Prevention of Child Maltreatment and Associated Impairment
Jane Barlow, DPhil; FFPH (Hon)
Warwick Infant and Family Well-being Unit, University of Warwick, United Kingdom
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, particularly in high-income countries1 and effective methods of prevention have begun to be identified during the past two decades.
Significant numbers of children experience abuse. A recent review of prevalence studies concluded that around 4-16% of children are physically abused; 10% are neglected or psychologically abused; 5-10% of girls and 5% of boys are exposed to penetrative sexual abuse, and 3 times more exposed to non-penetrative sexual abuse.1 The consequences of such abuse 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 including drug and alcohol misuse, risky sexual behaviour, and criminal behaviour, all of which continue into adulthood.1 The societal consequences of abuse are also high in terms of the costs, both direct (e.g., services to identify and respond to child abuse) and indirect (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.
One of the main difficulties associated with identifying ‘what works’ to prevent child maltreatment is an absence of rigorous research designs being applied to the field of assessing program effectiveness. There is also wide variation in the measurement of outcomes and an over-reliance on the use of parental self-reports and reports of child behaviour.
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 research 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 focus on both the effectiveness and cost-effectiveness of preventive approaches to child maltreatment, and address the four main types of maltreatment highlighted above in terms of the different levels of prevention. 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 abusing drugs; and parents for whom intimate partner violence is the main issue).
Key Research Results
The research suggests that a range of preventive strategies have considerable potential.
Although home-visiting is not uniformly effective, the Nurse Family Partnership4 and Early Start5 have been shown effective. Standardized parenting programs such as Triple P6 have also shown benefits, but further evaluation is needed specifically with high-risk populations. Hospital-based educational programs to prevent abusive head trauma7 show promise, alongside enhanced paediatric care8 for families of children at risk of physical abuse and neglect. Although school-based educational programs appear to be effective in improving children’s knowledge and protective behaviours,9 it is not currently known how effective they are in preventing sexual abuse.
Prevention of recurrence
There is very limited evidence available concerning what works to prevent the recurrence of abuse. Parent-Child Interaction Therapy (PCIT)10 has shown benefits in preventing recurrence of child physical abuse, but there is no randomized controlled trial evidence available addressing what works to prevent recidivism of the other types of abuse.
Prevention of impairment
The research suggests that the prevention of impairment requires a thorough assessment of the child and family. The best evidence for reduction in mental-health conditions among maltreated children is for cognitive-behavioural therapy (CBT) for sexually abused children with post-traumatic stress symptoms.11 Several interventions show promise: some child-focused types of therapy for neglected children including resilient peer treatment,12 an imaginative play program,13 multisystemic therapy14 and a day treatment intervention.15 There is also some evidence of the benefits of post-shelter counseling intervention for women exposed to intimate-partner violence,16,17 child-parent psychotherapy,18,19 and trauma-focused CBT for children with intimate partner violence-related post-traumatic stress disorder (PTSD) symptoms.20
For maltreated children
The research shows that foster care can lead to benefits across a range of domains including antisocial behaviour,21 sexual activity,22 school attendance and academic achievement,23 social behaviour and quality of life24 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.25
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 abuse. 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 mentalisation-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, and for the use of multimethod and multisource approaches to the assessment of maltreatment.26 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.
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 we identify effective methods of prevention and intervention, and there are some suggestions that a public health approach is now needed.27 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. The strongest evidence available supports the use of specific home visiting and parenting programs as part of targeted and population-based approaches to primary prevention. Much less is currently known, however in terms of approaches for preventing sexual abuse, psychological abuse and children’s exposure to intimate partner violence. Similarly, although there are a broad range of programs being used to prevent recurrence, there is little evidence currently about their effectiveness, and existing evidence-based programs such as PCIT have shown benefits for physical abuse but not neglect. The strongest evidence in relation to impairment is for improving the psychological functioning of children who have experienced sexual abuse where CBT appears to improve outcomes for children showing signs of PTSD, and for a small number of child-focused therapies for children who have experienced neglect. Finally, although out-of-home care is one of the most widely used interventions for maltreated children, there is limited evidence available, which is mostly focused on the benefits of foster care and adaptations of this model.
Implications for Parents, Services and Policy
The research suggests that strategies to prevent maltreatment should begin during pregnancy and encompass both population-wide approaches that aim to provide pregnant women/parents and 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 parent-child interaction therapy), and child-focused interventions (e.g., school-based educational programs, trauma-based CBT and CBT on its own, play therapy, multisystematic therapy, resilient peer programs and (enhanced) foster care.
This paper is based on the following publication: MacMillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. Interventions to prevent child maltreatment and associated impairment. Lancet 2009; 373(9671): 250-266.
- Gilbert R, Spatz Widom C, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet 2009; 373(9671):68-81.
- National MCH Center for Child Death Review. Available at: http://www.childdeathreview.org/causesCAN.htm. Accessed November 7, 2011
- American Academy of Experts in Traumatic Stress. Available at: http://www.aaets.org/article185.htm. Accessed November 7, 2011
- Olds DL, Eckenrode J, Henderson CR Jr, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA 1997;278:637–43.
- Fergusson DM, Grant H, Horwood LJ, Ridder EM. Randomized trial of the Early Start program of home visitation. Pediatrics 2005;116:e803–09.
- Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Population–based prevention of child maltreatment: the US Triple P system population trial. Prev Sci 2009;10(1):1-12.
- Dias MS, Smith K, DeGuehery K, et al. Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. Pediatrics 2005;115:e470–77.
- 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(3):858-64.
- 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;2:CD004380.
- 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.
- Macdonald GM, Higgins JP, Ramchandani P. Cognitive-behavioural interventions for children who have been sexually abused. Cochrane Database Syst Rev 2006;4:CD001930.
- Fantuzzo J, Sutton-Smith B, Atkins M, et al. Community-based resilient peer treatment of withdrawn maltreated preschool children. J Consult Clin Psychol 1996;64:1377–86.
- Udwin O. Imaginative play training as an intervention method with institutionalised preschool children. Br J Educ Psychol 1983;53:32–39.
- Brunk M, Henggeler SW, Whelan JP. Comparison of multisystemic therapy and parent training in the brief treatment of child abuse and neglect. J Consult Clin Psychol 1987;55: 171–78.
- Culp RE, Little V, Letts D, Lawrence H. Maltreated children’s self-concept: effects of a comprehensive treatment program. Am J Orthopsychiatry 1991;61:114–21.
- Sullivan CM, Bybee DI. Reducing violence using community-based advocacy for women with abusive partners. J Consult Clin Psychol 1999; 67: 43–53.
- Bybee D, Sullivan CM. Predicting re-victimization of battered women 3 years after exiting a shelter program. Am J Community Psychol 2005;36:85–96.
- 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 Psychiatry 2005;44:1241–48.
- Lieberman AF, Ghosh Ippen C, Van Horn P. Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2006;45:913–18.
- Cohen JA, Mannarino AP, Iyengar S. Community treatment of Post-Traumatic Stress Disorder for children exposed to intimate partner violence. Arch Pediatr Adolesc Med 2011;165(1):16-21.
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- Davidson-Arad B, Englechin-Segal D, Wozner Y. Short-term follow-up of children at risk: comparison of the quality of life of children removed from the home and children remaining at home. Child Abuse Negl 2003;27:733–50.
- Kessler RC, Pecora PJ, Williams J, et al. Effects of enhanced foster care on the long-term physical and mental health of foster care alumni. Arch Gen Psychiatry 2008;65:625–33.
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How to cite this article:
Barlow J. Prevention of Child Maltreatment and Associated Impairment. In: Tremblay RE, Boivin M, Peters RDeV, eds. MacMillan HL, topic ed. Encyclopedia on Early Childhood Development [online]. http://www.child-encyclopedia.com/maltreatment-child/according-experts/prevention-child-maltreatment-and-associated-impairment. Published February 2012. Accessed October 21, 2019.