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Primary care interventions provided to families where children have been subjected to abuse and neglect

A systematic review and assessment including economic and ethical aspects

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SBU Assessment

Presents a comprehensive, systematic assessment of available scientific evidence for effects on health, social welfare or disability. Full assessments include economic, social and ethical impact analyses. Assessment teams include professional practitioners and academics. Before publication the report is reviewed by external experts, and scientific conclusions approved by the SBU Board of Directors.

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Published: Report no: 280 Registration no: SBU 2017/71 ISBN: 978-91-88437-22-8 https://www.sbu.se/280e

Conclusions

  • A survey sent to the Swedish social and child psychiatry services revealed that the efficacity of only a minority of interventions provided to families where children had been abused and neglected had been scientifically evaluated. A better understanding of how well interventions work would help establish conditions where fewer children are subjected to abuse and neglect.
  • Project Support and Parent Child Interaction Therapy (PCIT) may help reduce abuse and neglect of pre-school aged children.
  • Project Support and PCIT may lead to decreased disruptive behavior among children. PCIT may also improve how the child and parent interact. Interventions aiming at improving attachment behavior among young children for example Attachment and Biobehavioral Catch-up (ABC), may result in the children having less disorganized attachment, which are associated with the development of mental health issues or difficulties with peers later in life.
  • The intervention costs for Project Support are some­­what higher than for PCIT. Project Support may lead to abuse cessation for slightly more children, so the intervention costs per child not exposed to further abuse may be similar for the two interventions.
  • According to SBU’s overall assessment, choice of intervention needs to be based on the child’s and family’s situation, and should take into account, for instance, age, type of abuse, and the effect on the child´s mental health and their relationships with peers. When a new intervention is introduced, it is important to consider the available empirical evidence for that intervention. When planning or initiating an intervention, the child’s legal rights need to be considered.
  • Studies using qualitative methodology indicate that parents experience that interventions can help them find better parenting strategies, but that the interventions do not always match the families’ specific needs. The staff’s ability to express trust and respect for personal integrity was pointed out as important; providing the intervention in a welcoming environment was also seen as important. Parents feel they need support after the intervention has ended. Too few studies evaluated children's experiences to be able to draw any meaningful conclusions.
  • According to reports from user organizations, children and youth who have been in contact with social services feel they did not receive the professional support they needed. They also feel that interventions are provided too late in their lives, and that they are not adequately informed about what kinds of help they are entitled to. These narratives highlight a situation which may be in conflict with children’s rights accord­ing to Swedish law and the Convention on the Rights of the Child.
  • To allow the comparison and synthesis of results from different studies, it is important for researchers to use consistent ways to measure outcomes. This consistency would also help with the interpretation of cost effectiveness. Future studies need more participants and longer follow-up. In addition, plausible negative effects need to be investigated. Children’s rights according to the Convention on the Rights of the Child always needs to be considered when children are involved in research.

Background and objective

Three to nine percent of children in the Nordic countries experience child abuse in their homes, and seven to twelve percent witness violence. The aim of this systematic review was to identify, appraise and synthesize the empirical evidence regarding a) the effectiveness and cost effectiveness of primary care interventions for families where children are exposed to child abuse and neglect and b) experiences of program participation. User perspectives, ethical aspects and children’s rights are included in this assessment.

Method

The systematic review was conducted in accordance with SBU’s methodology (www.sbu.se/en/method). The interventions should be provided to families where child abuse and neglect had been documented. Quantitative studies should include a control group and have a pre- and post-assessment. Studies evaluating experiences should be based on qualitative interviews. The economic aspects include a systematic review of the literature, estimates of intervention costs for selected manual based interventions, and cost-effectiveness analyses.

Effective interventions

A total of 11,386 abstracts were reviewed. Of these, 35 studies matched the inclusion criteria. Meta-analysis indicates that Project Support and Parent Child Interaction Therapy (PCIT) decreases abuse and neglect and reduces disruptive behavior among children. Attachment and Bio-behavioral Catch-up (ABC) were found to decrease the rates of disorganized attachment among children.

Economic aspects

The intervention costs per family for seven manual based programs varied between SEK 3 800 and 25 700 (Swedish krona year 2016). Treatment of 100 children with PCIT was estimated to cost SEK 1.27 million (of which SEK 0.7 million for social services) versus SEK 1.44 million (SEK 1 million for social services) for Project Support. The intervention costs per child with no further experience of family violence (15 out of 100 children for PCIT and 19 for Project Support) amounted to SEK 85 000 and SEK 76 000. The uncertainty in the effect estimates implies no evident difference in cost-effectiveness of the interventions. The analyses only include short-term costs for implementing the programs.

Parents and children’s experiences

There was a lack of empirical studies evaluating children´s experiences. Parent´s report that interventions may contribute to better parenting strategies, but do not always match the families’ specific needs. Staff’s ability to express trust and show respect for personal integrity, were stated as important as well as the envir­onment in which the intervention took place. Parents state that they need continuous support after intervention participation. According to Swedish organizations representing children who have suffered abuse, children report a lack of support from professionals to process their traumatic experiences. They also feel interventions are delivered too late in their lives and that their voices are not heard during family treatment.

Discussion

Social- and child psychiatric services use numerous interventions for families were children are exposed to abuse and neglect. Two interventions were shown to be able to decrease child abuse and neglect: Project Support and Parent Child Interaction Therapy (PCIT). It is important to acknowledge that lack of scientific evidence does not mean that an intervention is ineffective, it means that we do not know if it is effective or ineffective. Additionally, interventions that were not proven effective for the population studied in this review, nevertheless can be effective for other populations. For several interventions in this review, Swedish feasibility studies have been conducted.

Included/excluded studies and search strategies

The full report in Swedish

The full report Öppenvårdsinsatser för familjer där barn utsätts för våld och försummelse

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Project group

Experts

  • Ulf Axberg
  • Anders Broberg
  • Pia Enebrink
  • Staffan Janson
  • Stefan Wiklund

SBU

  • Lina Leander, Project Manager
  • Agneta Brolund, Information Specialist
  • Christel Hellberg, Assistant Project Manager
  • Pia Johansson, Health Economist
  • Naama Kenan Modén, Assistant Project Manager
  • Agneta Petersson, Assistant Project Manager
  • Anneth Syversson, Project Administrator
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