Interventions for families with complex needs

Interventions for families with complex needs, in which children and young people have experienced abuse and neglect An Evidence Check rapid review brokered by the Sax Institute for NSW Kids and Families. October 2015.

An Evidence Check rapid review brokered by the Sax Institute for NSW Kids and Families. October 2015. This report was prepared by: Michelle Macvean, Gina-Maree Sartore, Aron Shlonsky, Bianca Albers, Robyn Mildon October 2015 © Sax Institute 2015 This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusions of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the copyright owners. Enquiries regarding this report may be directed to the: Manager Knowledge Exchange Program Sax Institute www.saxinstitute.org.au [email protected] Phone: +61 2 91889500 Suggested Citation: Macvean M, Sartore GM, Shlonsky A, Albers B, Mildon R. Interventions for families with complex needs, in which children and young people have experienced abuse and neglect: an Evidence Check rapid review brokered by the Sax Institute (www.saxinstitute.org.au) for NSW Kids and Families, 2015.

Acknowledgements: We thank Ben Devine, Natalie Pill, and Sophia Spada-Rinaldis for their contributions to the report. Disclaimer: This Evidence Check Review was produced using the Evidence Check methodology in response to specific questions from the commissioning agency. It is not necessarily a comprehensive review of all literature relating to the topic area. It was current at the time of production (but not necessarily at the time of publication). It is reproduced for general information and third parties rely upon it at their own risk.

Interventions for families with complex needs, in which children and young people have experienced abuse and neglect: a review of systematic reviews

An Evidence Check rapid review brokered by the Sax Institute for NSW Kids and Famlies. October 2015. This report was prepared by Michelle Macvean, Gina-Maree Sartore, Aron Shlonsky, Bianca Albers, Robyn Mildon

Contents 1 Key definitions ............................................................................................................................................................................. 6 2 Executive Summary .................................................................................................................................................................... 9 2.2. Objective ................................................................................................................................................................................ 9 2.3. Methods ................................................................................................................................................................................. 9 2.4. Results..................................................................................................................................................................................... 9 2.5. Implications of the review findings ............................................................................................................................. 10 2.6. Next steps ........................................................................................................................................................................... 11 3 Introduction ............................................................................................................................................................................... 12 3.1. Background ........................................................................................................................................................................ 12 3.1.1. Overview ........................................................................................................................................................................ 12 3.1.2. Extent of the problem................................................................................................................................................ 12 3.1.3. Supporting families with complex needs............................................................................................................. 14 3.2. Purpose of this review of reviews ................................................................................................................................ 14 3.3 Structure of this report .................................................................................................................................................... 15 4 Methodology............................................................................................................................................................................. 16 4.1. Search strategy.................................................................................................................................................................. 16 4.2. Study selection .................................................................................................................................................................. 16 4.2.1. Inclusion criteria .......................................................................................................................................................... 16 4.2.2. Exclusion criteria.......................................................................................................................................................... 17 4.2.3. Systematic review criteria ......................................................................................................................................... 17 5 Results ......................................................................................................................................................................................... 18 Table 1: Systematic and non-systematic reviews included in the review of reviews ......................................... 18 5.1. Summary of the included reviews ............................................................................................................................... 20 5.1.1. Interventions covered in the reviews .................................................................................................................... 20 5.1.2. Populations covered in this review ........................................................................................................................ 23 5.1.3. Study designs included in the reviews ................................................................................................................. 23 5.1.4. Outcomes covered in the reviews.......................................................................................................................... 23 5.2. Findings of the included reviews ................................................................................................................................. 24 5.2.1. Working with families ................................................................................................................................................ 24 5.2.2. Working with children and young people in foster care and kinship care................................................ 28

6 Discussion................................................................................................................................................................................... 32 6.1. Summary of evidence...................................................................................................................................................... 32 6.2. Gaps in the evidence ....................................................................................................................................................... 33 6.3. The broader context of abuse and neglect .............................................................................................................. 36 6.4. Implications of the review findings ............................................................................................................................. 38 6.5. Limitations of this review ............................................................................................................................................... 38 6.6. Next steps ........................................................................................................................................................................... 39 7 References .................................................................................................................................................................................. 40 8 Appendices ................................................................................................................................................................................ 43 Appendix A: Review of reviews ............................................................................................................................................ 43 1. Search terms used to identify studies in PsycINFO................................................................................................ 43 2. Flowchart of studies through the selection process .............................................................................................. 44 3. Number of studies included in the 17 reviews ........................................................................................................ 45 4. Excluded studies ............................................................................................................................................................... 45 Appendix B: Review of reviews............................................................................................................................................. 50

SAX INSTITUTE | INTERVENTIONS FOR FAMILIES WITH COMPLEX NEEDS 5

1 Key definitions Child maltreatment

Maltreatment of children and young people is any non-accidental behaviour

(child abuse and neglect)

by parents and caregivers (or other adults or older adolescents) which is outside generally accepted norms of conduct, and which constitutes a significant risk of causing physical and/or emotional harm to the child or young person. While not accidental, such behaviours need not be intended to cause harm. Maltreatment includes acts of omission (neglect) and commission (abuse). Forms of maltreatment include neglect and any form of abuse: physical, sexual and emotional abuse, psychological harm, exploitation, and failure to adequately meet the child’s needs. Source: NSW FACS Mandatory Reporter guidelines (www.community.nsw.gov.au/kts/guidelines/documents/mandatory_reporter_guid e.pdf) ; Child Welfare Information Gateway (www.childwelfare.gov); Australian Institute of Family Studies (www3.aifs.gov.au/cfa/publications/what-child-abuseand-neglect); World Health Organisation (www.who.int/topics/child_abuse/en)

Domestic and family

Domestic abuse occurs when one person in an intimate relationship attempts

violence

to dominate and control the other. Domestic violence includes more than physical abuse; it can take many forms including emotional, economic, social, spiritual and sexual abuse. Domestic and family violence occurs in all age ranges, ethnicities, socio economic strata, and occurs in both heterosexual and same-sex relationships. The Federal Circuit Court of Australia lists common forms of violence: spouse/partner abuse (violence among adult partners and ex-partners) child abuse/neglect (abuse/neglect of children by an adult) parental abuse (violence perpetrated by a child against their parent), and sibling abuse (violence between siblings). Retrieved from: www.federalcircuitcourt.gov.au/wps/wcm/connect/fccweb/home/search?query=fa mily+law&collection=agencies&form=simple&profile=fcc

Family preservation

Family preservation interventions and services are intended to avoid placement of children and young people into out-of-home care by ensuring child safety and improving family functioning and parenting practices. Preservation services are short-term and family-focused; intensive family preservation services are shorter, more intense, and are generally crisisfocused. Source: Child Welfare Information Gateway (www.childwelfare.gov)

6 INTERVENTIONS FOR FAMILIES WITH COMPLEX NEEDS | SAX INSTITUTE

Outcome

An outcome is defined as a measurable change or benefit to a child or other family member. It may be either an increase in a desired behaviour (for example, improved parenting practice) or a decrease in an undesired behaviour (such as reduced child protection notifications). Target outcomes are the outcomes that an intervention aims to prevent, reduce, or improve. Outcomes may be focused on the child, parent, whole family or service providers.

Out-of-home care

Out-of-home care is the care and control of a child or young person at a place other than their usual home by a person that is not their parent. It includes care and control under an order of the Children’s Court or when they are a protected person for more than 14 days or for a total of more than 28 days in any 12-month period. Types of out-of-home care include but are not limited to foster care, kinship care, residential care and group homes. Source: Out-of-home Care Draft Service Provision guidelines. Retrieved from: www.community.nsw.gov.au/docs_menu/for_agencies_that_work_with_us/our_fun ding_programs/out_of_home_care_services.html

Placement prevention

Placement prevention refers to services and interventions designed to prevent placement of children and young people into out-of-home care or care outside the family home. Placement prevention programs may operate at varying levels of intensity and support, but have in common the aim of supporting families to prevent problems from escalating, and to reduce the likelihood of children and young people entering or remaining in out-ofhome care. This includes any care provided outside of the family home environment including involuntary (where there is a court order requiring a child to live out of their parents’ care) or voluntary (where there is no such court order) care. Source: NSW Department of Community Services (www.community.nsw.gov.au)

Reunification/restoration

Reunification is a planned process intended to return a child safely to their family of origin after a period of out-of-home care, and allowing them to remain there in the long term. Wherever it is in the child or young person’s best interest, planning for family reunification is part of planning for children in out-of-home care. Source: Victorian Department of Human Services (www.dhs.vic.gov.au)

Risk of significant harm

Risk of significant harm (ROSH) is the threshold for statutory intervention in NSW. It can result from a single act or omission, or cumulative acts or omissions. Assessing ROSH involves determining if circumstances causing concern for the safety, welfare, or wellbeing of a child or young person are present to a significant extent. ROSH is assessed against the following broad categories: physical abuse, neglect, sexual abuse, psychological harm, danger


to self or others, relinquished care, carer concern, unborn child. ROSH criteria specify when mandatory reporting responsibilities are activated. Source: NSW Department of Community Services (www.community.nsw.gov.au)

Poly-victimisation

Poly-victimisation refers to lifetime exposure to repeated and varied victimisation experiences, particularly in early childhood. It is a strong predictor of distress and traumatic symptoms in children. Source: Finkelhor, Ormrod (1)


2 Executive Summary 2.1. Overview This report details a review of systematic reviews of interventions for families with complex needs where a child has been exposed to maltreatment. The review was commissioned by NSW Kids and Families in order to assist the NSW health Child Protection Counselling Services (CPCS) in its continuing efforts to improve services. It specifically includes studies testing programs or services that address physical abuse or neglect, or that were applied in settings where children have been exposed to domestic and family violence (DFV). Due to its coverage elsewhere, sexual abuse is not included in this report, except in instances where children have experienced sexual abuse in combination with other forms of maltreatment. The broader family, social and community context of maltreatment and delivery of interventions to families with complex needs is considered. 2.2. Objective The purpose of this review was to draw together the findings of systematic reviews that have examined the evidence for interventions where children have been exposed to maltreatment or DFV. The aim of this is to provide an overview of which interventions have the best evidence for improving child wellbeing, health and safety outcomes and to report the reliability of these findings. 2.3. Methods A systematic search of 12 electronic databases was conducted to identify systematic reviews of interventions delivered to children and/or families where the child has been maltreated, where there has been DFV, or where the child is in out-of-home care (OOHC). A set of predetermined criteria was used to assess if the identified reviews were systematic or not. 2.4. Results Fourteen systematic reviews were identified. An additional three reviews that did not meet the systematic review criteria were also included because they covered populations and/or interventions that were not covered in the other 14 reviews. The findings of this review of reviews suggest that there is little clear, strong evidence for interventions for improving the safety, welfare and wellbeing outcomes for children exposed to physical abuse and neglect. There have been large numbers of evaluations of interventions for families with complex needs where a child has been maltreated, and many of these have been covered in systematic reviews, as summarised in the current review. Many of these evaluations, however, have been excluded from systematic reviews, possibly because of methodological shortcomings. Other interventions will have been included in systematic reviews but were found to have little or no effect on the outcomes of interest to the review, or they were found to use flawed methodology and the findings were not reliable.


Despite these shortcomings in the evidence, the systematic review authors were able to identify some interventions and approaches that have better evidence. Specific interventions that were found in this review to have possible benefit for improving some outcomes for children and young people included: Keeping Foster and Kinship Parents Trained and Supported, SafeCare, Parent-Child Interaction Therapy, and Multisystemic Therapy. Benefits were found for a range of outcomes such as reducing re-reports of physical abuse, and improving child mental and behavioural health, child psychopathology, healthy caregiver-child relationships, permanency, child safety, and family factors. Not all benefits were observed for all of the interventions referred to here. A specific intervention for children and young people in foster care (Treatment Foster Care) that also has a generic aspect in that its review synthesised several similar but distinct programs under the same name, also had some evidence of benefit for child outcomes. Rather than reporting on specific interventions, some reviews commented on groups of interventions. The broad groups of interventions that appear to have some positive impact include: behavioural and nonbehavioural psychological treatments, parenting programs, home visiting programs, kinship care, intensive family preservation services, and proactive multi-component interventions. The outcomes for which some improvements were seen included: prevention and reduction of OOHC placements, detection and prevention of maltreatment, improved parenting skills, and improved child, parent, and family functioning. All of the interventions identified were found to have a strong focus on families and parenting, including those delivered in foster care settings, and were more likely to focus on parents and families than on the individual child. 2.5. Implications of the review findings Given the complexity of families experiencing maltreatment, it is unsurprising that there are few rigorous evaluations and fewer systematic reviews; research in this area is also complex. Within this limited scope of research, few interventions with strong indications of effectiveness were found. Perhaps one of the reasons for the lack of evidence for single interventions is that working with families with complex needs requires complex solutions. Multicomponent interventions targeting several family members, addressing several issues, delivered in multiple modes and settings may address the multiple problems experienced by families with complex needs where children have been maltreated. A whole system response, taking into account the entire family and the social and community context, is warranted. Several of the reviews included here reported on outcomes that were not directly related to child safety or child protection. In fact, many included outcomes related to parenting, parent-child relationships, and parent stress. Outcomes such as parent and family functioning are closely related to child abuse and neglect outcomes. Parenting programs, of which some have good evidence in their favour, present core parenting principles that may be transferable to different family contexts. Adopted in conjunction with other more targeted approaches to address other issues experienced by families with complex needs, such as substance abuse, these parenting interventions may help to address some of the basic parent-child concerns that contribute to risk of maltreatment.


2.6. Next steps While the evidence reviewed here does not point to a clear direction to take when selecting interventions for families with complex needs where there has been child abuse and neglect, there are some considerations that may guide future work in this area: • •

Engage in further discussion about service context and needs, in light of these findings Look deeper into the interventions identified in this review that appear to show promise

•

Consider the wider scope of intervention options for families with complex needs, beyond those specifically targeting maltreated populations

•

Consider which outcomes are of key importance in these families – perhaps interventions targeting more general parent-child interaction, family functioning and child behaviour could be suitable options

•

Consider multicomponent and multiple intervention options that take into account the broader family, community and society context

•

Consider the accessibility of interventions: those delivered entirely or partially in group mode may be impractical for families who are not inclined to leave their homes; however interventions evaluated in group format may have limited evidence of effectiveness when delivered to individual families in the home.


3 Introduction 3.1. Background 3.1.1. Overview This report details a review of systematic reviews of interventions for families with complex needs where a child or young person has been exposed to maltreatment. The review was commissioned by NSW Kids and Families in order to assist the NSW health Child Protection Counselling Services (CPCS) in its continuing efforts to improve services. It specifically includes studies evaluating programs or services that address physical abuse or neglect, or that were applied in settings where children or young people have been exposed to domestic and family violence (DFV). Due to its coverage elsewhere, sexual abuse is not included in this report, except in instances where children and young people have experienced sexual abuse in combination with other forms of maltreatment. 3.1.2. Extent of the problem Child abuse and neglect is a significant social problem around the world. (2) Maltreatment of children and

young people is any non-accidental behaviour by parents and caregivers (or other adults or older adolescents) which is outside generally accepted norms of conduct, and which constitutes a significant risk of causing physical and/or emotional harm to the child or young person. While not accidental, such behaviours need not be intended to cause harm. Maltreatment includes acts of omission (neglect) and commission (abuse). (3) In this report, “child maltreatment” encompasses child abuse and neglect. Child maltreatment and related concerns are commonly divided into five main subtypes: physical abuse; emotional maltreatment; neglect; DFV, sexual abuse; and the witnessing of family violence. As well as the five main subtypes of child maltreatment and related concerns, researchers and legislative bodies have identified other types and subtypes, including: foetal abuse (i.e., behaviours by pregnant mothers that could endanger a foetus, such as the excessive use of tobacco, alcohol or illicit drugs); bullying or peer abuse; sibling abuse; witnessing community violence; institutional abuse (i.e., abuse that occurs in institutions such as foster homes, group homes, child care centres, and voluntary organisations such as the Scouts); organised exploitation (e.g., child sex rings, child pornography, child prostitution); and state-sanctioned abuse (e.g., female genital mutilation in parts of Africa, the "Stolen Generations" in Australia). (3) Although distinguishing between subtypes can be helpful in identifying and understanding the particular type of abuse, it can be misleading in that it creates the impression that strong lines of demarcation exist between the subtypes and that they occur in isolation (3) when, in fact, they can co-occur and many children and young people experience more than one form of maltreatment over time. Child protection statistics are the best available indicator of the extent of the problem of child abuse and neglect in Australia. However, they do not reveal with accuracy how many children and young people in the community have experienced abuse or neglect and are perceived as a conservative estimate of the occurrence of child maltreatment. (4) Of the total number of notifications to child protection services in 2013–14 (304,097), 137,585 cases (involving 99,210 children) of child abuse were investigated. Of these investigations, 127,614 (93%) were finalised by 31 August 2014 and 54,438 cases were substantiated. (5) Substantiations are categorised into one of four harm types: emotional abuse, neglect, physical abuse and


sexual abuse. Nineteen percent of substantiations of harm/risk of harm were related to physical abuse, 28% to neglect, 14% to sexual abuse and 39% to emotional abuse, which includes children and young people who have witnessed domestic violence. (5, pg. 72) In NSW in 2013–14, 109,583 children and young people were involved in at least one child protection report. There were 265,071 such reports made in total in that year, and a similar pattern was seen in the two preceding years; therefore many children and young people are involved in more than one child protection report in a given year. (6) Of these children and young people, 73,678 were assessed as being at risk or significant harm (ROSH). (6) Within NSW, only those cases reported to the Child Protection Helpline that meet the threshold for Risk of Significant Harm (ROSH) are referred to a Community Services Centre (CSC) for further assessment. Only children and young people who proceed to the secondary (face to face) assessments can have their cases substantiated, and this happens in only approximately 30% of cases meeting ROSH criteria. Sixty percent of Aboriginal children and young people and 75% of non-Aboriginal children and young people in NSW who were assessed to be at ROSH were not seen by a case worker for a full assessment. (7) These were likely to be the lower risk cases, but only in comparison to children and young people assessed to be at the highest risk at initial screening by a CSC. Thus, there is a large number of children and young people and families who technically meet the criteria for a full child protection services assessment but who are not seen in a face to face visit. However, these children and young people and their families may be seen by a range of providers in NSW. There is some evidence that more children at ROSH are receiving services and some of these services may prevent them from going into out-of-home care (OOHC). (7) In order to further these modest improvements, identifying interventions in the extant literature that have been demonstrated to be effective in improving the health, safety and wellbeing outcomes for children in families with complex needs could provide important assistance to agencies and service providers who work with children and young people who are highly likely to have experienced some form of abuse or neglect. Child abuse and neglect may lead to a wide-range of adverse consequences for children and adolescents across all domains of development — physical, psychological, emotional, behavioural, and social — all of which are interrelated. (8) Adverse consequences identified in the research literature include attachment and interpersonal relationship problems; learning and developmental problems; mental health problems (such as depression, anxiety, eating disorders and post traumatic stress disorder); self-harm; increased rates of suicidal ideation and attempted suicide; higher levels of substance use; behavioural problems (including internalising and externalising problems); physical health problems; increased violence and criminal activity; risk-taking behaviours; increased rates of risky sexual behaviours and teenage pregnancy; homelessness and housing instability; and death as a result of fatal abuse. (8) Exposure to DFV is often considered to be a form of child abuse (9), but there is a great deal of controversy surrounding this designation. NSW considers it a risk factor, not a form of actual maltreatment, and it is unclear whether child protection approaches are designed to adequately contend with the issues surrounding DFV. (10) Australian statistics (11) indicate that 54% of women experiencing violence perpetrated by their current partner were caring for children at the time. The witnessing of DFV may place children and young people at higher risk of ongoing emotional, behaviour, health, cognitive and social problems (12-17) than children who have not been exposed to these acts. In addition, being in a household


or family where there is violence may place children and young people at increased risk of physical, sexual and emotional abuse. (18) 3.1.3. Supporting families with complex needs Selecting suitable services and supports for families with complex needs where the child or young person has been maltreated is a complicated matter. Harm to children and young people has long been thought of as being influenced by various interrelated social and ecological factors within the individual, family, community and broader culture as described by Belsky, (19) building on the works of Bronfenbrenner (20) and Burgess. (21) What happens to one member of a family or within one family relationship does not occur in isolation. Problems experienced by one family member impact other family members, and likewise, interventions affecting one person also impact others. Families involved in the child protection or child welfare system therefore usually have multiple and interrelated complex problems involving multiple family members, including DFV, substance misuse, and mental health issues. Many families with complex needs are also experiencing additional social challenges, such as poor child and maternal health, past experiences of trauma, homelessness or unstable accommodation, poverty and social isolation, and disconnection of young people from families, schools and communities. (22) For example, it is estimated that child abuse and neglect co-occurs in 30–50% of families where there is DFV (e.g., 12, 23, 24). Research on poly-victimisation by Finkelhor, Ormrod (1) shows a linear relationship between the number of childhood adversities including child abuse, DFV, peer bullying and property crime, and the level of adverse outcomes for children and young people. A broad array of interventions, services, programs and practices exists in the service systems that support these families; all with varying purposes, target populations, methods of delivery and content. Interventions may be aimed at supporting parenting skills, assisting children and young people to recover physically and psychologically from their trauma, preventing further maltreatment, preserving or restoring families, or supporting carers in situations where the child has been removed from the family. Regardless of the specific objectives, service providers should be encouraged to choose interventions for families that have the best chance of improving parent and, ultimately, child outcomes. 3.2. Purpose of this review of reviews Identifying a strong evidence base is critical when selecting and implementing interventions. While not all interventions will have been evaluated, it is important to understand the comparative benefits and pitfalls, where reported, of evaluations of interventions. The most rigorous method for doing this is through the use of systematic reviews, which systematically locate and synthesise (statistically, where possible) the literature while attempting to control for known biases. Several systematic reviews exist in relation to interventions with families with complex needs and in relation to the abuse and neglect of children and young people. These systematic reviews identify what can be considered the best evidence that can be located for interventions contending with the effects of maltreatment or the risk of maltreatment. The purpose of this review of systematic reviews was to draw together the findings of these systematic reviews in order to provide an overview of which interventions have the best evidence for improving specific outcomes and to report the reliability of these findings.


3.3 Structure of this report The following section of this report outlines the methodology involved in this review of systematic reviews. Next, the included reviews are named and described. Populations and interventions covered by the systematic reviews are reported first, followed by details of the systematic review findings. The final section of the report draws together the findings, and discusses some of the broader contextual issues associated with the intervening with families with complex needs. Limitations and concluding remarks close this review of reviews.


4 Methodology 4.1. Search strategy This review involved a systematic search and selection process to identify systematic reviews of interventions for families with complex needs where the child or young person has been maltreated. The following electronic databases were searched: • •

PsycINFO Medline(R)

•

Embase Classic + Embase

• •

Social Work Abstracts Education Resources Information Centre (ERIC)

• •

Applied Social Sciences Index and Abstracts (ASSIA) Sociological Abstracts

• •

Social Services Abstracts Cumulative Index to Nursing and Allied Health Literature (CINAHL)

• •

Criminal Justice Abstracts The Cochrane Collaboration Library

•

The Campbell Collaboration Library.

Search terms were designed to identify interventions for children and young people exposed to a range of maltreatment types, including DFV. Search terms for OOHC were also used, as were terms designed to identify systematic reviews. Refer to Appendix A for complete search terms. To identify potential unpublished systematic reviews, the following websites were searched: • •

EPPI Centre – eppi.ioe.ac.uk/cms/ AHRQ Agency for Healthcare Research and Quality – www.ahrq.gov/index.html

Recommendations from content experts on the research team were also considered for inclusion in this review of reviews. 4.2. Study selection All database search results were exported into Endnote and duplicate references were removed. Titles and abstracts were read to determine suitability for inclusion in the review. Where this could not be determined, full text copies of the potential systematic reviews were read. Full text of the website search results and reviews recommended by experts were also read. Selection criteria follow. 4.2.1. Inclusion criteria This review included systematic reviews (see below for further criteria) of interventions, programs, practices, models, therapies, or treatments (referred to here as interventions) for children, young people, parents, families, and/or carers. These interventions were for children and young people who had been exposed to maltreatment (physical abuse or neglect) or DFV; or for children and young people in OOHC since a high


proportion of children in OOHC in NSW are likely to have been exposed to maltreatment. Interventions for children and young people exposed to multiple forms of maltreatment were eligible for inclusion (polyvictimisation). Only English language reviews were included, and there was no restriction on publication year. 4.2.2. Exclusion criteria This review did not include reviews that were solely about interventions for children and young people exposed to sexual abuse, or where children or young people were in residential care due to severe behavioural, health or other concerns. Sexual abuse and residential care are not services covered by the funder of this review and these populations were out of scope for their purposes. Books, chapters, theses and conference presentations were not included. 4.2.3. Systematic review criteria To ensure that the included reviews involved a level of rigour that is typically associated with systematic reviews, all reviews that appeared to be relevant were assessed to determine if they met the following criteria: •

The review addressed a clearly designed research question;

• •

There was an a priori search strategy and clearly defined inclusion and exclusion criteria; A minimum of three academic databases were searched;

•

Grey (unpublished) literature was specifically searched for; and

•

More than one rater/coder was used.


5 Results After removal of duplicate studies, 1089 papers were screened for inclusion in this review. Of these, fourteen systematic reviews of interventions relevant to families with complex needs where the child or young person had been maltreated were included. Additional reviews on this topic were identified, however they did not meet the aforementioned systematic review criteria and are included in the list of excluded studies (Appendix A). For reviews that were found to be somewhat systematic, but did not meet all of the above criteria, suitability was discussed amongst the research team. If these reviews included an intervention or population that was not covered in one of the systematic reviews that met the quality criteria, then the review was included. Three such reviews were identified in which grey literature searches were not conducted, and in the case of Roberts & Everly (25), only one rater or coder was used. The findings of these reviews should be considered with caution. Table 1 lists the 14 included systematic reviews, and three reviews that met some but not all of the systematic review criteria. Note that one Cochrane Collaboration publication (26) and one journal publication (27) were identified for the same systematic review. These two publications are considered here as one review. Refer to Appendix A for a list of studies excluded at full text screening stage, including reasons for exclusion. A flow chart of the study selection process is also included in Appendix A. Table 1: Systematic and non-systematic reviews included in the review of reviews Included reviews (n = 17) Systematic reviews (n = 14) Barlow J, Johnston I, Kendrick D, Polnay L, Stewart-Brown S. Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database of Systematic Reviews [Internet]. 2006; (3). doi: 10.1002/14651858.CD005463.pub2 Barlow J, Simkiss D, Stewart-Brown S. Interventions to prevent or ameliorate child physical abuse and neglect: Findings from a systematic review of reviews. Journal of Children's Services. 2006;1(3):6-28. Bronson DE, Saunders S, Holt MB, Beck E. A systematic review of strategies to promote successful reunification and to reduce re-entry to care for abused, neglected, and unruly children. The Ohio State University, College of Social Work, 2008. Everson-Hock E, Jones R, Guillaume L, Clapton J, Goyder E, Chilcott J, et al. The effectiveness of training and support for carers and other professionals on the physical and emotional health and well-being of lookedafter children and young people: A systematic review. Child: Care, Health & Development. 2012;38(2):16274. Goldman Fraser J, Lloyd SW, Murphy RA, Crowson MM, Casanueva C, Zolotor A, et al. Child exposure to trauma: Comparative effectiveness of interventions addressing maltreatment. Rockville, MD: RTIUNC Evidence-based Practice Center. 2013.


Heneghan AM, Horwitz SM, Leventhal JM. Evaluating intensive family preservation programs: A methodological review. Pediatrics. 1996;97(4):535-42. Littell J, Popa M, Forsythe B. Multisystemic Therapy for social, emotional, and behavioral problems in youth aged 10–17. The Cochrane Database of Systemic Reviews. 2005(4):Art.No.:CD004797.pub4. Macdonald G, Turner W. Treatment Foster Care for improving outcomes in children and young people. Cochrane Database of Systematic Reviews [Internet]. 2008; (1). doi: 10.1002/14651858.CD005649.pub2 Turner W, Macdonald G. Treatment foster care for improving outcomes in children and young people: A systematic review. Research on Social Work Practice. 2011;21(5):501-27. MacLeod J, Nelson G. Programs for the promotion of family wellness and the prevention of child maltreatment: a meta-analytic review. Child Abuse & Neglect. 2000;24(9):1127-1149. Skowron E, Reinemann DHS. Effectiveness of psychological interventions for child maltreatment: A metaanalysis. Psychotherapy. 2005;42(1):52-71. Turner W, Macdonald G, Dennis JA. Behavioural and cognitive behavioural training interventions for assisting foster carers in the management of difficult behaviour. Cochrane Database of Systematic Reviews [Internet]. 2007; (1). doi: 10.1002/14651858.CD003760.pub3 van der Stouwe T, Asscher JJ, Stams GJ, Dekovic M, van der Laan PH. The effectiveness of Multisystemic Therapy (MST): A meta-analysis. Clinical psychology review. 2014;34(6):468-81. doi: 10.1016/j.cpr.2014.06.006 Winokur M, Holtan A, Batchelder KE. Kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment. Cochrane Database of Systematic Reviews. 2014;1:CD006546. Z Ziviani J, Feeney R, Cuskelly M, Meredith P, Hunt K. Effectiveness of support services for children and young people with challenging behaviours related to or secondary to disability, who are in out-of-home care: A systematic review. Children and Youth Services Review. 2012;34(4):758-70.


Reviews that did not meet all of the systematic review criteria but included interventions or populations not covered in the systematic reviews listed above (n = 3) Allin H, Wathen C, MacMillan H. Treatment of Child Neglect: A Systematic Review. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie. 2005;50(8):497-504. Dalziel K, Segal L. Home visiting programmes for the prevention of child maltreatment: Cost-effectiveness of 33 programmes. Archives of Disease in Childhood. 2012;97(9):787-98. Roberts AR, Everly GS, Jr. A meta-analysis of 36 crisis intervention studies. Brief Treatment and Crisis Intervention. 2006;6(1):10-21. The next section summarises the included systematic reviews: what types of interventions were evaluated and how, what kinds of outcomes were measured, and for which populations; and lastly the findings of the reviews are presented next, highlighting which interventions have been shown to be effective for improving specific outcomes, and for whom. 5.1. Summary of the included reviews 5.1.1. Interventions covered in the reviews A wide array of interventions was included in the systematic reviews in this review (see Appendix B for a detailed summary of the reviews). Two systematic reviews assessed the evidence for psychological treatments for maltreatment. (28, 29) Psychological treatments for child or young people maltreatment aim to reduce incidence of maltreatment and address abuse-related problems in children, young people and families. Interventions may have a behavioural /cognitive-behavioural or non-behavioural (psychodynamic, humanistic, developmental-ecological) orientation and be delivered to individuals, in groups, family or milieu, or in some combination of these. (29) Goldman Fraser included parenting programs, trauma-focused care and enhanced foster care (intervention and supportive services for children in foster care), while Skowron included physiological treatments for children and/or parents. Trauma-informed and trauma-focused Trauma-informed care is a term that is regularly used in the context of addressing outcomes associated with trauma exposure, but there is no consensus definition that outlines clearly the nature of traumainformed care. For this report, we have adopted the following definition of trauma-informed care: Trauma-informed care refers to a framework grounded in an understanding and responsiveness to the impact of trauma, that emphasises physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment. It incorporates an awareness of the impact of trauma and traumatic stress and recognition of the potential longer-term interferences to one’s sense of control, safety, ability to self-regulate, sense of self, self-efficacy and interpersonal relationships.


Trauma-focused interventions Trauma-informed care is distinct from the delivery of discrete therapeutic trauma treatment, often referred to as trauma-specific interventions or trauma-focused interventions. (30) Trauma-focused interventions have been developed to address traumatic experiences and their consequences for individuals or families. (30) Trauma-specific/focused interventions directly address the impact of the trauma and its sequelae through the goals of decreasing symptoms and facilitating recovery. (30) Trauma-focused interventions for children/young people are designed specifically to target the child’s trauma and other mental health symptoms, but most also include a parent/caregiver component in sessions which may occur alone or with child. Trauma-specific treatment strategies include helping the child or young person develop a trauma narrative, cognitive reframing and coping skills related to the trauma; and exposure to and mastery traumatic reminders. According to the review by Goldman Fraser et al. (28) trauma-focused interventions are delivered over eight-24 sessions of one-1.5 hours; children may spend several cycles in treatment totalling up to 12 months in all. Where delivery location is specified (not specified in many cases), sessions are delivered in out-patient clinics, schools, hospitals, or in the community or home. (28) Three further reviews focused on parents, with Barlow et al. (31) reviewing parenting programs and Barlow et al. (32) and MacLeod & Nelson (33) covering a wider range of interventions targeting parents in addition to parenting programs, such as home visiting (see box below) and intensive family preservation services. Note that many interventions could be classified as more than one of these broad intervention types; an intervention could be both a parenting program and a home visiting program or intensive family preservation service. The delineation between these different types of interventions is not clear cut, although they may be discussed separately in the literature. Parenting programs Parenting interventions or parent-mediated approaches have as their primary aim the modification of parenting behaviour, in order to improve child/ young people outcomes. With maltreating parents, parenting interventions target the core caregiver and family risk factors which are associated with child wellbeing, such as: increasing attunement, sensitivity, and responsiveness to the child’s needs; improving caregiver’s negative attitudes toward the child or the parenting role; teaching positive discipline techniques as an alternative to corporal punishment; improving family functioning; and reducing safety risks in the home. Parenting interventions with maltreating families may also aim to reduce parent stress and promote emotional wellbeing, and may include practical assistance and support. Many have the parent-child attachment relationship, emotion regulation, and education about child development and effective behaviour management as their primary emphasis. Parenting interventions are commonly delivered in the home, but may also be delivered in a clinic. Usually to individual parents and carers, but they may also be delivered to groups or to biological-foster parent


pairs. Sessions are usually conducted weekly, for one-two hours and eight-24 sessions (though some programs deliver up to 50 sessions). Some interventions are manualised, and all are individualised to the main concerns of the parent-child dyad. Parents learn parent-child skills via video examples of parent-child interaction, video feedback, live coaching, and similar methods (28). Intensive family preservation services are in-home support programs for families in which maltreatment has already occurred. Typically delivered by child welfare agencies, the focus of intensive family preservation services is on preventing further maltreatment and preventing out-of-home placement of the child or young person. A review by Dalziel & Segal (34) included only home visitation programs. One of the included systematic reviews focused on intensive family preservation based on the Homebuilders model (intensive short-term contact from family workers with small caseloads, emphasis on resolving the immediate crisis and improving family function). (35) In a similar vein, Bronson et al. (36) included studies on reunification and reduction of re-entry into care. The definition of reunification in this review was based on return to birth family in less than 12 months from date of most recent entry to foster care, and re-entry to foster care was measured in a 12-month window. Home visiting programs Home visiting programs are proactive interventions that centre on the relationship between home visitors and parents. Home visitors provide support and information on child health and development, mother-child attachment, and parenting strategies in the families’ own homes. Home visiting programs typically begin before the child’s birth and continue for varying amounts of time after birth. (33) Given that service delivery takes place in the home environment, home visitors may be better equipped to tailor their service delivery to specific needs of families, while families may experience a greater level of convenience around accessing and utilising services. (37) Two reviews assessed the impact of training for foster carers (38, 39), including one cognitive behaviour therapy (CBT) training intervention. CBT approaches to foster care use a skill-based training format with the intention of changing maladaptive thoughts and beliefs by correcting problematic thinking patterns. They aim to provide foster carers with the information and skills necessary to help them fulfil their responsibilities. (39) There was one systematic review, reported in two publications, on Treatment Foster Care (TFC) (26, 27) and another systematic review compared the outcome of kinship care to foster care. Both forms of care are provided to children and young people who have been removed from their parents. Kinship care is provided by relatives, members of tribes or clans, godparents, step-parents, or other adults with a kinship bond with the child, whereas in foster care the child is placed with unrelated foster parents. (40) Ziviani et al. (41) also included interventions for young people in OOHC.


Only one review specifically assessed the effectiveness of interventions targeting neglect. (42) One crisis intervention review was identified. (25) In this review, crisis interventions were classified as either family preservation; multi-session or multicomponent critical incident stress management; or single-session or group crisis debriefing. All had the aim of facilitating families’ resolution and mastery of crisis situations. Two reviews of Multisystemic Therapy (MST) were included in this review. (43, 44) 5.1.2. Populations covered in this review Most of the reviews identified that the children or young people involved in interventions had been exposed to some form or possibly more than one form of maltreatment (28, 29, 31, 32, 36, 40, 42) or were at risk of maltreatment. (32, 33) There were other systematic reviews in which exposure to maltreatment was not the primary population descriptor or where only a portion of the children or young people was maltreated. These were some of the interventions in OOHC, interventions for young people with social, emotional and behavioural problems, (26, 41, 43, 44) and training interventions for carers (39, 45). Three did not clearly articulate details of the populations included; however, the population could be inferred from details of the interventions. Where age of children was indicated, most of the reviews included a wide scope of years; zero–17 or 19 was the age spread in six reviews. (26, 40, 41, 43, 44, 46) Two reviews included a narrower range, with MacLeod & Nelson (33) only including children up to the age of 12 years and Goldman Fraser et al. (28) limiting their review to studies involving children up to 14 years of age. 5.1.3. Study designs included in the reviews As with the interventions and target populations, the reviews accepted varied study designs. Barlow et al. (32) required the highest level of rigour, including only systematic reviews, which were critically appraised and scored against criteria. Barlow et al., (31) Goldman Fraser et al. (28) and Littell et al. (43) included only randomised controlled trials (RCTs), with various forms of control conditions. Macdonald et al. (47)/Turner & Macdonald (27) and Turner et al. (39) included RCTs or quasi-randomised controlled trials. Several other reviews (29, 33-35, 42) required all studies to use a control or comparison group, but randomisation to intervention or control was not specified. Studies included in Bronson et al. (36) were referred to as empirical, which included experimental and quasi-experimental designs, and correlational or qualitative research. While Winokur et al. (40) included RCTs and quasi-experimental studies, less rigorous designs were also accepted such as longitudinal studies with a non-randomised comparison group. Ziviani et al. (41) similarly included studies of these designs, but also cohort studies. Everson-Hock et al. (45) accepted a wide-range of study designs, including RCTs right through to pre-post studies with no comparison group. Roberts & Everly (25) also accepted pre-post studies as minimum criteria. While acknowledging the challenges of conducting RCTs of interventions with these populations, the inclusion of less rigorous studies, particularly pre-post studies, limits the reliability of the findings of the systematic review. 5.1.4. Outcomes covered in the reviews As well as including particular interventions and populations, it is a convention of systematic reviews to select studies for inclusion based on a set of predetermined outcomes of interest. Broadly, the outcomes included in the reviews covered child/ young person health, safety and wellbeing, as well as parenting and


parent outcomes, and child protection outcomes. For example: child mental and psychological health, child behaviour, social and emotional outcomes, parent-child relationships, child development and health, child cognitive processing, peer relationships, school attendance and achievement, parenting behaviour and attitudes, parent and family functioning, parental psychological functioning, parent stress, child abuse and neglect, placement prevention, family preservation, placement stability, and family re-unification. 5.2. Findings of the included reviews In this section the findings of the included studies are summarised according to two broad categories: working with families, and working with children in foster care and kinship care, followed by a small section on cost effectiveness. The first two categories overlap to a considerable degree. For example, Keeping Foster and Kinship Parents Trained and Supported (KEEP) fits both groups. It is classified by Goldman Fraser, Lloyd (28), the review from which it was sourced, as a parenting program due to its emphasis on improving parenting skills and the parent-child relationship; however, the parents in question for this program are foster parents and kinship carers. Similarly, a program such as SafeCare is generally classified as a home visiting program but could with equal validity be considered a parenting program because of its focus on the role of the parent in the development of the child. For each named intervention and intervention-type, the general aims and primary target are described. This is mainly to indicate where they may be effective but also to reflect their multiple potential classifications. 5.2.1. Working with families Parenting programs are interventions that aim to support the behaviours and attitudes of parents and can be used to address a wide-range of family concerns, including treating physical maltreatment. A recent large review compared the effectiveness of a range of interventions addressing maltreatment, for children aged 0–14 who were exposed to physical abuse, neglect, and sexual abuse. (28) Twenty-five studies were included in this review. Of these, ten parenting interventions, four trauma-focused interventions (two excluded due to focus on child sexual abuse), and four enhanced foster care interventions addressed child wellbeing outcomes such as child mental health, behaviour, and development; healthy caregiver-child relationship; and school-based functioning. Five parenting and four enhanced foster care interventions evaluated child welfare outcomes. No trauma-focused interventions targeting child welfare outcomes were identified. Of the 25 studies included in the Goldman Fraser review, only Keeping Foster and Kinship Parents Trained and Supported (KEEP) and SafeCare showed moderate strength of evidence, with the remaining interventions having either low strength of evidence or insufficient evidence. KEEP was found to improve mental and behavioural health; healthy caregiver-child relationships; and permanency. Permanency refers to ensuring that living arrangements for children become permanent, either by reunifying them with biological parents or another relative, or adoption. Note that KEEP is an intervention aimed at improving the parenting skills of foster and kinship parents, and is outlined in more detail in that section below on working with children and young people in foster care. SafeCare, an intervention primarily targeting child neglect, was found to increase child safety. Although SafeCare was only shown to benefit a single outcome (in contrast to KEEP for which benefits were shown across a range of outcomes) the rigour of the Goldman Fraser review means that the conclusions drawn about these named interventions can be relied upon.


SafeCare SafeCare addresses family functioning, child behaviour and development, child safety and physical wellbeing, and prevention of maltreatment (in particular, neglect) in parents of children aged zero to five years. The treatment has three components, each divided into assessment and training: a) planned activities (time management, rules, reinforcing behaviours, setting expectations, incidental teaching); b) home safety (identifying and removing hazards); c) infant and child health (recognition and response to illness and injury). SafeCare involves weekly home visits, lasting 1.5 hours, over the span of 18 to 20 weeks. Parents are coached on skills which they rehearse and are then evaluated. Training uses modelling and role rehearsal to reach set criteria, with booster training offered when performance does not meet criteria. Quality assurance measures monitor staff fidelity to the intervention model; the model does not require particular qualification other than meeting fidelity criteria. (48) Barlow et al. (31) reviewed seven individual or group-based interventions, and concluded that there was not sufficient evidence to support the use of parenting programs to directly treat physical abuse or neglect. Only three studies included an objective measure of child abuse, and problems with insufficient follow-up and samples sizes made it difficult to determine impact of these interventions on abuse and neglect. Barlow et al. (31) did find some evidence to suggest that parenting programs can improve some of the outcomes associated with physically abusive parenting. One study found that Parent-Child Interaction Therapy (PCIT) reduced re-reports of physical abuse, increased positive parenting behaviour and decreased negative parenting. In another study included in the same review, PCIT was found to have positive effects on intensity and number of child behaviour problems. There was evidence in the Goldman Fraser review referred to previously that a variant of PCIT, Parent-Child Interaction Therapy Adaptation Package, had moderate strength evidence for retaining parents in treatment. Goldman Fraser et al. also found that adding a motivational phase in the treatment also had a small effect of parent engagement in treatment. However, despite these positive findings for retention and engagement, Goldman Fraser et al. found that the evidence for PCIT Adaptation Package to improve child safety outcomes was low or insufficient. Goldman Fraser et al. (28) also reviewed the evidence for PCIT Adaptation Package compared to other combinations of treatments such as services as usual and PCIT without the adaptation component. Goldman Fraser concluded that, while the strength of the evidence was low, there were indications that PCIT Adaptation Package resulted in significantly reduced future child abuse reports, than in the other treatment combinations, including standard PCIT. Taken together, the findings of the Barlow and Goldman Fraser reviews provide initial suggestions of the benefits of PCIT, particularly for child abuse reports and particularly when using the Adaptation Package. However, given that there are still some conflicting findings and that the strength of the evidence is not high, the benefits of this intervention for improving child outcomes are therefore yet to be clearly established. It is of some concern that PCIT has been shown to have some evidence of benefit for child outcomes in one review, but no clear evidence of benefit for child outcomes in a more recent review (although there was


evidence of benefit for retaining parents in treatment). However, it is not possible to make a direct comparison of these two reviews as Goldman Fraser et al. were investigating a modified version of PCIT; and also evaluated a different set of outcomes. On the set of outcomes where the reviews overlap, there is reasonable agreement: PCIT and PCIT Adaptation Package had limited to no evidence of effect on abuse and neglect. Both reviews do show some evidence of benefit on relevant outcomes such as increasing positive parenting behaviour, decreasing negative parenting, reducing the number and intensity of child behavioural problems, and increasing parent engagement with and retention in treatment. Parent-Child Interaction Therapy PCIT targets children aged two to seven years who present with behaviour problems as well as difficulties in the parent-child relationship (including presence or risk of maltreatment). The aim of PCIT is to improve child development, behaviour and family functioning. PCIT involves two components: a) child directed interactions: parents are coached on responding positively to their child on positive/neutral behaviour and ignoring negative behaviours; b) parent directed interactions: parents learn to effectively direct the child's behaviour. Parents learn ways to utilise social reinforcers for positive child behaviours and are coached on behaviour management skills in response to negative behaviour. Coaching occurs as practitioners observe parents through a one-way mirror and direct them through wireless communication. Parents attend one to two hour group sessions weekly. Sessions target one element at a time and continue until all elements are mastered (10–20 weeks). Parents consolidate learning with homework. The intervention is delivered in community or outpatient settings by licensed health care providers with graduate or masters clinical training. - Parenting Research Centre (48) Parent-Child Interaction Therapy Adaptation One example of a PCIT adaptation targets abusive or neglectful parents. In this intervention, parents go through a motivational phase in addition to the two PCIT phases (child directed interactions and parent directed interactions). Sessions and delivery mode are as described above, with the addition of six parent group sessions for the motivational phase. As in PCIT, parents are coached by therapists on modelling, reinforcement and selective attention. Parents rehearse skills in therapy sessions as they receive live feedback from therapists (Goldman Fraser et al. (28)). A narrower non-systematic review, focusing on the effectiveness of child neglect treatment programs, (42) found only very limited evidence of benefit for child outcomes from any of the interventions evaluated in the 14 studies able to be included. However, note that SafeCare, previously called Project 12-Ways and Project SafeCare, is a well-known intervention for children exposed to neglect and was not tested in an RCT until after 2005, which explains why it appears in the Barlow et al. (31) and Goldman Fraser (28) reviews but not in the review by Allin et al. (42)


A large but non-systematic and older review (29) evaluated psychological interventions for child abuse and neglect, including child sexual abuse, which were aimed at children and parents. Twenty-one studies examining 25 treatments were considered, encompassing individual, group, family, milieu, multicomponent approaches and behavioural and non-behavioural interventions. There was some evidence that psychological treatments for child abuse and neglect led to improvements across a range of outcomes, with a medium average effect size comparable to other meta-analyses. However, there was very limited evidence that gains were maintained as only a very small proportion of studies provided follow-up data. Skowron & Reinemann (29) did not find any differences in effects according to treatment modality or individual/group delivery. Of potential importance was the lack of difference in parent outcomes depending on whether participation was mandatory or voluntary. Very few specific details of interventions were provided. Following instances of child abuse and/or neglect children and young people may be removed from the home temporarily. Bronson et al. (36) reviewed 71 studies in an attempt to determine which ‘promising practices’ increase successful family reunification and reduce re-entry to OOHC for abused, neglected, or unruly children and young people. Unfortunately, the authors concluded that due to insufficient rigorous evaluations in their included studies, it was not possible to determine the effectiveness of the interventions identified in their review. An earlier review of intensive family preservation programs, (35) which took prevention and reduction of OOHC placements as the primary outcome measures, found evidence in only a small minority of included studies, only one of which was of good methodological quality. As well as addressing the sequelae of child abuse and neglect, interventions may be aimed at preventing maltreatment occurring or reoccurring. A systematic review of reviews of interventions to prevent or ameliorate child physical abuse and neglect identified 15 systematic reviews of interventions for high-risk families. (32) The interventions identified were classified as parenting programs, home visiting interventions, early (multimodal) preventive interventions, intensive family preservation services, family-focused interventions, and social support interventions. Although the evidence was not strong, the best indications for improvements were from home visiting as a means of detecting maltreatment and improving parenting in high-risk families; and parenting programs for improving parent, child, and family and functioning. It was also found that, although there is inadequate evidence for impact on objective measures of abuse and neglect, intensive family preservation services improve outcomes such as parental disposition and family functioning which are associated with abuse. An earlier review (33) considered a range of prevention programs relating to maltreatment of children and young people over 12 years of age, including home visiting, multi-component, social support/mutual aid, intensive family services, and parent training. Fifty-six studies met the inclusion criteria, and the authors concluded that most interventions to prevent child abuse and neglect were successful, with largest effect sizes from multi-component interventions and home visiting interventions, both commenced proactively and prenatally or at birth. However, this review is of lesser quality than the Barlow et al. (32) review, which did not find adequate evidence of reduction of maltreatment. The review also found larger effect sizes for measures of family wellness, similar to those that Barlow et al. (32) noted as being related to maltreating behaviours in parents. Effect sizes were smaller for verified or proxy measures of child abuse and neglect such as numbers of accidents, admissions to hospitals, and emergency room visits for injuries or ingestions.


Interventions may also seek to intervene across a broad range of child and family challenges. Multisystemic Therapy (MST) has been evaluated for children and young people with social, behavioural, and emotional problems and their families. (43) This includes abused, neglected and dependent children and young people at risk of OOHC, as well as children and young people with mental health problems placing them at risk of hospitalisation, and those at risk of incarceration. According to Littell et al., (43) evidence about the effectiveness of MST was inconclusive, compared with other interventions for this group (usual services, alternate treatments, or no treatment). Note, this review was of MST for older children and young people, aged 10–17. A later review of MST (44) for juvenile delinquents and/or adolescents with social, emotional, and behavioural problems, found small but significant treatment effects on the primary outcome (delinquency) and secondary outcomes (psychopathology, substance use, family factors, out-of-home placement and peer factors including peer delinquency and peer relations). However, after taking publication bias into account only the psychopathology and family factor improvements seemed to remain significant. There were larger effect sizes for studies where the average age of participants was under 15 and for studies with a higher proportion of Caucasian juveniles, indicating that MST may be less effective for older and minority youth. Multisystemic Therapy Multisystemic Therapy is an intensive community or home-based therapy targeting young people aged 12– 17, with the objective of reducing criminal misconduct and out-of-home placements. More specifically, the program is for young people who are at high risk of placement due to aggressive behaviour (physical or verbal), substance use problems, or serious offenses. While the standard target population of MST is offending young people, a range of adaptations of the MST standard model have been developed targeting specific target groups such as children and young people who have experienced abuse and neglect, who have severe substance abuse problems or who have psychiatric problems. MST works on both individual and systems levels by addressing child behaviour, family functioning, support networks and systems outcomes. The intensity of the sessions is determined based on the needs, however support is available on a 24/7 basis to individual families, suggesting that this is a reasonably intensive service. Sessions for each family can vary from three times a week to daily, with sessions lasting between 50 minutes to two hours. The whole of the intervention typically lasts three to five months. MST is delivered by therapists with a Master's degree. MST sessions bring together different treatment modalities to empower caregivers and respond to risk factors (peer, family, school, and community levels) in an effort to engender youth behaviour change. The intervention is delivered in community settings and in the home. Quality assurance protocols measure treatment fidelity and positive outcomes. (48)

5.2.2. Working with children and young people in foster care and kinship care Goldman Fraser et al., (28) as part of their large review of the effectiveness of interventions addressing maltreatment of children aged up to 14 years, found that there was moderate quality evidence in favour of Keeping Foster and Kinship Parents Trained and Supported (KEEP), a training program to improve the


parenting skills of foster parents and kinship carers. KEEP showed benefit for child mental health and behavioural outcomes, for caregiver-child relationship outcomes, and for permanency. Keeping Foster and Kinship Parents Trained and Supported (KEEP). KEEP is a training program for carers of children aged five–12 years which is also an example of a parenting intervention as described above. KEEP focuses on positive discipline strategies with the aim of increasing foster and kin parents’ positive reinforcement relative to discipline, giving them effective tools for dealing with their child’s externalising and other behavioral and emotional problems. Didactic training is delivered by a trained facilitator and co-facilitator using group discussion, role-plays, videotapes, and homework practice. Participants attend 16 weekly group sessions of 1.5 hours duration; with 15-minute presentations by facilitators followed by group discussion and activities. Sessions are typically conducted in community agencies (28). Additional information from www.cebc4cw.org/program/keeping-foster-and-kin-parentssupported-and-trained/. A review of Treatment Foster Care (TFC) (26, 27) assessed the impact of TFC on psychosocial and behavioural outcomes, delinquency, placement stability, and discharge status in children aged up to 18 years in OOHC. Children/ young people were placed in TFC due to mental health problems which might otherwise require hospitalisation, substance dependency, or being at risk of incarceration or of placement in restrictive residential setting due to delinquent behaviour. Five studies were included in this review. It was not possible to determine intervention effects for all outcomes because there were many outcomes measured in relatively few studies. There was a slight benefit of treatment for school attendance, homework completion, several delinquency measures (though the effects here were extremely small), days in treatment, days living at home, days as a runaway, and days in a locked setting; many other measured outcomes showed no evidence of benefit. Despite these observed benefits, the authors suggest that while TFC is a promising intervention for children with these complex needs, the evidence base is less robust than has sometimes been reported, due to poor reporting of study quality and high risk of bias in included studies. It must be emphasised that although the review authors treat TFC as specific named program, and evaluate the evidence in its favour on that basis, treatment foster care could also be considered as a generic term comprising several other programs and treatments, for example Multidimensional Treatment Foster Care (Chamberlain 2007a, cited in Macdonald & Turner 2008 (26)). In their review the authors included all studies with a focus on treatment foster care as described below, whether specifically named as TFC or as part of a multidimensional intervention.


Treatment Foster Care TFC targets children and young people aged 18 or younger in out-of-home care. It aims to equip foster carers with skills required to respond to difficult behaviours, medical conditions and issues related to child abuse and neglect. TFC works directly with children and parents, in addition to addressing peer networks in an effort to reduce their negative influences. TFC as defined in this review follows the definition given by Macdonald & Turner, (26) who distinguish it from similar interventions such as specialised foster care, wraparound foster care, and multidimensional foster care. Interventions classed as TFC for the purposes of this review are those which have the following characteristics: 1.

They serve children and young people who would otherwise be in (or at risk of being in) more

2.

restrictive non-family settings They have strong community links and individual, measurable, treatment and education plans

3.

Foster carers are selected and trained to provide therapeutic care for children and young people with emotional disturbance, developmental disabilities, behavioural difficulties, or special medical

4.

needs Care is provided in a family setting

5. 6.

No more than two children placed in the home Foster carers receive support, consultation, and supervision, with round-the-clock crisis intervention

7.

services Foster carers are regarded and treated as professional members of the placing service

8.

Foster carers receive payments above those provided for regular foster care

9.

The program is administered by a specialist agency or designated unit of a broader host agency.

Depending on the study, intervention includes: pre-service training of foster carers; implementation of behaviour management plan; individualised treatment plan for child/young person; daily telephone calls and weekly groups for foster carers; and case manager on call 24/7 for biological and/or foster parents as needed. Less intensive versions offer weekly two-hour peer support groups for foster carers, led by a facilitator who had once been a foster parent, and thrice-weekly telephone support. (27) Everson-Hock et al. (45) investigated whether additional training and support, for carers and other professionals caring for or working with children and young people in OOHC, improves child outcomes. Training interventions for foster carers, which were the only interventions identified, had limited impact on behavioural problems, placement stability, and emotional and mental health and wellbeing, but included studies varied widely and both methodological and reporting quality were poor so these findings should be viewed with caution. In contrast, in a review of seven studies, Turner et al. (39) assessed the effectiveness of behavioural and cognitive-behavioural training interventions for foster carers of children and adolescents with difficult behaviour. A wide range of child wellbeing welfare outcomes was measured, but there was no evidence of efficacy for any intervention.


Kinship care is an alternative to foster care for children removed from the home due to abuse, neglect, or other maltreatment. Kinship care is fast becoming the predominant placement type in NSW and across Australia. Kinship caregivers may have different needs than foster parents since they are more likely to experience adverse outcomes, be older, in poor health, and be impoverished. Yet kinship families typically receive fewer services and supports than non-kinship foster carers. (49) A review of 71 studies comparing kinship care with foster care (40) found significantly better outcomes for behaviour problems, adaptive behaviours, psychiatric disorders, and wellbeing, placement stability, guardianship, and institutional abuse. Kinship care performed similarly to foster care when the outcomes were reunification, length of stay, educational attainment, family relations, and use of physicians and developmental services. Children in kinship care were less likely to utilise mental health services and achieve adoption, and were more likely to still be in placement at follow-up than were children in foster care. Children and young people in OOHC may have a range of additional vulnerabilities. Ziviani et al. (41) compared interventions for children with challenging behaviours related to or secondary to a disability, who were in OOHC for reasons primarily pertaining to issues of abuse and neglect. Four studies were included in this review, all of them were interventions intended to reduce children’s behavioural problems and support their adjustment and emotional wellbeing while also supporting carers’ capacity, knowledge, and psychological functioning. There was evidence for some positive child outcomes, but outcomes for caregivers’ were mixed. The review found significant reduction in potential for child abuse in one of the four included studies.

Cost effectiveness Only one, non-systematic, review examined the cost-effectiveness of child maltreatment programs. Dalziel and Segal (34) evaluated home visiting programs for child maltreatment prevention. The most expensive programs were found to be those that targeted higher risk families, used professional home visitors in a multi-disciplinary team and included more than just home visiting. As this review was not found to meet the systematic review quality criteria, the findings should be viewed with caution.


6 Discussion This review of systematic reviews identified 14 systematic reviews meeting inclusion criteria, and an additional three reviews which did not meet the systematic review quality criteria but which provided information on populations and interventions not covered by the systematic reviews. The reviews assessed the effectiveness of interventions targeting various wellbeing, health and safety outcomes for children and young people in families with complex needs who have experienced abuse and/or neglect. 6.1. Summary of evidence The findings of this review suggest that there is little clear, strong evidence for interventions for improving the safety, health and wellbeing outcomes for children and young people exposed to physical abuse and neglect. There have been large numbers of evaluations of interventions for families with complex needs where a child or young person has been maltreated, and many of these have been covered in systematic reviews — as summarised in the current review. Many of these evaluations, however, have been excluded from systematic reviews, possibly due to methodological shortcomings. Other interventions will have been included in systematic reviews but were found to have little or no effect on the outcomes of interest to the review, or they were found to use flawed methodology and so the findings were not reliable. Despite these shortcomings in the evidence, the systematic review authors were able to identify some interventions and approaches that have better evidence. Specific interventions that were found in this review to have possible benefit for improving select outcomes for particular groups of children and young people included: KEEP, SafeCare, PCIT, and MST. Benefits were found for a range of outcomes such as reducing re-reports of physical abuse, child mental and behavioural health, child psychopathology, healthy caregiver-child relationships, permanency, child safety, and family factors. PCIT should be viewed with a degree of caution: it shows promise in some studies, but the high quality Goldman Fraser review found limited evidence for improved outcomes. Note that engagement and retention of participants was improved in the version of PCIT with an adaptation package. It should be noted that not all outcomes were measured for all interventions; care should therefore be exercised when selecting an intervention to ensure that it has been shown to have benefit for the particular outcome which may be of interest. Rather than reporting on specific interventions, some reviews commented on groups of interventions. The broad groups of interventions that appear to have some positive impact include: behavioural and nonbehavioural psychological treatments, parenting programs, home visiting programs, kinship care rather than foster care, intensive family preservation services, proactive multi-component interventions. The outcomes for which some improvements were seen include: prevention and reduction of OOHC placement, detection and prevention of maltreatment, improved parenting, and improved child/ young person, parent, and family functioning. It should be remembered, though, that not all interventions within a broad category will be the same. They will have varying characteristics and degrees of effectiveness, and should be assessed for suitability in the specific circumstances in which they are proposed to be used.

INTERVENTIONS FOR FAMILIES WITH COMPLEX NEEDS | SAX INSTITUTE 32

Finally, the authors (Macdonald & Turner) reviewing treatment foster care argue that while it is a promising intervention type they saw fewer benefits in their review than had been observed in previous, less rigorous, studies. On the whole, the interventions found to have better effect have a strong focus on families and parenting, including those delivered to foster care settings, and were more often oriented towards families and parents than the individual child. 6.2. Gaps in the evidence The search process for this review identified several additional systematic reviews on maltreatment, in particular sexual abuse, which were not of relevance to the current review. Sexual abuse, in the absence of additional forms of maltreatment (poly-victimisation) is very different in nature and treatment to other forms of abuse, and is not always accompanied by as many complex family issues as physical abuse and neglect. Interventions for sexual abuse have been subject to more evaluations and also more systematic reviews. Comparatively few systematic reviews specifically addressing physical abuse were identified, and even fewer on neglect. Indeed there were very few interventions found to specifically target neglect, the notable exception being SafeCare, which has recently been launched in NSW. Some of the reviews included here had a broader range of populations than just those with substantiated maltreatment, although exposure to maltreatment was probable in most, given that many were in OOHC. Although the impact of trauma in children exposed to maltreatment is an important issue and traumafocused and trauma-informed approaches have garnered a lot of interest recently, this review found no compelling evidence for the use of trauma-informed or trauma-focused approaches with children or young people exposed to physical abuse or neglect. For instance, Eye Movement Desensitization and Reprocessing (EMDR) is an intervention currently in use within NSW. The review by Goldman Fraser et al. (28) found only one study of EMDR that was suitable for inclusion and this involved sexually abused Iranian girls. Goldman Fraser found this study had insufficient strength of evidence to make a recommendation about the utility of EMDR. In contrast, EMDR is considered to be Well Supported according to the California Evidence-Based Clearinghouse for Child Welfare (www.cebc4cw.org/program/eye-movement-desensitization-andreprocessing/detailed). In a review of literature on Intensive Family Services (IFS) for vulnerable families recently conducted by the PRC, the EMDR studies reported by CEBC were considered for their applicability to maltreated children. It was found that there was only cursory evidence for the use of EMDR with maltreated children and young people, with most studies focusing on other trauma types. While this intervention may have relevance for children who have been physically abused or neglected, the evidence for use with these populations is not yet well established. Applicability to non-disaster and non-sexual abuse populations is not yet known. The nature of trauma associated with multi-problem, complex families is likely quite different to those who have experienced, for example, an accident, natural disaster, or war, and indeed also, those who have experienced sexual abuse. Another intervention that has been widely publicised in recent years is Neurosequential Model of Therapeutics (NMT). Recently, the PRC and the Australian Centre for Posttraumatic Mental Health (ACPMH) undertook a multi-methods analysis of trauma approaches that involved a rapid evidence assessment, practitioner survey and manager consultations (30). It was found that NMT was the most frequently


reported approach that practitioners were aware of when asked about evidence-based approaches for the treatment or prevention of trauma. In contrast to this, the evidence available to support this intervention was drawn only from two single group pre-post studies, reported in one paper. A targeted search conducted in August 2015, updating the previous search conducted in 2012, identified no further studies. As a new approach, it is understandable that NMT was not identified in any of the systematic reviews included in this review. It typically takes some time to establish the feasibility of new interventions, as well as to conduct the multiple rigorous studies required in order to determine effectiveness. Despite the high-profile nature of NMT, the benefits of this intervention for maltreated children and young people are not yet known. Another well-known trauma approach was similarly found to have limited evidence for the population of relevance in this review. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was included in the review by Goldman Fraser et al. (28) and found to have low or insufficient evidence. The three RCTs included in Goldman Fraser et al. (28) were, however, with sexually abused children. The aforementioned trauma review by PRC and ACPMH included some additional studies that were not included in the Goldman Fraser review. Two studies were based on a pre-post single group design and involved a DFV population. The third study was an RCT and addressed a mixed trauma population that also included DFV and sexual abuse. Similar to EDMR, the CEBC rates TF-CBT as well supported; however most of the studies, with the exception of one related to DFV, involve sexually abused children. Applicability to children and young people exposed to physical abuse and neglect is not established. Another well-known trauma approach, Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT) was found by Goldman Fraser to have low or insufficient evidence. Unlike the other trauma approaches reported above, the CPC-CBT study involved physically abused children. Similarly, the recently conducted IFS review mentioned above found the evidence for this intervention to be limited. Taken together, this indicates that the evidence base for trauma approaches is still inconclusive. Further research is needed to determine if there is evidence to support trauma approaches, as opposed to other interventions that still acknowledge the impact of abuse but do not take a specific trauma approach. There is also need to consider the evidence specifically for children and young people exposed to physical abuse and neglect, as opposed to sexual abuse or other trauma, as there may be a distinction between these types of trauma. A further gap in the research exists in the evidence for use of interventions with specific populations of relevance to the NSW context. There is little rigorous evidence for interventions with Aboriginal and Culturally or Linguistically Diverse families. Systematic reviews specifically targeting interventions addressing maltreatment within these populations were not identified. Recently, the PRC undertook a scoping review of interventions for parents of Indigenous children (50). While the review focused on interventions that aimed to improve child psychosocial outcomes and was not related to maltreatment, the finding that culture was heavily infused in all aspects of intervention content and delivery may be of interest to policy makers and practitioners undertaking work with Indigenous populations. The most recent and relevant systematic review included here, Goldman Fraser et al., (28) did not include interventions for children over 14 years of age because they acknowledged that this age group presents with different issues and therefore interventions are typically different. A recent review of interventions


specifically for middle to older adolescence is needed, particularly one that focuses on young people maltreatment. This review included systematic reviews targeting populations that were likely exposed to maltreatment, even if this was not explicitly stated. It is for this reason that MST was included. A related intervention that was not identified in this review was MST for Child Abuse and Neglect (MST-CAN). This intervention is aimed at children and young people in the six–17 age range who are at risk of maltreatment, with the aim of preventing further abuse and out-of-home placement. Further investigation may be needed to determine the evidence for this adaptation of the standard model of MST. In addition, it was also found that benefits were stronger for young people under 15, suggesting a gap in services for older young people. Multisystemic Therapy – Child Abuse and Neglect (MST-CAN) Multisystemic Therapy for Child Abuse and Neglect (MST-CAN) targets children aged six–17 who have been maltreated or who are at risk of maltreatment. The intervention is delivered to all family members, typically in the home, or in a chosen location in the community. The objective is to prevent re-abuse and placement in OOHC. Intensive, 24/7 services are available to the family, delivered by therapists with Masters degrees. Contact with families varies from daily to three times a week. Sessions may last from 50 minutes to two hours. Total service provision is between six to nine months. In comparison to the standard MST program, MST-CAN puts greater emphasis on safety planning, treatment for anger management difficulties, parental or youth substance abuse, and family problem solving and communication problems. Also, a full-time crisis caseworker and a part-time psychiatrist are added to the standard treatment team. (48) The review by Goldman Fraser et al. (28) identified some key gaps in the evidence. These authors found no rigorous studies that had examined the comparative effectiveness of different intervention modalities or settings, and only two studies were found that compared different theoretical orientations. Furthermore, there is currently little clear evidence about what is the optimal timing, dosage and intensity of interventions for families with complex needs. Further rigorous study into these variations would assist policy makers and practitioners to make decisions about interventions that may potentially be more effective, while possibly also factoring in theoretical orientations of the service/providers. Another gap in the evidence identified by Goldman Fraser was that few studies assessed the impact of interventions or strategies for improving the engagement or retention of families. Engaging families with complex needs in interventions may be challenging for various reasons. Further research into effective methods for encouraging and building engagement and retention of families would be beneficial as interventions cannot hope to produce positive outcomes if families are not fully engaged for the duration. Generally, there is a lack of rigorous studies within this area of research. Inadequate designs and reporting make it difficult to be confident about the impact of interventions. Furthermore, many studies do not use outcome measures that are suitable. These are some of the reasons why research evaluating interventions cannot be included in systematic reviews or cannot be assessed for effectiveness.


6.3. The broader context of abuse and neglect As already highlighted above, the Parenting Research Centre (PRC) recently undertook a review of the evidence for intensive family services. (48) This review was comprised of interventions for vulnerable families experiencing a range of complex and interrelated issues including child and young people maltreatment, risk of maltreatment, parent and youth substance abuse, parent and youth mental illness, DFV, parent intellectual disability, and youth risky behaviours and delinquency. Findings from existing evaluations were gathered from online evidence-based clearinghouses and from other relevant reviews by the PRC. The interventions were then rated to highlight which ones had the best evidence for improving outcomes. The evidence synthesised in the IFS review was not as rigorous as the systematic reviews reported in the current review; however its findings provide some valuable insight into common characteristics and factors to consider when working with populations that are at risk of maltreatment. While the concept of vulnerable families in the IFS review was broader than in the current review where the interest is in families where the child or young person has been abused or neglected, the complexity of families and the issues they experience are comparable. The IFS review identified 45 interventions with at least emerging evidence to suggest that they may have a positive impact on child and young person, parent, family or service outcomes. While the scope of the review encompassed a broad range of family vulnerabilities, it was found that much of the evidence focused on families where the child or young person had been maltreated or was at risk of abuse or neglect. First of all, this meant that even though not all interventions in the IFS review were specifically developed to address child/ young person maltreatment, much of their evidence centred on families where the child has been maltreated or is at risk of maltreatment. This is not surprising, as maltreatment risk is often present when families are brought to the attention of child and family serving agencies, and although it may not have been stated in intervention descriptions, many will have prevention of maltreatment as an objective. In addition, the interventions in the IFS review typically covered more than one type of family vulnerability, and thus may have encompassed several child, parent and/or family factors that influence risk of maltreatment or harm. Again, this was not unexpected given that families typically present with more than one issue and the multicomponent interventions targeting these families tend to work across the various issues families present with. An example of such a multi-component approach is the basis of another project undertaken by the PRC, the “UnitingCare Burnside Domestic Violence Project”. This project builds on the implementation of the evidence-informed “Working with Families Affected by Domestic Violence Framework” and addresses the improvement of a number of child and parent related outcomes.


The Burnside Project – Working with Families Affected by Domestic Violence Practice Framework A multi-component approach to preventing child abuse and neglect in families experiencing domestic violence informs a project conducted by PRC in collaboration with UnitingCare Burnside. The practice framework to be implemented as part of this project includes three main areas of clinical work. The framework begins with safety planning, which includes the use of functional assessments, consideration and management of high risk indicators, applying a harm reduction approach/strategies, engaging (when appropriate) both parents and other adults in safety planning, ongoing monitoring and revision of safety plans. Second, a parenting skill component where various parenting practices are taught to parents designed to improve warmth, responsiveness, positive behavioural management, and family routines. Here practitioners utilise prescribed teaching strategies to practice and coach parental skill development during the home visit. Thirdly, the framework includes strategies designed to improve parental coping skills e.g. problem solving, self-regulation and communication. This section utilises simplified cognitive behavioural techniques that are designed to enable parents to increase their ability when applying parenting skills and aspects of a safety plan. A planning module is also included to assist engagement, strengthen relationship to family’s goals, and organise subsequent home visiting content. Together, these components are designed to improve family/parental functioning and improve safety for children and adults. In terms of the outcomes targeted by the interventions in the IFS review, it showed that prevention of child abuse and neglect was not identified as a main outcome for a large proportion of interventions, but the ultimate objective of targeting other outcomes (such as behaviour and functioning) may have been to reduce the risk of future maltreatment. The highest proportion of interventions targeted child behaviour (88%), which can be a key factor that places them at risk of maltreatment; and so addressing child behaviour and parent strategies for dealing with behaviour is a frequent target of both parent-oriented and childoriented interventions. Family functioning was targeted by the next highest proportion of interventions (80%). As with child behaviour, this was expected as improving relationships within families, interactions between parents and children, and parent wellbeing was a part of most interventions. These additional insights remind us of the need to consider child abuse and neglect, and indeed all issues vulnerable families are experiencing, in the broader family, social and community context. As noted earlier in this report, these complex issues are not experienced in isolation. Child abuse and neglect may result because of multiple vulnerabilities within the family or their wider social or community circle. The vulnerabilities within a family are connected. Similarly, interventions addressing one concern within a family will impact other vulnerabilities and other family members. Addressing some of the core issues within the family, such as child behaviour and relationships between family members, may be the foundation for indirectly addressing maltreatment, as well as other interrelated family problems. Hence it is worth considering the evidence for interventions that target populations and outcomes closely related to those where child abuse and neglect is the explicit focus and has been substantiated. While these general conclusions from the IFS review are probably transferrable to the context of the current review, it should be noted that the methodology used in the review was not the same as that used here, as interventions had not be submitted to the rigor of a systematic review. Further, while most of the populations in the IFS interventions were relevant here, some were perhaps of less interest, such as young people with mental health problems.


6.4. Implications of the review findings Given the complexity of families experiencing maltreatment, it is unsurprising that there are few rigorous evaluations and fewer systematic reviews; research in this area is also complex. Within this limited scope of research, few interventions with strong indications of effectiveness were found. Perhaps one of the reasons for the lack of evidence for single interventions is that working with families with complex needs requires complex solutions. Multicomponent interventions targeting several family members, addressing several issues, delivered in multiple modes and settings may address the multiple problems experienced by families with complex needs where children and young people have been maltreated. A whole system response, taking into account the entire family and the social and community context, is warranted. Several of the reviews included here reported on outcomes that were not directly related to child safety or child protection. In fact, many included outcomes related to parenting, parent-child relationships, and parent stress. As noted by Barlow et al.,(32) outcomes such as parent and family functioning are closely related to child abuse and neglect outcomes. In addition to the more targeted parenting interventions reported here such as KEEP, SafeCare, and PCIT, there is an array of interventions available that do not specifically target maltreatment outcomes or families where children or young people have been maltreated, nor do they have a specific focus on the impact of trauma arising from child abuse and neglect. Instead, they focus on the underlying parent-child relationship and how the parent responds to challenges in parenting, such as difficult child behaviour. These parenting programs, for which some have good evidence, present core parenting principles that may be transferable to different family contexts. Adopted in conjunction with other more targeted approaches to address other issues experienced by families with complex needs, such as substance abuse, these parenting interventions may help to address some of the basic parent-child concerns that contribute to risk of maltreatment. 6.5. Limitations of this review Although this review relied on high quality systematic reviews as a source of evidence, there are some limitations. An extensive academic database search was conducted, however the grey literature was not searched. Some relevant unpublished systematic reviews may have been missed. Likewise, some relevant non-English language systematic reviews may have been missed due to our language limit. There may also have been books or conference papers that reported systematic reviews but these were not included here. Another limitation of this review is that the evidence under consideration here may be limited by the topics of past systematic reviews. Systematic reviews are generally limited to narrow populations, interventions and outcomes, based on the particular need or interest of the reviewers. These may not align with the purpose of the current review. For example, some reviews included some interventions that were only for children exposed to sexual abuse. Further to this, the extent of the evidence available may have been limited by the age of the systematic reviews. While systematic reviews are sometimes updated, there may be additional important studies on the relevant interventions that have yet to be included in a systematic review.


6.6. Next steps While the evidence reviewed here does not point to a clear direction to take when selecting interventions for families with complex needs where there has been child or young person maltreatment, there are some considerations which may guide future work in this area: • •

Engage in further discussion about service context and needs, in light of these findings Look deeper into the interventions identified in this review that appear to show promise

•

Consider the wider scope of intervention options for families with complex needs, beyond those specifically targeting maltreated populations

•

Consider which outcomes are of key importance in these families – perhaps interventions targeting more general parent-child interaction, family functioning and child behaviour could be suitable options

•

Consider multicomponent and multiple intervention options that take into account the broader family, community and society context.

Service accessibility should also be considered when selecting and implementing interventions with families with complex needs. For instance, interventions that are clinic-based may not be as readily accessed by families as ones that are based in the home. An outreach approach may be beneficial if families are not inclined to leave their homes. A consequence of this may be that interventions delivered entirely or partially in group mode, may be impractical. The potential barrier to access presents limitations in terms of interventions that may have an evidence base as some interventions of interest may be optimally delivered outside the home or in group format, with no evidence for their use in other settings or modes.


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8 Appendices Appendix A: Review of reviews 1. Search terms used to identify studies in PsycINFO 1.

(foster care* or foster child* or foster youth* or child* in care or youth* in care or kinship care or relative care or congregate care or looked after child* or out of home care or out-of-homecare).mp.

2.

(residential care or group care) and (infan* or child* or minor or minors or toddler* or baby or babies or adolescen* or teen* or young person or youth* or young people).mp.

3.

((infan* or child* or minor or minors or toddler* or baby or babies or adolescen* or teen* or young person or youth* or young people) adj3 (maltreat* or neglect* or abuse* or reabus* or reabuse*)).mp.

4.

(expos* or witness*) adj3 (domestic violence or intimate partner violence or wife abuse or wife batter* or woman abuse or adult conflict or family conflict or family violence or marital conflict).mp.

5.

(meta-anal* OR meta anal* OR metaanal* OR systematic review* OR systematic synthesis or synthesis of studies or realist synthesis or realist review).mp.

6.

(intervention* or program* or therap* or practice* or service* or support* or model* or approach* or common element* or framework*).mp.

7. 8.

1 or 2 or 3 or 4 5 and 6 and 7.



Screening

Identification

2. Flowchart of studies through the selection process

1677 papers identified through databases

597 duplicates removed

1080 abstracts screened for inclusion

1022 abstracts excluded

Inclusion

Eligibility

58 full text assessed for eligibility

14 papers reporting 13 reviews included

44 excluded

Three papers identified via websites

Seven paper identified by experts

Three papers assessed for eligibility

Two excluded

Six papers assessed for eligibility

Three reviews included

One review included

17 reviews included

One paper excluded – duplicate

Three excluded

3. Number of studies included in the 17 reviews Three of the included reviews did not report the total number of studies they screened for inclusion. The total number of studies screened in the remaining 14 reviews was 27,486, with 457 studies included across the 17 reviews. As these reviews covered similar topics, there may be duplication in the studies included in the reviews. 4. Excluded studies Studies excluded at full text screening stage and reasons for exclusion Not a review Balcazar FE, Davies GL, Viggers D, Tranter G. Goal attainment scaling as an effective strategy to access the outcomes of mentoring programs for troubled youth. International Journal on School Disaffection. 2006;4(1):43-52. Christofferson MN, Corcoran J, Depanfilis D, Daining C. Cognitive-behavioural therapy for parents who have physically abused their children. Cochrane Database of Systematic Reviews. 2008;3:CD007329. doi: 10.1002/14651858.CD007329 Gardner F, Bjornstad GJ, Ramchandani P, Tao X, Montgomery P. Family therapy for children who have been physically abused. Cochrane Database of Systematic Reviews. 2009;12:CD007827. doi: 10.1002/14651858.CD007827.pub2 Riitano D, Pearson A. The effectiveness of interventions designed to improve academic outcomes in children and adolescents in out-of-home care: A systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports. 2014;12(1):13-22. Not a systematic review Falconnier LA, Tomasello NM, Doueck HJ, Wells SJ, Luckey H, Agathen JM. Indicators of quality in kinship foster care. Families in Society. 2010;91(4):415-420. Walter UM, Petr CG. Best practices in wraparound: A multidimensional view of the evidence. Social Work. 2011;56(1):73-80. Craven PA, Lee RE. Therapeutic interventions for foster children: A systematic research synthesis. Research on Social Work Practice. 2006;16(3):287-304. Gillies D, Taylor F, Gray C, O'Brien L, D'Abrew N. Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database of Systematic Reviews. 2012;Issue12.Art.No.: CD006726. doi: 10.1002/14651858.CD006726.pub2 Hahn RA, Bilukha O, Lowry J, Crosby A, Fullilove MT, Liberman A, Moscicki E, Snyder S, Tuma F, Corso P, Schofield A. The effectiveness of therapeutic foster care for the prevention of violence: A systematic review. American Journal of Preventative Medicine. 2005;28(2 Suppl.1):72-90. Kinsey D, Schlosser A. Interventions in foster and kinship care: A systematic review. Clinical Child Psychology & Psychiatry. 2013;18(3):429-463.


Leenarts L, Diehle J, Doreleijers T, Jansma E, Lindauer R. Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: A systematic review. European Child & Adolescent Psychiatry. 2013;22(5):269-283. Lin C-H. Evaluating services for kinship care families: A systematic review. Children and Youth Services Review. 2014;36:32-41. MacMillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. Interventions to prevent child maltreatment and associated impairment. The Lancet. 2009;373(9650):250-266. Montgomery P, Gardner F, Bjornstad G, Ramchandani P. Research Brief. Systematic reviews of interventions following physical abuse: Helping practitioners and expert witnesses improve the outcomes of child abuse. UK: Department for Children, Schools and Families, 2009. Reddy LA, Pfeiffer SI. Effectiveness of treatment care with children and adolescents: A review of outcome studies. Journal of the American Academy of Child & Adolescent Psychiatry. 1997;36(5),:581-8. White OG, Hindley N, Jones DPH Risk factors for child maltreatment recurrence: An updated systematic review. Medicine, Science and the Law. 2014. doi: 10.1177/0025802414543855 Curtis NM, Ronan KR, Borduin CM. Multisystemic treatment: A meta-analysis of outcome studies. Journal of Family Psychology. 2004;18(3):411-419. Oliver, J., & Washington, K.T. (2009). Treating perpetrators of child physical abuse: A review of interventions. Trauma Violence & Abuse. 2009;10(2):115-24. Silverman WK, Ortiz CD, Viswesvaran C, Burns BJ., Kolko DJ, Putnam FW, Amaya-Jackson L. Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. Journal of Clinical Child & Adolescent Psychology. 2008;37(1):156-183. Population not relevant to this review Armelius BA, Andreassen Tore H. Cognitive – behavioural treatment for antisocial behaviour in youth in residential treatment. Cochrane Database of Systematic Reviews. 2007;17(4):1-35. Avellar SA, Supplee LH. Effectiveness of Home Visiting in improving child health and reducing child maltreatment. Paediatrics. 2013:S90-99. Berg RC, Denison E. Interventions to reduce the prevalence of female genital mutilation/cutting in African countries. Campbell Systematic Reviews. 2012;9. doi: 10.4073/csr.2012.9 Bilukha O, Hahn RA, Crosby A, Fullilove MT, Liberman, A, Moscicki, E, Snyder, S, Tuma, F, Corso P, Schofield A, Briss PA. The effectiveness of early childhood home visitation in preventing violence: A systematic review. American Journal of Preventive Medicine. 2005;28(2Suppl.1):11-39. Boothby N, Wessells M, Williamson J, Huebner G, Canter K, Rolland EG, Bader F, Diaw L, Levine M, Malley A, Michels K, Patel S, Rasa T, Ssewamala F, Walker V. What are the most effective early response strategies and interventions to assess and address the immediate needs of children outside of family care? Child Abuse & Neglect. 2012;36(10);711-721.


De Swart J, Van den Broek H, Stams G, Asscher J, Van der Laan P, Holsbrink-Engels, G, Van der Helm G. The effectiveness of institutional youth care over the past three decades: A meta-analysis. Children and Youth Services Review. 2012;34(9):1818-1824. Everson-Hock E, Jones R, Guillaume L, Clapton J, Duenas A, Goyder E, Chilcott J, Cooke J, Payne N, Sheppard L, Swann C. Supporting the transition of looked-after young people to independent living: A systematic review of interventions and adult outcomes. Child: Care, Health and Development. 2011;37(6):767-779. Nelson HD, Selph S, Bougatsos C, Blazina I. Behavioral interventions and counseling to prevent child abuse and neglect: Systematic review to update the U.S. Preventive Services Task Force Recommendation Evidence Synthesis (Vol. 98). Rockville, MD: Agency for Healthcare Research and Quality, 2013. Penn H, Barreau S, Butterworth L, Lloyd E, Moyles J, Potte RS, Sayeed R. What is the impact of out-of-home integrated care and education settings on children aged 0–6 and their parents? Research Evidence in Education Library. London: EPPI-Centre, Social Science Research Unit, Institute of Education, 2004. Segal L, Sara Opie R, Dalziel K. Theory! The missing link in understanding the performance of neonate/infant home-visiting programs to prevent child maltreatment: A systematic review. Milbank Quarterly. 2012;90(1):47-106. Population not relevant to this review and not a systematic review Dagenais C, Begin J, Bouchard C, Fortin D. Impact of intensive family support programs: A synthesis of evaluation studies. Children and Youth Services Review. 2004;26(3):249-263. Lee BR, Ebesutani C, Kolivoski KM, Becker KD, Lindsey MA, Brandt NE, Cammack N, Strieder FH, Chorpita BF, Barth RP. Program and practice elements for placement prevention: A review of interventions and their effectiveness in promoting home-based care. American Journal of Orthopsychiatry. 2014;84(3):244-256. Naccarto T, DeLorenzo E. Transitional youth services: Practice implications from a systematic review. Child & Adolescent Social Work Journal. 2008;25(4):287-308. Population and intervention not relevant to this review Solomon SD, Gerrity ET, Muff AM. Efficacy of treatments for posttraumatic stress disorder. An empirical review. The Journal of the American Medical Association. 1992;268(5):633-688. Intervention not relevant to this review Liabo K, Gray K, Mulcahy D. A systematic review of interventions to support looked-after children in school. Child & Family Social Work. 2013;18(3):341-353. Sexual abuse only Adler-Nevo G, Manassis K. Psychosocial treatment of pediatric posttraumatic stress disorder: The neglected field of single-incident trauma. Depression and Anxiety. 2005;22(4):177-189. Amand AS, Bard DE, Silovsky JF. Meta-analysis of treatment for child sexual behavior problems: Practice elements and outcomes. Child Maltreatment 2008;13(2:145-166.


Corcoran J, Pillai V. A meta-analysis of parent-involved treatment for child sexual abuse. Research on Social Work Practice. 2008;18(5):453-464. Harvey ST, Taylor JE. A meta-analysis of the effects of psychotherapy with sexually abused children and adolescents. Clinical Psychology Review. 2010;30(5):517-535. Hetzel-Riggina MD, Brausch AM, Montgomery BS. A meta-analytic investigation of therapy modality outcomes for sexually abused children and adolescents: An exploratory study. Child Abuse & Neglect. 2007;31(2):125-141. Kowalik J, Weller J, Venter J, Drachman D. Cognitive behavioral therapy for the treatment of pediatric posttraumatic stress disorder: A review and meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry. 2011;42(3);405-413. MacDonald G, Higgins JP, Ramchandani P, Valentine JC, Bronger LP, Klein P, O'Daniel R, Pickering M, Rademaker B, Richardson G, Taylor M. Cognitive-behavioural interventions for children who have sexually abused. Cochrane Database of Systematic Reviews. 2012;Issue5.Art.No.: CD001930. doi: 10.1002/14651858.CD001930.pub3 Passerela CDM, Mendes DD, De Jesus Mari J. A systematic review to study the efficacy of cognitive behavioral therapy for sexually abused children and adolescents with posttraumatic stress disorder. Revista de Psiquiatria Clinica. 2010;37(2):63-73. Ramchandani P, Jones, DP. Treating psychological symptoms in sexually abused children: from research findings to service provision. British Journal of Psychiatry. 2003;183(6):484-490. Reeker J, Ensing D, Elliott R. A meta-analytic investigation of group treatment outcomes for sexually abused children. Child Abuse & Neglect. 1997;21(7):669-680. Sanchez-Meca, J, Rosa-Alcazar AI, Lopez-Soler C. The psychological treatment of sexual abuse in children and adolescents: A meta-analysis. International Journal of Clinical and Health Psychology. 2011;11(1):67-93. Walton JS, Chou S. The effectiveness of psychological treatment for reducing recidivism in child molesters: A systematic review of randomized and nonrandomized studies (Provisional abstract). Trauma Violence and Abuse. 2014;6:1-17. Conference paper Heidotting T. A Quantitative Synthesis of Child Sexual Abuse Prevention Programs. Paper presented at the Annual Meeting of the American Educational Research Association (New Orleans, Louisiana, April 4-8, 1994), 1-35. Empty review (i.e., no studies were identified that met inclusion criteria and so no studies were included in the review) Donkoh C, Underhill K, Montgomery P. Independent living programmes for improving outcomes for young people leaving the care system. Cochrane Database of Systematic Reviews. 2006;3:CD005558. doi: 10.1002/14651858.CD005558.pub2


Parker B, Turner W. Psychoanalytic/psychodynamic psychotherapy for children and adolescents who have been sexually abused. Cochrane Database of Systematic Reviews. 2013;7:CD008162. doi: 10.1002/14651858.CD008162.pub2


Appendix B: Review of reviews 1.

Goldman Fraser J, Lloyd SW, Murphy RA, Crowson MM, Casanueva C, Zolotor A, et al. Child exposure to trauma: Comparative effectiveness of interventions addressing maltreatment. Rockville, MD: RTIUNC Evidence-based Practice Center, 2013.

Aim:

"To assess the comparative effectiveness of interventions (psychological and/or pharmacological) for children age 0–14 exposed to maltreatment in addressing child well-being outcomes" (viii).

Population:

Children aged 0–14 exposed to maltreatment. Includes physical abuse, neglect and sexual abuse; foster and biological parents.

Intervention:

Psychological or pharmacological, although no pharmacological interventions were identified. Interventions are grouped by: Parenting; trauma-focused, enhanced foster care through any mode, duration or setting.

Types of studies:

RCTs comparing intervention groups to active or inactive controls; usual care; alternative, derivative.

Outcomes:

Child wellbeing (child mental health, child behaviour, healthy caregiver-child relationship, healthy development, school-based functioning); child welfare (safety, placement stability, permanency); treatment engagement/adherence; adverse events.

Exclusion criteria:

• •

Children over 14 years Studies where child age was not reported (in these cases we assumed all ages were included).

Limits:

1990–2012.

Research question 1:

What is the comparative effectiveness of interventions promoting child wellbeing with children exposed to maltreatment?

Broad findings:

Of the 10 parenting interventions, four trauma interventions (we have excluded two for child sexual abuse), and four enhanced foster care interventions, most had insufficient or low strength of evidence, with only one intervention (parenting intervention named Keeping Foster and Kinship Parents Trained and Supported or KEEP) showing moderate quality evidence for improving child mental and behavioural health and healthy caregiver-child relationship outcomes (small effect).


What is the comparative effetiveness of interventions with children exposed to maltreatment for promoting child weflare outcomes?


Broad findings:

Of the 5 parenting interventions, zero trauma-focused interventions, and four enhanced foster care interventions, most were found to have insufficient evidence or be of low strength. Only KEEP and SafeCare (both parenting interventions) were of moderate strength; KEEP for permanency (effect size not reported); and SafeCare for safety (HR = 0.74 to 0.83).


Among the interventions, how do interventions with particular characteristics (modality, theoretical orientation, setting) compare in improving child outcomes?

Broad findings:

No interventions were found that compared different modalities or settings. Two compared theoretical orientation. Findings suggest that attachmentbased interventions resulted in significantly better outcomes than didactive interventions, and cognitive behavioural interventions resulted in better outcomes than psycho-dynamic interventions. However, the strength of the evidence for these findings was low.


How do interventions compare for improving child outcomes within population subgroups? (child age, type of maltreatment, severity maltreatment, presence of mental or behavioural health problems in child or parent, primary caregiver context eg biol parent, foster, kin, adoptive, residential, group home, parent sociodemographics).

Broad findings:

No new findings are presented here regarding interventions and outcomes, but the findings are carved up differently to address the question; therefore all but KEEP and SafeCare (both parenting interventions) presented low strength of evidence. Seven interventions were found to target the early childhood years, with only SafeCare found to be of moderate strength for safety outcomes (HR = 0.74 to 0.79). One intervention for middle childhood and one intervention for early adolescence were found to be of low strength. Two interventions targeted neglect (one was SafeCare), and two low strength interventions targeted physical abuse. Four interventions were found to include children with mental of behavioural health problems or other special needs; seven interventions involved maltreating parents (including SafeCare); three involved foster or kinship parents.


What is the comparative effectiveness of intervnetions with children exposed to maltreatment for engaging children and/or caregivers in treatment?

Broad findings

Two interventions of moderate strength of evidence were found that used motivational strategies to engage children/caregivers in treatment. Motivational Intervention improved treatment engagement (small effect) and Parent-Child Interaction Therapy Adaptation Package improved treatment retention.



What adverse events are associated with interventions for children exposed to maltreatment?

Broad findings:

One intervention invovled active surveillance of harms and found that a greater number of children in the comparator were removed because of of sexually inappropriate behaviour (TF-CBT).

Meta-analysis:

None.

Author conclusions:

Moderate strength of evidence for improving outcomes was found for only two interventions. The rest of the evidence was insufficient or of low strength, largely due to methodological flaws or lack of replication, rather than demonstration of no effect.

Gaps:

Reviewer notes:

• •

Pre-1990 Children older than 14 excluded

• •

Most interventions involved early childhood Few interventions targeting neglect.

Two interventions with sexual abuse in title that were excluded. Need to look at population in other interventions to see if there are any others to remove. Check TF-CBT in particular.

Compared to AHRQ:

2.

Barlow J, Johnston I, Kendrick D, Polnay L, Stewart-Brown S. Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database of Systematic Reviews [Internet]. 2006;(3).

Aim:

"To assess the efficacy of group-based or one-to-one parenting programmes in addressing child physical abuse or neglect" (p.3).

Population:

Parents of children aged 0–19 years who have a history of physical abuse or neglect.

Intervention:

Brief (6–30 weeks) individual or group-based targeted parenting interventions that aimed to prevent maltreatment.

Types of studies:

RCTs comparing programs to wait-list, no-treatment, placebo, or alternative.

Outcomes:

At least one indicator of abuse, neglect or maltreatment, non-organic failure to thrive or OOH placement. Also outcomes in primary caretakers that are associated with abuse such as parental psychopathology, parenting attitudes


and practices, family functioning. Exclusion criteria:

None.

Limits:

To May 2005.

Research questions:

As stated in aim.

Broad findings:

Seven interventions were included: three RCTs with control group, four studies with alternative treatment. Only three studies assessed the impact of the program on child abuse. These studies used small sample sizes, however "one study suggests that parent-child interaction therapy can reduce rereports of physical abuse" (p.9). A range of other outcomes show small to medium significant effects favouring the parenting programs over controls (e.g. parental autonomy-support, child management skills, intensity and number of behavioural problems, and for favouring the parenting programs compared to alterative treatment (e.g., force, positive parent behaviour, parental anger, parental-effectiveness training).

Meta-analysis:

None.

Author conclusions:

"There is insufficient evidence to support the use of parenting programmes to treat physical abuse or neglect. There is, however, limited evidence to show that some parenting programmes may be effective in improving some outcomes that are associated with physically abusive parenting"

Gaps:

Fairly old.

Reviewer notes:

Findings of each intervention not reported in this spreadsheet.

Compared to AHRQ:

Parenting interventions for maltreatment covered by AHRQ, but also 15+.


3.

Barlow J, Simkiss D, Stewart-Brown S. Interventions to prevent or ameliorate child physical abuse and neglect: Findings from a systematic review of reviews. Journal of Children's Services. 2006;1(3):6-28.

Aim:

"to identify existing systematic reviews of studies of the effectiveness of targeted or indicated interventions for parents that aimed to prevent, reduce or ameliorate incidents of physical abuse or neglect, in order to identify 'what works'" (p. 7).

Population:

"Parents at risk of abusing or who had already abused or neglected their children" (p. 8).

Intervention:

"Targeted or indicated interventions aimed at parents and designed to prevent, reduce or amerliorate child phsyical abuse and neglect" (p. 7). Includes parenting programs, home visiting interventions, early (multimodal) preventive interventions, intensive family preservation services, familyfocused interventions, social support interventions.

Types of studies:

Systematic review.

Outcomes:

"Documented or reported abuse or neglect, or predictors of abuse parenting such as parenting attitudes and practices, anger and stress levels" (p. 9).

Exclusion criteria:

None.

Limits:

To December 2005.

Research questions:

As stated in aim.

Broad findings:

Fifteen systematic reviews met the inclusion criteria. Findings suggest that "following intervention the average parent was functioning better...than control group parents" (p.23). Although the evidence is not strong, the best indicators for improvements from these interventions were: home visiting as a means of detecting maltreatment and for improving parenting in high-risk families; parenting programs for improving aspects of parent, child and family functioning; and intensive family preservation services for improving various outcomes associated with abuse such as parent and family functioning.

Meta-analysis:

None.

Author conclusions:

There is "evidence to demonstrate the effectiveness of a range of services in improving many outcomes that are associated with physical abuse and neglect" but there is "inadequate evidence about their impact on objective measures of abuse and neglect" (p. 25).


Gaps:

Fairly old.

Reviewer notes:

Review of reviews on parenting interventions for maltreament populations.

Compared to AHRQ:

•

Parenting interventions for maltreatment covered by AHRQ, but also

•

15+ Preventive.


4.

Bronson DE, Saunders S, Holt MB, Beck E. A systematic review of strategies to promote successful reunification and to reduce re-entry to care for abused, neglected, and unruly children. The Ohio State University, College of Social Work, 2008.

Aim:

"To 1) conduct a comprehensive, unbiased review of the research literature, 2) describe the review process with enough specificity that it can be replicated or updated by others interested in the topic, 3) appraise the available research for quality and credibility, 4) identify 'best practices' based on the best available evidence, and 5) to disseminate the results of the review for use by practitioners and policy-makers" (p.8).

Population:

Abused, neglected or unruly children following a foster care placement or re-entry to OOHC following family reunification.

Intervention:

Programs to increase reunification or decrease re-entry to care.

Types of studies:

Empirical study evaluating programs, or research to identify factors associated with reunification or re-entry to care.

Outcomes:

Reunification and re-entry to care.

Exclusion criteria:

None.

Limits:

Up to Feb 2008.

Research questions:

1.

2.

What interventions or 'promising practices' appear to result in a) increasing successful family reunification and b) reducing re-entry to OOHC for abused, neglected, or unruly youth/children? What factors are correlated with successful family reunification and what factors are associated with re-entry to care?

3.

What research is needed to develop more effective interventions for successful family reunification and to reduce re-entry to care following reunification?

Broad findings:

Seventy-one studies met the inclusion criteria, including six experimental or quasi-experimental studies. Due to the methodological limitations for these studies, it was not possible to determine the effectiveness of interventions for improving reunification and reducing re-entry. The authors were able to identify common features of these interventions: "1) increased contact betwen workers and parents; 2) parent contacts with child; 3) parenting skills training (including cognitive-behavioural models); 4) mental health and substance abuse services to parents; 5) concrete services to the family; and 6) social support networks" (pp 75-75).

Meta-analysis:

None.


Author conclusions:

Insufficient rigourous evaluations from which to draw definitive conclusions about effectiveness of these interventions for increasing reunification or reducing OOHC re-entry.

Gaps: Reviewer notes: Compared to AHRQ:

5.

Reunification and re-renty not covered by AHRQ.

Everson-Hock E, Jones R, Guillaume L, Clapton J, Goyder E, Chilcott J, et al. The effectiveness of training and support for carers and other professionals on the physical and emotional health and well-being of looked-after children and young people: A systematic review. Child: Care, Health & Development. 2012;38(2):162-74.

Aim:

"To identify and synthesize evdience that evaluates the effectiveness of additional training and support provided to approved carers …,professionals…and volunteers…involved in the care of or working directly or indirectly with (looked after children and young people)" (p.163).

Population:

Carers (foster carers, residential carers, birth family), professionals (teachers, social workers) and volunteers (eg independent visitors, mentors).

Intervention:

Additional training and support for carers, professionals, volunteers in OOHC.

Types of studies:

RCTs, non-RCTs, case controlled, prospective cohort, retrospective cohort, and non-comparative. Type of comparisons included usual training or no training/support.

Outcomes:

Physical and emotional health and wellbeing of looked after children; also longer term outcomes in adult life and other outcomes such as behavioural problems and placement stability.

Exclusion criteria:

Treatment foster care.

Limits:

1990 to Nov 2008.

Research questions:

As stated in aim.

Broad findings:

Only evaluations of training for foster carers was identified (n=6). Key messages were that these programs "have limited impact" (p.173) on behavioural problems, "placement stability and emotional and mental health and well-being" of looked after children. "The most effective interventions


were conducted in the USA, had a longer duration of training (10–14 weeks), a narrower age range of participants (focused on younger children) but a shorter follow-up period" (p173). Meta-analysis:

None.

Author conclusions:

The poor methodological and reporting quality and wide varation in the studies, findings must be approached with caution.

Gaps:

Pre 1990 excluded, treatment foster care excluded.

Reviewer notes: Compared to AHRQ:

6.

Assessing impact of carer training on child outcomes.

Heneghan AM, Horwitz SM, Leventhal JM. Evaluating intensive family preservation programs: A methodological review. Pediatrics. 1996;97(4):535-42.

Aim:

"to determine the adequacy of evaluations of family preservation services (FPS), which are designed to support families and prevention out-of-home placements of children at risk of abuse or nelgect, and to assess the effectiveness of FPS at reducing out-of-home placements of children" (p.535).

Population:

Population not explicitely specified but presumably included families involved in family preservation services where the child is at risk of removal from the home.

Intervention:

Family preservation services including Homebuilders and services like Homebuilders.

Types of studies:

Studies using a comparison group.

Outcomes:

Prevention and reduction of OOHC placements.

Exclusion criteria:

Reviews.

Limits:

English; 1977 to 1993.

Research questions:

As stated in aim.

Broad findings:

Ten studies met the inclusion criteria. Two studies were rated acceptable, four were adequate and four were unacceptable. Relative risk of OOH


placement was significantly reduced in two studies Meta-analysis:

None.

Author conclusions:

Overall poor methodology of studies; demonstrated "no benefit with regard to placement in eight of 10 studies, whereas in two studies, the rates of outof-home placements were reduced after families recieved FPS" (p.540).

Gaps:

Fairly old; some aspects of review design are not clearly articulated.

Reviewer notes:

Only one of the two studies with improvements was an RCT, the other was quasi-experimental so it was less rigorous.

Compared to AHRQ:

Family preservation.

7.

Littell J, Popa M, Forsythe B. Multisystemic Therapy for social, emotional, and behavioral problems in youth aged 10-17. The Cochrane Database of Systemic Reviews. 2005(4):Art.No.:CD004797.pub4.

Aim:

"To assess the impacts of MST on out-of-home living arrangements, crime and delinquency, and other behavioral and psychological outcomes of youth and families" (p. 3).

Population:

Children and youth (0–17) with social, behavioural and emotional problems, and their families. Include abused, neglected and dependent children/youth at risk of OOHC, those with mental helath problems at risk of hospitalisation, delinquent youth at risk of incarceration/residential treatment.

Intervention:

Multisystemic Therapy.

Types of studies:

RCTs compared to usual services, alternate treatments, or no treatment.

Outcomes:

•

Behavioural – antisocial behaviour (such as arrests, convictions); drug use; school attendance

•

Psychosocial – psychiatric symptoms, school performance, peer relations, self-esteem

•

Family – such as in-home vs OOHC, family functioning.

Exclusion criteria:

Non-licensed multisystemic treatments.

Limits:

Up to 2003.

Research questions:

As stated in aim.


Broad findings:

Eight studies met the criteria for inclusion. Compared to other social interventions, there are more RCTs of MST, thus the evidence for MST is more robust. "The evidence about the effectiveness of MST is inconclusive" (p.11). It is not possible to determine if MST has a greater effect than other services, or vice versa. The study in this review with the most rigorous design found no significant difference between MST and usual services in the number of arrests, convictions, or restrictive OOH placements.

Meta-analysis:

None.

Author conclusions:

"There is inconclusive evidence of the effectivenes of MST when compared with other interventions with youth. There is no evidence that MST has harmful effects" (p. 2).

Gaps: Reviewer notes:

Add to more recent MST review by van der Stouwe.

Compared to AHRQ:

Covers children over 14 years, covers MST.

8.

Macdonald G, Turner W. Treatment Foster Care for improving outcomes in children and young people. Cochrane Database of Systematic Reviews [Internet]. 2008;(1). DOI: 10.1002/14651858.CD005649.pub2 Turner W, Macdonald G. Treatment foster care for improving outcomes in children and young people: A systematic review. Research on Social Work Practice. 2011;21(5):501-27.

Aim:

"To assess the impact of Treatment Foster Care on psychosocial and behavioural outcomes, delinquency, placement stability, and discharge status for children and adolescents who require out-of-home placement" (p.4).

Population:

Children aged up to 18 years in OOHC. Reasons for placement include: mental health problems and may require hopsitalisation, substance dependancy, delinquency and at risk of incarceration or placement in restrictive residential settings, abuse or neglect.

Intervention:

Treatment Foster Care.

Types of studies:

Random or quasi-random allocation to groups (eg by day of the week, case number). Studies comparing to control – no treatment, wait-list, or regular foster care.

Outcomes:

•

Behavioural outcomes – externalising behaviour (eg aggresssion, selfharm, rule-breaking, defiance, truancy), anti-social behaviour (delinquency, arrest, conviction, incarceration), sustance abuse, use of


prescription medication for behavioural symptom management •

Psychological functioning – psychiatric diagnoses, confidence, resilience, adaptability

•

Educational outcomes – school attendance and achievement, training and employment outcomes

• •

Interpersonal functioning – community participation, peer relationships Mental health status – wellbeing, self esteem, psychiatric issues, use

•

prescription medications Physical health – treament foster carer skills and interpersonal functioing placement stability, restrictiveness of placement, independent living skills costs.

Exclusion criteria:

None.

Limits:

Up to 2007.

Research questions:

As stated in aim.

Broad findings:

Five studies were included in the review. Findings suggest that "TFC is a promising social intervention for children and young people at risk of placement" in restrictive settings (p.19), in particular children and youth with complex emotional, behavioural and psychologial needs.

Meta-analysis:

None.

Author conclusions:

"Although the inclusion criteria for this systematic review set a study design threshold higher than that of previous reviews, the results mirror those of earlier reviews but also highlight the tendency of the perceived effectiveness of popular interventions to outstrip their evidence base. Whilst the results of individual studies generally indicate that TFC is a promising intervention for children and youth experiencing mental health, behavioural problems or problems of delinquency, the evidence base is less robust than usually reported" (p.2).



9.

MacLeod J, Nelson G. Programs for the promotion of family wellness and the prevention of child maltreatment: a meta-analytic review. Child Abuse & Neglect. 2000;24(9):1127-49.

Aim:

"To determine the effectiveness of programs in promoting family wellness and preventing child maltreatment and to identify factors that moderate program success" (p.1127).

Population:

Children aged up to 12 years.

Intervention:

All types of prevention programs related to child maltreatment and family wellness including home visiting, multi-component, social support/mutual aid, media, intensive family preservation services, parent training.

Types of studies:

Prospective controlled design.

Outcomes:

Placement rates, maltreatment, parent attitude, parent behaviour, HOME (Home Observations for Measurement of the Environment).

Exclusion criteria:

Children over 12 years; therapies and treatment interventions; sexual abuse prevention programs.

Limits:

1979–1998.

Research questions:

1.

Which program types are most successful in the prevention of child maltreatment and the promotion of family wellness?

2.

Which outcomes are the most affected by programs?

Broad findings:

Fifty-six studies met the inclusion criteria. "Most interventions to promote family wellness and prevent child maltreatment are successful" (p.1114). Interventions with the largest effect sizes were multicomponent proactive interventions and home visiting interventions and these both were proactive rather than reactive and commenced prenatally or at birth. Proactive interventions had larger effect sizes at follow-up than immediately at post intervention, whereas the opposite was found for reactive interventions, suggesting sustained gains for proactive interventions. Intensive family preservation that are strengths based, that involve more participant involvement, and social support had a higher effect size than those without. Effect sizes were higher in home visitation and intensive family preservation if the participants were of mixed SES, rather than all low SES.

Meta-analysis:

Yes.

Author conclusions:

"Findings from this review demonstrated that child maltreatment can be prevented and that family wellness can be promoted" (p.1127).


Gaps:

Children over 12 years.

Reviewer notes:

Similar interventions to the Barlow 2006 review of reviews. Lacks clarity regarding some aspects of review procedures and inclusions (eg comparator types). A broad range of interventions/studies were included, with not very specific inclusion critieria.

Compared to AHRQ:

Preventive.

10. Turner W, Macdonald G, Dennis JA. Behavioural and cognitive behavioural training interventions for assisting foster carers in the management of difficult behaviour. Cochrane Database of Systematic Reviews [Internet]. 2007;(1). Aim:

"To assess the effectiveness of behavioural and cognitive-behavioural training interventions in improving a) placement stability, b) foster carers' psychological well-being and functioning, and c) looked-afer children's behavioural and relationship problems" (p.4).

Population:

Foster parents/carers looking after children and adolescents up to and including 18 years of age.

Intervention:

Group and individual interventions which were described as behavioural, cognitive-behavioural, OR a combination of CBT plus one of operant learning, classical learning, social learning theory, cognitive learning, OR one or more of the latter list.

Types of studies:

Studies where participant allocation to experimental or control group was random or quasi-random; wait-list or no-treatment controls only.

Outcomes:

•

Child outcomes – psychological functioning, behaviour problems, interpersonal functioning

•

Carer outcomes – skills, knowledge, attitudes, psychological functioning

•

Foster family outcomes – family functioning, carer-child relations

•

Agency outcomes – placement stability, placement completion.

Exclusion criteria:

None listed.

Limits:

To September 2006.

Research questions:

As stated in aim.

Broad findings:

Seven studies (six randomised trials) met eligibility criteria. Very little effect on child outcomes, carer outcomes, or agency outcomes. "[N]o evidence that training foster carers in cognitive-behavioural methods has a significant


impact on psychological functioning of looked-after children, their behavioural profile or their interpersonal functioning" (p. 16). Meta-analysis:

Data from three studies only, child psychological outcomes and foster carer skills only.

Author conclusions:

No evidence of efficacy of behavioural or cognitive-behavioural training interventions for foster carers.


11. van der Stouwe T, Asscher JJ, Stams GJ, Dekovic M, van der Laan PH. The effectiveness of Multisystemic Therapy (MST): A meta-analysis. Clinical psychology review. 2014;34(6):468-81. Aim:

To examine the effectiveness of MST for juvenile delinquents and/or adolescents showing social, emotional, and behavioural problems.

Population:

Juvenile delinquents and/or adolescents showing social, emotional, and behavioural problems. (Could not find participant inclusion criteria; we are assuming they included children 18 years and under, but don't know if there was a lower limit.)

Intervention:

Multisystemic theory (MST). Elements cited in intro: targets individual, family, peer, school, neighbourhood characteristics simultaneously; focuses on improving family functioning; is flexible; addresses specific individual risk factors; include therapist visits to families at home/in community; 24/7 therapist availability; session frequency can go up to daily if needed. Training, supervision, and organisational support for therapists.

Types of studies:

MST vs one or more control groups (no specification of random assignment); pre- and post-treatment measures and/or follow-up measures available; statistics suitable for meta-analyses available.

Outcomes:

Primary: delinquency. Secondary: Psychopathology, skills and cognitions, substance use, family factors, out-of-home placement, peer factors.

Exclusion criteria:

Not stated.

Limits:

To 2012.


Research questions:

"1) To what extent is MST effective in the prevention of recidivism (primary outcome)? 2) To what extent is MST effective in improving juveniles' functioning on other psychological (secondary) outcomes? 3) Which sample, treatment and study characteristics have a moderating effect on (heterogeneous) outcomes? 4) What is the unique contribution of significant moderators when controlling for other significant moderating variables?" (p. 470).

Broad findings:

Fifty-one studies met criteria, yielding 22 independent samples. Small but significant treatment effects on primary outcome (delinquency) and secondary outcomes (psychopathology, substance use, family factors, out-ofhome placement and peer factors). After taking publication bias into account, theeffect sizes decreased for all outcomes--only psychopathology and family factors remained significant. (But authors argue that the "file draw" (file drawer) effect does not exist for delinquency outcomes and therefore that the effect should stand.) There were larger effect sizes for studies where the average participant age was under 15 and studies with larger proportions of Caucasian juveniles. No moderating effect for research design – no difference between randomised and non-randomised studies.

Meta-analysis:

Yes.

Author conclusions:

MST most effective for juveniles under 15, with severe baseline conditions. For older juveniles, MST may be more effective if treatment focuses more on peer relationships and school risk and protective factors.



12. Winokur M, Holtan A, Batchelder KE. Kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment. Cochrane Database of Systematic Reviews. 2014;1:CD006546. Aim:

Evaluate the effect of kinship care placement (vs foster care) on safety, permanency, and well-being of children removed from the home due to maltreatment.

Population:

Children and youth under age 18, removed from home for abuse, neglect, or other maltreatment.

Intervention: Types of studies:

Controlled experimental and quasi-experimental studies, cross-sectional or longitudinal comparison with foster care.

Outcomes:

Behavioural development, mental health, placement stability, permanency, educational attainment, family relations, service utilisation, re-abuse.

Exclusion criteria:

Kinship care in restrictive settings.

Limits:

To March 2011.

Research questions:

As stated in aim.

Broad findings:

Seventy-one studies included. Significant effects were found for: behavioural development; mental health; placement stability; re-abuse. Mixed effects for: permanency; service utilisation. No significant effects for: educational attainment; family relations.

Meta-analysis:

Sufficient data for meta-analysis of 21 out of 29 outcomes.

Author conclusions:

"It appears that children in kinship care experience better outcomes in regard to behaviour problems, adaptive behaviours, psychiatric disorders, wellbeing, placement stability, guardianship, and institutional abuse than do children in foster care. There were no detectable differences between groups on reunification, length of stay, educational attainment, family relations, developmental service utilisation, and physician service utilisation. However, children placed with kin are less likely to achieve adoption and to utilise mental health services, while being more likely to still be in placement than are children in foster care" (p.20).



Compared to AHRQ:

13. Ziviani J, Feeney R, Cuskelly M, Meredith P, Hunt K. Effectiveness of support services for children and young people with challenging behaviours related to or secondary to disability, who are in out-of-home care: A systematic review. Children and Youth Services Review. 2012;34(4):758-70. Aim:

"To ascertain current best practices and efficacy of service delivery to CYP [children and young people] with behavioural issues related to or secondary to disability, who are in out-of-home care" (p. 759).

Population:

CYP from birth to 18 years, with psychological and/or behavioural issues and/or a disability, who are in out-of-home care. NOTE from intro, it seems clear that the CYP are in OOHC due to factors which "primarily pertain to issues of neglect and abuse". Authors are arguing this without stating *must be in OOHC due to abuse/neglect* in the inclusion criteria; exclusion criteria - if reason for OOHC is alternative to residential care or incarceration due to conduct disorder etc.

Intervention:

Fostering Individualized assistance program (FIAP) – Clark et al 1994, 1998. Small group training on challenging behaviour management – Pithouse et al 2002. Parent-child Interaction therapy (PCIT) Timmer et al 2006.

Types of studies:

Experimental or quasi-experimental longitudinal studies (randomised, quasirandomised, and non-randomised controlled trials, and cohort studies).

Outcomes:

Intervention aims related both to CYP and caregivers/parents. "Broadly, all interventions aimed to reduce children's behavioural problems, supporting their adjustment, emotional or other mental health issues." (p. 761). Behaviour, delinquency, placement stability, community participation. Aims for carers differed across interventions, included: increase knowledge of behaviour management strategies, enhance capacity, reduce stress and potential for abuse, improve psychological functioning, develop more positive and fulfilling relationship, increase ability to offer stable and nurturing home life.

Exclusion criteria:

Studies with participants who were in treatment foster care as an alternative to residential care or incarceration due to severe antisocial behaviour, delinquency problems, or being chronic juvenile offender.

Limits:

Dissertations, reports, or studies in peer-reviewed journals or books, 1990– September 2010.

Research questions:

As stated in aim.


Broad findings:

Two RCTs and Two non-randomised CTs identified. Two (Pithouse and Timmer) were of behavioural parent-training interventions, with systematic protocols. Other two (Clark et al) involved caregiver training in implementing strategies in home, and information provision. Interventions led to positive outcomes in some areas for some CYP. Less clear effect on outcomes for foster caregivers/parents. Evidence of improvement in CYP outcomes in three of four studies. The two studies measuring emotional and psychological functioning in caregivers showed no change; attitude (one study) did not change; knowledge and responses to challenging behaviour (one study) did not change. There was significant reduction in potential for child abuse (one study).

Meta-analysis:

No.

Author conclusions:

"Overall, results of the included studies showed that interventions lead to some positive outcomes for the CYP; however, interventions for caregivers/parents showed mixed results. The impact of these interventions varied greatly from program to program" (p. 768).


Fair amount of detail re outcomes and measures available in review.

Compared to AHRQ:

14. Skowron E, Reinemann DHS. Effectiveness of psychological interventions for child maltreatment: A meta-analysis. Psychotherapy. 2005;42(1):52-71. Aim:

Test effectiveness of psychological treatments for child maltreatment (CM); examine if CM treatment effects differ according to the type and target of outcomes; explore impact of any other relevant study characteristics.

Population:

Participants referred for child maltreatment, physical abuse, sexual abuse, and/or physical neglect. Also included mandated and voluntary participants, attempted to compare effectiveness between groups.

Intervention:

Psychological treatments for children and/or parents. Compared individual, group, family, milieu, and multicomponent approaches; behavioural and nonbehavioural interventions.

Types of studies:

CM treatment vs no-treatment, placebo, and standard case management controls. Investigated if size of treatment effects covaried with quality of study design.


Outcomes:

child cognitive process; child personality (e.g. self-esteem, depression, anxiety); parent attitudes, behaviours; parent ratings of child; teacher ratings of child; behavioural observations of child; behavioural observations of family.

Exclusion criteria: Limits:

1974–2000; English only.

Research questions:

As stated in aim.

Broad findings:

Twenty-one studies examining 25 treatments met inclusion criteria. Outcome effect sizes: child cognitive process (.28); child personality self-report (.44); parent ratings of child behaviour (.42); behavioural observations of child (.30); parent self-report (.53); behavioural observations of family (.21). All were significant, some CIs close to 0. Psychologcial treatments for CM improved outcomes for participants when compared with control; the average effect size was .54 (medium effect size). This is comparable to other published meta-analyses. There was very limited evidence regarding maintenance of gains, with only a small number of studies providing data at follow-up (follow-ups ranged from three months to 12 years post-treatment.

Meta-analysis:

Yes.

Author conclusions:

Psychological treatments for CM led to improvements among participants, compared with wait-list, placebo, or community case management. Treatments for child sexual abuse had slightly larger effects, but also had significant within-group variance. Insufficient data to report critical moderators of child sexual abuse treatment effectiveness, such as length of treatment, severity of abuse, abuse comorbidity. (?Does this imply that the same holds for other CM types). Treatment length was confounded with behavioural/non-behavioural comparisons – non-behavioural treatments were more effective but also longer. Effects did not vary by modality or individual/group delivery; or as a function of mandatory vs voluntary participation. Limited evidence of effect at follow-up.



15. Allin H, Wathen C, MacMillan H. Treatment of Child Neglect: A Systematic Review. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie. 2005;50(8):497-504. Aim:

"To systematically evaluate the available evidence regarding the effectiveness of child neglect treatment programs, including those focused on victims of childhood neglect and (or) their caregivers" (p. 497).

Population:

Samples of children and/or families exposed to neglect (may also have included abuse, because the two could not be separated).

Intervention:

Child neglect interventions; any treatment type, but not prevention.

Types of studies:

Any study with an observational or experimental design that included a control group.

Outcomes:

Child discipline, parent-child interaction, family function, recidivism, incidence, family reunification, parent and child functioning.

Exclusion criteria:

Prevention programs.

Limits:

1980–2003

Research questions:

As stated in aim.

Broad findings:

Fourteen studies met both content and design criteria. Only two studies rated as 'good', three as 'fair'. There was some evidence supporting play therapy. One study rated as 'good' found that group play training improved child cooperation and interaction with peers. Another study rated as 'good' found that withdrawn children showed more interactive play after resilient peer treatment. However another study did not show benefits of play therapy. In a study rated as 'fair', child self-reported cognitive competency, peer acceptance and maternal acceptance were higher after therapeutic day treatment.

Meta-analysis:

No

Author conclusions:

Some evidence of effectiveness. Some specific play therapy programs were beneficial. A day treatment program beneficial on one(!) outcome: child selfesteeem.


Pretty good intervention details provided — but benefits appear extremely limited — or at least, no strong evidence of effectiveness. Cannot report on effectiveness of any other treatment types, and no studies meeting criteria


involved treatment aimed specifically at neglectful parents. Compared to AHRQ:

16. Roberts AR, Everly GS, Jr. A meta-analysis of 36 crisis intervention studies. Brief Treatment and Crisis Intervention. 2006;6(1):10-21. Aim:

To conduct an exploratory meta-analysis of crisis intervention treatment modalities.

Population:

Not stated but presumably people involved in crisis intervention; includes families and adults outside of the family context.

Intervention:

Crisis intervention.

Types of studies:

Pre-post design.

Outcomes:

"Specific outcome measures".

Exclusion criteria:

None.

Limits:

None.

Research questions:

Not reported.

Broad findings:

Thirty-six studies were included, 12 of those were RCTs with control groups. High average effect sizes were observed for abusive families in acute crisis as well as adults in acute crisis, who received multicomponent critical incident stress management and intensive crisis intervention.

Meta-analysis:

Yes.

Author conclusions:

"Intensive home-based crisis intervention with families as well as multicomponent critical incident stress management are effective interventions".


This review did not meet our systematic review criteria and details of the methodology are not clear. Further, it is unclear what populations were included, though adult populations were included. Study designs included pre-post. The findings should be considered with caution.


Compared to AHRQ:

17. Dalziel K, Segal L. Home visiting programmes for the prevention of child maltreatment: Costeffectiveness of 33 programmes. Archives of Disease in Childhood. 2012;97(9):787-98. Aim:

"To investigate the cost-effectiveness of home visiting programmes compared to current practice for the prevention of child maltreatment".

Population:

Not specified, but assummed families participating in home visiting, no indication of history or risk.

Intervention:

Home visiting programs commencing during pregnancy or within 6 months of birth.

Types of studies:

Any study with a control group, a core home visiting component.

Outcomes:

Child maltreatment, out of home care, injury or accident or hospitalisation. Must report information on cost effectiveness and details of programme component costings.

Exclusion criteria:

None.

Limits:

Up to 2010.

Research questions:

As stated in aim.

Broad findings:

Twenty-eight trials of 33 programs were included. The most expensive programs were targeting higher risk families. Programs that delivered much more home visiting were more expensive. The seven best performing adequate quality programs in terms of cost-effectiveness were Child and Youth Program, a home visiting program in Australia for high-risk teenage mothers, Special Families Care Project in Minnesota, Nurse Home Visiting Program, Early Start New Zealand, Nurse Family Partnership.

Meta-analysis:

None.

Author conclusions:

Most cost effective tend to be professional-delivered in a multi-disciplinary team, for high-risk populations and involving more than just a home visiting component.


Note that this did not meet our criteria for systematic review and results


should be considered with caution. Compared to AHRQ:
