Prevention of Child Maltreatment and Associated Impairment

Introduction

Child maltreatment encompasses four main types of abuse – physical, sexual, emotional abuse and neglect. More recently, exposure to intimate partner violence has also been identified as a form of child abuse. Child maltreatment is a significant public health and social welfare problem, in both high- and low-income countries and effective methods of prevention have begun to be identified during the past two decades.

Subject

Significant numbers of children experience abuse with prevalence levels varying by maltreatment type, gender and setting.  The most recent review of prevalence studies concluded as follows: (n.b. the median or 50^th percentile in addition to the 25^th to 75^th centile are presented, which means that 50%, 25% and 75% respectively of the values are below these centiles: 

“Sexual abuse is the most commonly studied form of maltreatment across the world with median (25th to 75th centile) prevalence of 20.4% (13.2% to 33.6%) and 28.8% (17.0% to 40.2%) in North American and Australian girls respectively, with lower rates generally for boys. Rates of physical abuse were more similar across genders apart from in Europe, which were 12.0% (6.9% to 23.0%) and 27.0% (7.0% to 43.0%) for girls and boys respectively, and often very high in some continents, for example, 50.8% (36.0% to 73.8%) and 60.2% (43.0% to 84.9%) for girls and boys respectively in Africa. Median rates of emotional abuse were nearly double for girls than boys in North America (28.4% vs 13.8% respectively) and Europe (12.9% vs 6.2% respectively), but more similar across genders groups elsewhere. Median rates of neglect were highest in Africa (girls: 41.8%, boys: 39.1%) and South America (girls: 54.8%, boys: 56.7%) but were based on few studies in total, whereas in the two continents with the highest number of studies, median rates differed between girls (40.5%) and boys (16.6%) in North America but were similar in Asia (girls: 26.3%, boys: 23.8%).¹”

The consequences of such maltreatment are wide-ranging with a significant impact on morbidity and mortality. In the U.S. for example, over 2000 children die due to abuse and neglect every year, with 86% of all maltreatment deaths being under the age of 6 years and 43% being infants less than one year of age.² The long-term consequences for survivors include wide-ranging mental health problems such as depression, drug and alcohol misuse, risky sexual behaviour, and criminal behaviour, all of which continue into adulthood.³ The societal consequences of abuse are also high in terms of both direct (e.g., services to identify and respond to child abuse) and indirect costs (e.g., services to deal with associated problems such as mental health problems; substance misuse; criminality, etc.).³

The high prevalence and serious consequences of child maltreatment point to the importance of effective prevention and treatment programs. Preventive strategies focus on a) primary prevention, which is aimed at intervening before abuse has been identified and utilizes two types of approach – population and targeted; b) prevention of recurrence of abuse after it has been identified; and c) prevention aimed at reducing associated impairment.

Problems

One of the main difficulties associated with identifying what is effective in preventing child maltreatment is a paucity of rigorous research designs that can be applied to the field of assessing program effectiveness. There is also wide variation in the measurement of outcomes and an over-reliance on parental self-report and proxy measures of outcome.  Within low-income countries there is a lack of rigorous research across all types of abuse and prevention levels.  

Research Context

Although child maltreatment is a significant public health problem both in terms of the individual and societal consequences, there is a limited body of research that explicitly addresses prevention, and much of the available evidence focuses on secondary/tertiary (i.e., intervening once abuse has occurred) rather than primary prevention. Similarly, much of the available research within primary prevention focuses on approaches that target high-risk groups as opposed to universal or population-based approaches.

Key Research Questions

The key research questions in relation to the prevention of child maltreatment focus on both the effectiveness and cost-effectiveness of preventive approaches and address the four main types of maltreatment in terms of the different levels of prevention highlighted above. Other questions focus on the specific approaches that are best suited to the different population groups that pose a risk in terms of child maltreatment (e.g., parents with serious mental illness, or who are abusing drugs; or for whom intimate partner violence is the main issue); and whether interventions that have been found to be effective in high-income countries can be translated to low-resource settings, and what cultural adaptation is needed. 

Key Research Results

Part (a) of this section describes evidence-based interventions at the three different levels of prevention referred to above – primary prevention; prevention of recurrence, and prevention of impairment. Part (b) describes possible intervention strategies that go beyond the level of intervention.  

a.   Interventions for prevention 

Primary prevention

There is, to date, limited evidence of the effectiveness of population-based interventions in high-income countries for the prevention of child maltreatment.  One promising intervention appears to be population-based Triple P involving the delivery of Triple P professional training for the existing workforce, in addition to the delivery of universal media and communication strategies.⁴

The research also suggests that a number of targeted primary preventive interventions have potential in high-income countries.  Although home-visiting is not uniformly effective, the Nurse-Family Partnership has been found to have the greatest number of benefits in terms of reducing the risk of child maltreatment.⁵

Other primary preventive approaches that have been shown to have promise in high-income settings include hospital-based educational programs to prevent abusive head trauma, alongside enhanced paediatric care, for families of children at risk of physical abuse and neglect.⁴ Although school-based educational programs appear to be effective in improving children’s knowledge and protective behaviours, it is not currently known how effective they are in preventing sexual abuse.⁶

There is limited evidence available regarding the effectiveness of primary preventive approaches in low- and middle-income countries (LMICs), most of which is focused on middle- rather than low-income settings, and in many cases involves the adaptation of interventions developed in high-income countries.⁷ Promising approaches include home visits (via existing health services; health clinics; or as stand-alone interventions) and group-based delivery (in community settings or work places), by paraprofessionals or professionals, with limited evidence currently of the effectiveness of intervention by lay individuals.⁷ 

Prevention of recurrence

There is also limited evidence available concerning what works to prevent the recurrence of maltreatment.8 Parent-Child Interaction Therapy (PCIT), a behavioural skills training intervention, has been found to be effective in preventing the recurrence of child physical abuse, and home-based training such as SafeCare can also produce small reductions in the recurrence of child maltreatment for preschool children.⁸ There is also some evidence that multisystemic therapy can lead to small reductions in recurrence for children (aged 10-17 years) exposed to physical abuse.⁸ There is no randomized controlled trial evidence available addressing what works to prevent recidivism of the other types of abuse,⁸ or that are effective in LMICs.⁷

Prevention of impairment

The research suggests that the prevention of impairment requires a thorough assessment of the child and family. Evidence regarding the reduction of mental-health problems for maltreated children in high-income countries suggests that psychological interventions, such as cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT), should be considered for children and adolescents who have been exposed to maltreatment and are experiencing emotional disorders, and that trauma-focused CBT should be provided for children who have been sexually abused and are suffering with post-traumatic stress symptoms.⁵ There is also some evidence of the benefit  of child-parent psychotherapy, and trauma-focused CBT for children with intimate partner violence-related post-traumatic stress disorder (PTSD) symptoms.⁵ There is no English language evidence from RCTs currently available regarding the prevention of impairment in children in LMICs. 

For maltreated children who need to be removed from the parental home 

The research shows that in high-income countries, foster care can lead to benefits across a range of domains including antisocial behaviour, sexual activity, school attendance and academic achievement, social behaviour, and quality of life, compared with children who remain at home or who reunify following foster care, and that enhanced foster care can produce even better outcomes in terms of fewer mental and physical health problems.⁴ There is no English language evidence from RCTs currently available regarding  effective alternatives to parental care for maltreated children in LMICs.

b.   Strategies for prevention

The Spectrum of Prevention describes seven levels at which prevention activities can take place, and moves beyond individual services and community education.⁹ It encourages creative and effective prevention projects, and can help communities develop activities that have a greater chance of success as a result of the fact that they complement the strengths that already exist within a community.⁹ 

Research Gaps

More research is needed to identify approaches and strategies that can be used as part of both a primary population-based approach (e.g., available to everyone), and also targeted-approaches (e.g., with high-risk groups) to the prevention of child maltreatment. Population-based strategies include wide-ranging changes to the legal systems that protect children better from the use of aversive parenting methods (e.g., physical punishment), and the application of population-based strategies to the delivery of evidence-based parenting programs (e.g., population-level Triple-P). Further evaluation is needed of the value of targeted approaches such as video-interaction guidance, attachment- and mentalization-based interventions, and parent-infant psychotherapy, all of which are early interventions aimed at improving parent-infant/toddler interaction in high-risk families. 

There is a need for further long-term follow-up particularly of interventions that are delivered during the first three years of a child’s life, and for the use of multi-method and multisource approaches to the assessment of maltreatment.¹⁰ There is also a need for further research into potentially beneficial approaches to the prevention of recurrence and impairment, where once again, the evidence is limited. Such research should build on what is already known about what works. 

Further research is also needed on the effectiveness of programs in LMICs, including the extent to which existing evidence-based programs can be adapted for use within low resource settings, and the possibility of using lay providers to deliver such interventions.⁷ Other research issues in these settings include the need for more complete reporting, increased standardization of outcomes and use of validated measures, and more studies focusing on older children.⁷ Further research is also needed to identify interventions to prevent recurrence and impairment among maltreated children. 

Conclusions

Given the high prevalence of child maltreatment and the serious consequences in terms of its impact on the lives of the individuals concerned, their families, and society more generally, it is important that effective methods of prevention and intervention are identified. Although there is limited research available in terms of what works to prevent child maltreatment, there have been significant gains over the past 20 years in terms of the development of new approaches. 

Implications for Parents, Services and Policy

The research suggests that strategies to prevent maltreatment should begin early and encompass both population-wide approaches that aim to provide pregnant women and parents of new babies with access to wide-ranging universal support (such as population level Triple-P), alongside the provision of targeted approaches (i.e., intensive home visiting such as Nurse-Family Partnership) to families who face additional risks that increase the vulnerability of the baby. Prevention of recurrence and impairment should include the provision of interventions that target parents (post-shelter counseling), the dyad (e.g., parent-infant psychotherapy and PCIT), and child-focused interventions (e.g., school-based educational programs, trauma-focused CBT). Foster care and enhanced foster care programs can also lead to improved outcomes for children.

References

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2. National MCH Center for Child Death Review. http://www.childdeathreview.org/causesCAN.htm. Accessed January 11, 2020.
3. Child Welfare Information Gateway. Long-term consequences of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. 2013. https://homvee.acf.hhs.gov. Accessed December 20, 2018.
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8. WHO guidelines for the health sector response to child maltreatment. Technical report. Geneva, Switzerland: World Health Organization, 2019. https://www.who.int/violence_injury_prevention/violence/child-abuse-guidelines-technical-report/en/. Accessed January 11, 2020.
9. Prevention Institute. The spectrum of prevention: Developing a comprehensive approach to injury prevention. https://www.preventioninstitute.org/publications/spectrum-prevention-developing-comprehensive-approach-injury-prevention. Published August 1999. Accessed January 11, 2020.
10. Skowron E, Reinemann DHS. Effectiveness of psychological interventions for child maltreatment: a meta-analysis. Psychotherapy: Theory, Research, Practice, Training 2005;42:52–71.