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

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

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 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 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)

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

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

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 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

Source: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 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

Prevention

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 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 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 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)

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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 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 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 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 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 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 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

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 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 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 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

Preventing recurrence and impairment

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 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)

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 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)

Evidence from LMIC

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

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.,

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 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

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

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: amilyskillstraining.html 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: Barrera, M., and González-Castro, F. A Heuristic framework for the cultural adaptation of interventions. Clinical Psychology: Science and Practice, 2006, 13, 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: PMID: 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: Cohen JA, Deblinger E, Mannarino AP, Steer RA. A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry 2004; 43: Cohen JA, Mannarino AP, Iyengar S. Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: a randomized controlled trial. Arch Pediatr Adolesc Med. 2011;165(1): Dias MS, Smith K, deGuchery K, Mazur P, Li V, Shaffer ML. Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. Pediatrics 2005;115:e Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK) model. Pediatrics 2009;123: Feder G, Ramsay J, Dunne D, Rose M, Arsene C, Norman R, Kuntze S, Spencer A, Bacchus L, Hague G, Warburton A, Taket A. How far does screening women for domestic (partner) violence in different health- care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technol Assess Mar;13(16):iii-iv, xi-xiii, 1-113, *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.

References Fergusson DM, Grant H, Horwood LJ, Ridder E. Randomized trial of the Early Start Program of home visitation. Pediatrics 2005;116:e803-e9. Geeraert L, Van D, Noortgate W, Grietens H, Onghena P. The effects of early prevention programs for families with young children at risk for physical child abuse and neglect: a meta-analysis. Child Maltreat 2004;9: PMID: doi: / Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;373: Kilburn MR, Karoly LA. The economics of early childhood policy: what the dismal science has to say about investing in children. Santa Monica, CA: Rand Corporation; Klevens J. Prevention of inflicted childhood neurotrauma: what we know, what we dont, and what we need to know. In: Reece R, Nicholson C, eds. Inflicted childhood neurotrauma: proceedings of a multi- disciplinary, modified, evidence-based conference. Elkgrove Village, IL: American Academy of Pediatrics; pp Knerr W, Gardner F & Cluver, L. Parenting and the prevention of child maltreatment in low- and middle-income countries: a systematic review of interventions and a discussion of prevention of the risks of future violent behaviour among boys.,SVRI, 2011 See: Lieberman AF, Van Horn P, Ippen CG. Toward evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence. J Am Acad Child Adolesc Psychiatr 2005;44: Lieberman AF, Ghosh Ippen C, Van Horn P. Child-parent psychotherapy: 6-month follow-up of a randomised controlled trial. J Am Acad Child Adolesc Psychiatr 2006;45: MacMillan HL, Thomas BH, Jamieson E, Walsh CA, Boyle MH, Shannon H, Gafni A. Effectiveness of home visitation by public-health nurses in prevention of the recurrence of child physical abuse and neglect: a randomized controlled trial. Lancet 2005;365: MacMillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. Interventions to prevent child maltreatment and associated impairment. Lancet. 2009;373: Mikton C, Butchart A (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization, 87(5):353–361.

References Olds DL, Sadler L, Kitzman H. Programs for parents of infants and toddlers: recent evidence from randomized trials. J Child Psychol Psychiatry 2007;48: Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Population-based prevention of child maltreatment: the U.S. Triple p system population trial. Prev Sci 2009;10(1):1-12. Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, Busza J, Porter JD.Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet Dec 2;368(9551): Zwi KJ, Woolfenden SR, Wheeler DM, O'brien TA, Tait P, Williams KW. School-based education programmes for the prevention of child sexual abuse. Cochrane Database Syst Rev 2007: