Interventions to prevent child maltreatment and associated impairment

Summary

Although a broad range of programmes for prevention of child maltreatment exist, the effectiveness of most of the programmes is unknown. Two specific home-visiting programmes—the Nurse–Family Partnership (best evidence) and Early Start—have been shown to prevent child maltreatment and associated outcomes such as injuries. One population-level parenting programme has shown benefits, but requires further assessment and replication. Additional in-hospital and clinic strategies show promise in preventing physical abuse and neglect. However, whether school-based educational programmes prevent child sexual abuse is unknown, and there are currently no known approaches to prevent emotional abuse or exposure to intimate-partner violence. A specific parent-training programme has shown benefits in preventing recurrence of physical abuse; no intervention has yet been shown to be effective in preventing recurrence of neglect. A few interventions for neglected children and mother–child therapy for families with intimate-partner violence show promise in improving behavioural outcomes. Cognitive-behavioural therapy for sexually abused children with symptoms of post-traumatic stress shows the best evidence for reduction in mental-health conditions. For maltreated children, foster care placement can lead to benefits compared with young people who remain at home or those who reunify from foster care; enhanced foster care shows benefits for children. Future research should ensure that interventions are assessed in controlled trials, using actual outcomes of maltreatment and associated health measures.

Introduction

The first paper of this Series summarised the nature and consequences of child maltreatment.¹ We review here what is known about approaches to reduce the five major subtypes of child maltreatment: physical abuse, sexual abuse, psychological abuse, neglect, and exposure to intimate-partner violence, and the impairment associated with these experiences. The framework we follow (figure 1) addresses interventions aimed at prevention of maltreatment before it occurs, including both universal and targeted approaches (panel 1), and prevention of recurrence and adverse outcomes associated with maltreatment (panel 2). Efforts to reduce child maltreatment by improving the social, economic, and political environments in which children and families live is beyond the scope of this article; these issues are discussed in the fourth paper in this Series.²

We highlight the relevant processes for designing and evaluating interventions according to the public-health model and as summarised in the 2006 WHO report³ on preventing child maltreatment: define and measure the problem; identify causal, risk, and protective factors; develop and determine effectiveness of interventions; and implement interventions with ongoing monitoring of outcomes. Too often, interventions are implemented before undergoing adequate evaluation—the term “promising” is sometimes misinterpreted as sufficient evidence for widespread dissemination.

When available, we have used good quality syntheses of the literature on maltreatment prevention, ideally a systematic review;⁴ when randomised controlled trials (RCTs) exist, we have not included information from cohort or case–control studies. We have provided more details of studies showing positive effects with higher levels of evidence, or in areas where debate exists about the effectiveness of an intervention.

Key messages

• Home-visiting programmes are not uniformly effective in reducing child physical abuse, neglect, and outcomes such as injuries; those that have shown benefits are the Nurse–Family Partnership (best evidence) and Early Start

• The Triple P—Positive Parenting Program has shown positive effects on maltreatment and associated outcomes, but further assessment and replication are needed

• Hospital-based educational programmes to prevent abusive head trauma and enhanced paediatric care for families of children at risk of physical abuse and neglect show promise but require further assessment

• School-based educational programmes improve children's knowledge and protective behaviours; whether they prevent sexual abuse is unknown

• Parent–child interaction therapy has shown benefits in preventing recurrence of child physical abuse; no interventions have been shown effective in preventing recidivism of neglect

• Preventing impairment associated with child maltreatment requires a thorough assessment of the child and family. Cognitive-behavioural therapy shows benefits for sexually abused children with post-traumatic stress symptoms. There is some evidence for child-focused therapy for neglected children and for mother–child therapy in families with intimate-partner violence

• For maltreated children, foster care placement can lead to benefits compared with young people who remain at home or those who reunify from foster care, and enhanced foster care leads to better mental-health outcomes for children than does traditional foster care

Selection of outcomes is a crucial methodological issue. Official reports are thought to be the most objective assessment of outcome, but represent only the tip of the iceberg.⁵ Conversely, relying solely on caregiver self-reports of behaviour is problematic because of biases due to social desirability and stigma. There is evidence for the reliability and validity of children's self-reports of victimisation,⁶ but much maltreatment is experienced by children too young for self-report. Where possible we have reported objective measures of child and caregiver behaviours and experiences of maltreatment, and have not included studies that rely solely on parental self-reports of abusive behaviour.