1. Prevention of Child Maltreatment and Associated Impairment: An Evidence-based Overview Dr Harriet MacMillan Dr Christopher Mikton

2. Disclosure information: Neither of us has any relevant financial relationships to disclose Introduction

3. Why CMP is a priority for WHO –Magnitude of the problem –Life-long and far-reaching consequences –Risk factor for other forms of violence

4. 4 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)

5. 5 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 childs 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)

6. 66 Public Health Approach Surveillance Whats the problem? Risk Factor Identification Whats the cause? Intervention Evaluation What works? Implementation How do you do it? ProblemResponse

7. 7

8. Epidemiology of child maltreatment

9. 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 Source: Reza et al., 2007; UNICEF/CDC/Muhimbili University, 2011

10. 10 Personality disorders Relationship problems Employment problems Chronic disease including heart disease, cancer Impairment across lifespan InfancyChildhoodAdolescenceAdulthood Injury Affect regulation Attachment Growth Developmental delay Anxiety disorders including PTSD Mood disorders Disruptive behaviour disorders (e.g. ADHD) Academic failure Poor peer relations Conduct disorder Alcohol abuse Drug abuse Other risk-taking behaviours Recurrent victimization

11. 11 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

12. Source: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 2002. Lack of adequate legislation Social, economic and health policies that lead to poor living standards or socio-economic inequality Cultural norms that promote or glorify violence, including physical punishment Social and cultural norms that diminish the status of the child in parent-child relationships Tolerance of violence Gender and social inequality in the community Lack of services to support families High levels of unemployment Lack of parent-child attachment Family breakdown Intimate partner abuse Being socially isolated Breakdown in support in child rearing from extended family Parent was maltreated as child Parent misuses drugs or alcohol Parent is socially isolated Child was unwanted as a baby Child shows symptoms of mental ill- health Risk factors for child maltreatment

13. Prevention

14. Prevention points Physical abuse Sexual abuse Emotional abuse Neglect Exposure to IPV Long-term outcomes Prevention before occurrence Prevention of recurrence Prevention of impairment UniversalSelected Indicated Interventions (MacMillan et al., 2009)

15. 15 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)

16. 16 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

17. 17 Nurse Family Partnership First-time disadvantaged mothers received home visits by nurses Began prenatally and extended until childs 2nd birthday Nurses promoted 3 aspects of maternal functioning: –health-related behaviors –maternal life course development –Parental care of children (Olds et al., 2007)

18. 18

19. 19 Low-income whites Semi-rural Low-income blacks Urban Large portion of Hispanics Nurse versus paraprofessional visitors Elmira, NY 1977 N = 400 Memphis, TN 1987 N = 1,138 Denver, CO 1994 N = 735 Randomized controlled trials Courtesy of David Olds, PhD

20. 20 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

21. 21 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

22. 22 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 self- reported child abuse Level of evidence: RCTs

23. 23 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)

24. 24 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

25. 25 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

26. 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

27. 27 Sexual abuse Unknown if educational programmes reduce occurrence of child sexual abuse Some evidence that they improve childrens knowledge and protective behaviours Could have some adverse effects (Zwi et al., 2007) Level of evidence: systematic reviews with RCTs

28. 28 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

29. 29 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

30. Preventing recurrence and impairment

31. 31 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

32. 32 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)

33. 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

34. 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

35. Impairment following IPV exposure Community TF-CBT appears promising in reducing childrens IPV-related PTSD & anxiety (Cohen et al., 2011) Some evidence for mother–child therapy in reducing childrens 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)

36. Evidence from LMIC

37. Source: Mikton, C. Butchart, A. (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization. 87, 353–361 Evidence mainly from HIC

38. 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)

39. 39 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

40. 40 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

41. 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 Results

42. Implications for LMIC

43. 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

44. 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 http://www.unodc.org/unodc/en/prevention/f amilyskillstraining.html –"A heuristic framework for the cultural adaption of interventions (Barrera et al., 2006)

45. 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

46. 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

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