a study in Korea showing that nurses with adequate knowledge of violence against children showed higher levels of detection and reporting of abuse.
Weaknesses in professional training pose a barrier to identifying violence and often mean that practitioners are unaware of the existence of child protection services and/or the role they play in child protection, indicating the need to address this issue on degree and specialist training courses 29, 30, 39, 45. One of the articles 36 reported that a pedagogy degree failed to address child maltreatment and violence against women, people with disabilities, and older persons when addressing violence in general.
Other factors that contribute to the detection of child maltreatment include complementary childcare training and experience with caring for children, as shown by one of the studies28. Green52 suggests that limited experience can generate uncertainty, which may make the professional defer suspected cases of child abuse and reporting to colleagues who are usually more experienced or senior in rank. Tiyyagura et al. 53 also reported that one of the barriers to recognition is uncertainty about the diagnosis of maltreatment and fear of wrongly reporting a case.
According to Maia et al.17, a correct diagnosis is essential for the professional to decide the appropriate measures and referral for maltreatment. In this regard, the effective communication of child maltreatment via a MR enables professionals to coordinate actions to ensure the child receives adequate care and assistance10.
Despite being mandatory, it appears that many professionals lack of knowledge of MR, given that they often fill out the form incorrectly or fail to complete it, hampering not only interventions but also the characterization of violence and development of strategies to address the problem2, 14. It is important to highlight that some studies35, 41, 42, 43 showed that many professionals were unaware of or unfamiliar with mandated reporting of child maltreatment or that MR forms were not available in their workplace, making it impossible to communicate violence.
In addition, sometimes professionals do not see themselves as part of the child protection network, deferring the responsibility for reporting to colleagues6, 18. This happens in the case of dental surgeons and nurses, who pass on the decision to file a report to doctors because they do not see themselves as responsible for reporting violence31, 32.
Article 83 of the Child and Adolescent Statute10 provides for the creation of the Sistema de Garantia de Direitos or “rights guarantee system”, which consists of a network of government and non-governmental actors who come together to implement joint actions to promote child defense and assistance9. Child protection therefore involves education, health, social assistance, public security services, and the justice system working together in a planned manner10, 14. However, it is interesting to note that the areas of education36 and public security38 accounted for only one article each in this review and that none of the articles investigated the justice services, indicating possible weaknesses in these areas of the protection network.
The literature9, 14 shows that the child protection network is disjointed, fragmented, and ineffective in preventing child maltreatment, holding perpetrators accountable, and protecting victims. Some of the studies analyzed by this review33, 34, 42, 34 point out that the network faces a number of challenges because it depends on a series of actions coordinated by a range of different professionals, with fragmentation across services hampering the continuity of actions.
Many professionals view the network as an independent institution responsible for receiving referrals and promoting child protection, demonstrating their lack of knowledge of the Sistema de Garantia de Direitos and the role it plays in the protection network11. This lack of knowledge results not only in difficulties in everyday practice, but also the need for multidisciplinary training and development for professionals, prioritizing the coordination of violence prevention actions and harm reduction, as shown by two studies24, 35.
In the same vein, one of the studies reported that the lack of access to or knowledge of identification and reporting protocols represented a weakness in professional practice and that this knowledge can help improve outcomes among maltreated children47. One of the articles30 highlighted that the absence of protocols guiding actions and explaining what to do and how to approach situations of child maltreatment generated uncertainty and undermined legal requirements. On the other hand, gaps between the guidance set out in protocols and actual practice suggest weaknesses in training, as shown by one of the studies24.
Finally, it is worth noting that one of the studies37 suggests that combating violence goes beyond improvements in professional training, also involving parent education and public awareness campaigns. Another study46 highlights that strengthening parent-child relationships and actions that bring together families and communities are factors that facilitate the work of professionals dealing with child violence and promoting child protection.
FINAL CONSIDERATIONS
Despite being the topic matter of integrative reviews3, 17, 18, 19, there is a lack of literature on practices for dealing with violence against children in Brazil. This review therefore provides important new insights into these practices across different professional contexts. Our findings show that practices have been investigated predominantly from the perspective of health professionals, with other areas being underrepresented in the literature, which may hamper the promotion of interdisciplinary working.
The results also show that professional practices have a fragile structure and are marked by deficiencies, indicating that, despite public policies8, 10, 49 designed to protect children, shortcomings in training and lack of professional development hamper the prevention of this type of violence. Professionals whose task it is to protect children are therefore ill-equipped to identify and report child maltreatment, contributing to the underreporting and perpetuation of violence.
The articles analyzed in this review show that most professionals do not follow theoretical or practical guidance, either due to the lack of identification, reporting and care protocols or lack of knowledge/non-compliance with these guidelines when they do exist. Our findings indicate directions for future research, including how violence against children is approached in the curriculums of undergraduate and postgraduate degrees taken by professionals involved in caring for children and further in-depth studies to understand professional practices for dealing with violence against children, identifying initiatives to develop or strengthen protocols that can serve as a frame of reference.
It is also essential to investigate professionals’ perceptions and degree of certainty regarding the reporting of violence as well as the dynamics of the violence that pervades Brazilian society and the consequences for tackling child maltreatment. Finally, it is important to assess how distrust in child protection agencies and the justice system contribute to the underreporting of child maltreatment.
This study contributes to a broader understanding of professional practices for dealing with child maltreatment in Brazil, underlining barriers to comprehensive child protection and the provision of care and assistance that minimizes the suffering of victims and their families. It is important to highlight that given the scarcity of publications in different professional areas, this study focused mainly on articles in the area of health. This is a potential limitation insofar as the sample may not represent a full understanding of professional practices for dealing with violence against children.

Authors’ contributions:
SBP contributed to study conception, data collection, analysis and interpretation, and writing the article.
CD contributed to study conception, data collection, analysis and interpretation, and writing the article, and approved the final version to be published.

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