Prevention of Child Maltreatment and
Associated Impairment:
An Evidence-based Overview
Dr Harriet MacMillan
Dr Christopher Mikton
Introduction
• Disclosure information:
Neither of us has any relevant financial
relationships to disclose
Why CMP is a priority for WHO
– Magnitude of the problem
– Life-long and far-reaching
consequences
– Risk factor for other forms of violence
Objectives
•
To review and discuss the scientific
evidence for prevention of child
maltreatment including:
- universal
- selective (targeted)
- indicated (treatment)
•
To explore the implications of this
evidence for low- and middle-income
countries (LMIC)
4
Types of maltreatment
• Definition of CM: "all forms of physical and/or emotional
ill-treatment, sexual abuse, neglect or negligent
treatment or commercial or other exploitation, resulting
in actual or potential harm to the child’s health, survival,
development or dignity in the context of a relationship of
responsibility, trust or power"
•
•
•
•
•
Physical abuse
Sexual abuse
Emotional abuse (psychological abuse)
Neglect
Exposure to intimate partner violence (sometimes
grouped with emotional abuse)
5
Public Health Approach
Implementation
How do you do
it?
Intervention
Evaluation
What works?
Risk Factor
Identification
What’s the cause?
Surveillance
What’s the
problem?
Problem
Response
6
7
Epidemiology of child maltreatment
• WHO global estimates:
– 20% of women and 5-10% of men  sexually abused as children
– 25-50%  physically abused
• Recent high-quality studies in Africa
Prevalence of child maltreatment in Swaziland and Tanzania
Sexual abuse
Physical abuse
Emotional abuse
100
Percenetage %
90
73.5
80
70
71.7
60
50
40
30
20
10
33.3
25.1
29.5
27.9
27.5
23.6
13.4
0
Swaziland (girls)
Tanzania (girls)
Source: Reza et al., 2007; UNICEF/CDC/Muhimbili University, 2011
Tanzania (boys)
Impairment across lifespan
Injury
Affect
regulation
Attachment
Growth
Developmental
delay
Infancy
Anxiety disorders
including PTSD
Mood disorders
Disruptive behaviour
disorders (e.g.
ADHD)
Academic failure
Poor peer relations
Childhood
Conduct disorder
Alcohol abuse
Personality
disorders
Drug abuse
Relationship
problems
Other risk-taking
behaviours
Employment
problems
Recurrent
victimization
Chronic disease
including heart
disease, cancer
Adolescence
Adulthood
10
Child maltreatment as a risk factor
for other types of violence
• Risk factor for involvement in youth
violence
• Risk factor for intimate partner and
sexual violence as victim and
perpetrator
• Risk factor for committing child
maltreatment as a parent
11
Risk factors for child maltreatment
• Lack of parent-child attachment• Parent was maltreated as child
• Lack of adequate legislation • Family breakdown
• Parent misuses drugs or alcohol
•
Tolerance
of
violence
• Social, economic and health policies
that partner
lead to poor
• Intimate
abuseliving standards
• Parentor
is socio-economic
socially isolated inequality
•
Gender
and
social
inequality
in
the
community
• Cultural norms that promote or• Being
glorifysocially
violence,
including physical
punishment
isolated
• Child
was unwanted as a baby
•
Lack
of
services
to
support
families
• Social and cultural norms that diminish
the status
of the
parent-child
relationships
• Breakdown
in support
inchild
childin
rearing
• Child
shows
from extended
symptoms
family
of mental ill• High levels of unemployment
health
Source: World report on violence and health edited by Krug, E. et al. Geneva, World
Health Organization, 2002.
Prevention
Prevention points
Prevention
of
recurrence
Prevention
before
occurrence
Prevention
of
impairment
Physical abuse
Sexual abuse
Emotional abuse
Neglect
Exposure to IPV
Universal
Selected
Long-term
outcomes
Indicated
Interventions
(MacMillan et al., 2009)
Physical abuse and neglect
• Home visitation
– Nurse Family Partnership (NFP) (best)
– Early Start (New Zealand) (promising)
• Parent training programs
– Triple P Positive Parenting Program
(promising)
• Abusive head trauma education
programs (promising)
• Enhanced pediatric care (promising)
15
Physical abuse and neglect
• Home visiting programmes are not
uniformly effective in reducing child
physical abuse and neglect
• Any home visiting programme should
not be assumed to reduce child abuse
and neglect
• Level of evidence: systematic reviews
with RCTs
16
Nurse Family Partnership
• First-time disadvantaged mothers
received home visits by nurses
• Began prenatally and extended until
child’s 2nd birthday
• Nurses promoted 3 aspects of maternal
functioning:
– health-related behaviors
– maternal life course development
– Parental care of children
(Olds et al., 2007)
17
18
Randomized controlled trials
Elmira, NY
1977
Memphis, TN
1987
Denver, CO
1994
N = 400
N = 1,138
N = 735
•
Low-income
whites
•
Low-income
blacks
•
Large portion of
Hispanics
•
Semi-rural
•
Urban
•
Nurse versus
paraprofessional
visitors
Courtesy of David Olds, PhD
19
Nurse Family Partnership
• Reduced child physical abuse and
neglect, as measured by official child
protection reports
• Reduced associated outcomes such as
injuries in children of first-time,
disadvantaged mothers
• Level of evidence: RCTs
20
Early Start
• Reduced associated outcomes such as
injuries and hospital admissions for
child abuse and neglect
• Rates of child protection reports did not
differ between the intervention and
control groups
(Fergusson et al., 2005)
• Replication recommended
• Level of evidence: one RCT
21
Paraprofessional home visitation
• Includes the Hawaii Healthy Start
Program and Healthy Families America
• Have not been shown effective in
reducing child protection reports
• Recent RCTs showed conflicting
evidence with regard to maternal selfreported child abuse
• Level of evidence: RCTs
22
Triple P – Positive Parenting Program
Population-level supports for families
1. use of media/information strategies
2. consultations with parents; seminars
3. consultations with active skills training
4. sessions with skills training, home
visits or clinic observation or group
program
5. augmented version of level 4
(Prinz et al., 2009)
23
Triple P - Positive Parenting Program
• Positive effects on substantiated child
protection services reports, out-of-home
placements, and reports of injuries
• Analysis is not clear
• Further evaluation and replication is
recommended
• Level of evidence: one RCT
24
Abusive head trauma education
• Positive effects from one study suggest
that hospital-based educational
programmes can reduce abusive head
injuries (shaken impact syndrome)
(Dias et al., 2005)
• Level of evidence: cohort study with
historical control; replications underway
25
Enhanced pediatric care
• Program for families at risk
• “Safe Environment for Every Kid”
-special training to identify family
problems and social worker available
• Promising effects suggest that
enhancing physicians’ abilities help
families decrease risk factors
(Dubowitz et al., 2009)
• Level of evidence: one RCT
Sexual abuse
• Unknown if educational programmes
reduce occurrence of child sexual abuse
• Some evidence that they improve
children’s knowledge and protective
behaviours
• Could have some adverse effects
(Zwi et al., 2007)
• Level of evidence: systematic reviews
with RCTs
27
Emotional abuse
Therapeutic counselling
• Attachment-based interventions might
improve insensitive parenting and infant
attachment insecurity
• But there is no direct evidence that
these interventions prevent emotional
abuse
(Bakersman-Kranenburg et al., 2003)
• Level of evidence: RCTs
28
Exposure to IPV
• Most direct way is to prevent the violence
itself – i.e. reduce IPV
• No evidence of any existing programmes for
primary prevention of intimate partner
violence against women and by extension,
children
(Feder et al., 2009)
• Level of evidence: systematic review
29
Preventing recurrence and
impairment
Principles of intervention
• Maltreatment is an exposure not a
disorder
• Outcomes are not exposure-specific; a
wide range of symptoms/disorders are
associated with the five main types of
maltreatment
• It is important to ensure treatment is
not occurring in environment of ongoing
abuse and/or neglect
31
Recurrence of physical abuse and
neglect
• Parent-child interaction therapy (PCIT)
is a behavioural approach to skills
training
• PCIT reduced recurrence of child
protection services reports of physical
abuse but not neglect (RCT)
(Chaffin et al., 2004)
• Nurse home visitation did not prevent
recurrence of physical abuse or neglect
(RCT)
(MacMillan et al., 2005)
32
Recurrence of specific types of
maltreatment
• Insufficient evidence that neglect-specific
interventions reduce recurrence of
neglect
• For sexual abuse, little known about how
to prevent revictimization
• Limited evidence for effectiveness of
interventions for caregivers who
emotionally abuse their children
• For IPV, promising evidence for select
advocacy/empowerment programs for
women
Impairment following sexual abuse
• Evidence for cognitive-behavioural therapy
(CBT) in reducing internalizing and externalizing
symptoms among children with PTSD symptoms
• Programs such as trauma-focused CBT involves
cognitive reframing, positive imagery, parent
management training, problem solving with
educational elements
(Cohen et al., 2004)
• Level of evidence: systematic reviews with RCTs
Impairment following IPV exposure
• Community TF-CBT appears promising in
reducing children’s IPV-related PTSD & anxiety
(Cohen et al., 2011)
• Some evidence for mother–child therapy in
reducing children’s internalizing and
externalizing behaviour problems and symptoms
• Therapy provided to mothers and preschoolers
together with sessions focused on eliciting
trauma play and social interaction
(Lieberman et al., 2005, 2006)
Evidence from LMIC
Evidence mainly from HIC
Source: Mikton, C. Butchart, A. (2009). Child maltreatment prevention: a systematic
review of reviews. Bulletin of the World Health Organization. 87, 353–361
Recent review focusing on LMICs
• Systematic review of parenting interventions for:
– reducing harsh or abusive parenting
– increasing positive parenting practices, attitudes, and
knowledge
– improving parent-child relationships
• Universal and selective
• Conducted in LMIC
• Using RCTs
(Knerr et al., 2011 www.svri.org)
Results
• 12 studies met inclusion criteria
• 9 countries: Brazil, Chile, China, Ethiopia,
Iran, Jamaica, Pakistan, Turkey, South
Africa
• Half home-visiting programmes
• Only 2 had child maltreatment as explicit
goal
• Only 1 indigenous; the others adapted
from other countries or unclear
• None used NFP, Early Start or Triple P
39
Results
• Measures of negative, harsh or abusive
parenting
- 3 studies (Turkey, Iran, and Chile)
- Chile: no cases of abuse in either group
- Turkey and Iran: positive effects, but based
on parent self-reports
• Other outcomes: (parent-child interaction,
parent attitudes and knowledge)
- Most of the studies
- Many more positive effects
40
Results
• Conclusion: "suggests that parenting
interventions in some LMIC can improve
parent child relationships and reduce negative
parenting practices – both of which are
protective factors for child maltreatment"
• However:
– only 1 study used a direct measure of CM
– Most used risk factors for CM
• Nonetheless, shows that RCTs can and have
been conducted in LMIC
Implications for LMIC
Use & adapt evidence-based HIC
programmes or develop anew?
• Weight of opinion: use and adapt
– EB programmes years in making & supported by
body of peer-reviewed scientific research
– Will help to prevent unintended harm
– Include programme theory – how results are
achieved
– Significant $ savings – developing anew costly
• Issues
– Cost of HIC programmes and fee-waivers
– Fidelity-adaptation balance
Fidelity-adaptation balance
• Extensive changes  new programme
• Recommendation  "minor adaptation"
– Keep structure and core elements
– Rigorous evaluation
• Adaptation models, e.g.:
– UNODC:
http://www.unodc.org/unodc/en/prevention/f
amilyskillstraining.html
– "A heuristic framework for the cultural
adaption of interventions“
(Barrera et al., 2006)
Issues to consider when adapting
• Language and literacy
• Diversity in family structure
• Poverty and other pressures
– Need to consider complex intervention?
• Staffing
• Community support and engagement
• Practical considerations
Conclusions
• Case for evidence-based approaches ethical – to do
as much good as possible with scarce resources
"people have been harmed – sometimes on a massive scale – by
failure to prepare and take account of scientifically defensible
reviews of reliable evidence about the effects of interventions"
(Chalmers et al., 2005)
• Evidence-base approaches relatively new, but EB for
CMP fast increasing
• EB for the prevention of violence no worse than for
many other public health problems
• Taking action and generating evidence
References*
•
Bakermans-Kranenburg M, van IJzendoorn MH, Juffer F. Less is more: meta-analyses of sensitivity and
attachment interventions in early childhood. Psychol Bull 2003;129:195-215.
•
Barrera, M., and González-Castro, F. A Heuristic framework for the cultural adaptation of
•
interventions. Clinical Psychology: Science and Practice, 2006, 13, 311-316.
•
Bilukha O, Hahn RA, Crosby A, Fullilove MT, Liberman A, Moscicki E, et al. The effectiveness of early
childhood home visitation in preventing violence: a systematic review. Am J Prev Med 2005;28:11-39.
PMID:15698746
•
Chaffin M, Silovsky JF, Funderburk B. et al. Parent-child interaction therapy with physically abusive
parents: Efficacy for reducing future abuse reports. J Consult Clin Psychol 2004;72:500-10.
•
Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for children with
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•
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•
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•
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*Numerous additional references (for paraprofessional home visitation trials and other systematic reviews, for
example) are listed in the MacMillan et al. Lancet 2009 and the Mikton and Butchart, 2009 Bulletin of WHO
articles.
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