IMPRoving Outcomes for children exposed to domestic ViolencE (IMPROVE): an evidence synthesis

Adrenocortical deviations and adverse clinical outcomes in children and adolescents exposed to interparental intimate partner violence: A systematic review

Childhood exposure to interparental intimate partner violence (i-IPV) is a pervasive form of child maltreatment, posing major public health concerns and elevating risks for enduring adverse clinical and developmental consequences. However, assessing the full spectrum of clinical effects is challenging, potentially leading to inconsistent identification of children in need of early intervention. This systematic review aimed to identify hypothalamic-pituitary-adrenocortical axis dysfunction following i-IPV exposure, elucidating the underlying biopsychobehavioural mechanisms and predicting adverse outcomes. We searched Embase, MEDLINE, and PsycINFO for peer-reviewed studies from infancy through adolescence, screened reference lists and conducted forward searches. Analysis of 23 publications (N = 1848) revealed associations between i-IPV and altered adrenocortical function from early childhood, influenced by FKBP5 haplotype, parental caregiving and offspring emotional insecurity. Results showed that the adrenocortical stress response may predict internalising and externalising problems, childhood asthma, impaired executive function and poor academic performance. Nonetheless, inconsistencies in findings between studies suggest methodological heterogeneity and potential bias. Identifying biomarkers such as cortisol can enhance prediction and mechanism-based intervention efforts but long-term studies with a common theoretical and methodological framework are needed for comprehensive understanding. Integrating biological, emotional, and behavioural assessments could potentiate trauma services and research, ultimately improving outcomes for affected children.

Service evaluation of an independent domestic violence advocate post in a children's hospital

Domestic violence and abuse (DVA) has detrimental effects on the health and well-being of children and young people exposed to it, whether they witness or experience it. The introduction of independent domestic violence advocates in UK hospitals has enhanced the safety of victims of DVA. In 2020-2021 an independent domestic violence advocate post was piloted at a children's hospital for one year, the advocate's role being to train hospital staff and support women who had experienced DVA. A service evaluation showed that the training and support provided by the independent domestic violence advocate had benefits for women, children and staff. It also confirmed that the commissioning of services for children exposed to DVA is often underfunded and overshadowed by the provision of support to adults.

Harmonising outcome measurement for child focused domestic abuse interventions. Reflections on the development and implementation of a core outcome set

There is appetite in the UK to better measure the impact of domestic violence and abuse (DVA) interventions on children. The spread of outcomes-based commissioning means outcome measurement is no longer just the territory of academic researchers but is now firmly within the purview of practitioners and policy makers. However, outcomes measured in trials only partially represent the views of those delivering and using services with respect to how success should be defined and captured. Even within trials there is huge inconsistency in the definition and measurement of important endpoints. This yields a body of evidence that is difficult to make sense of, defeating the ends for which it was produced - to improve the response to children and families who have experienced abuse. Development of Core Outcome Sets (COS) is seen as a solution to this problem, by establishing consensus across key stakeholder groups regarding a minimum standard for outcome measurement in trials, and increasingly in service delivery contexts. To date COS development has addressed outcomes relating to health conditions or interventions, with limited application to public health challenges. We reflect on our efforts to develop a COS to evaluate psychosocial interventions for children and families experiencing DVA. We highlight the value of COS development as a mechanism for improving evidence quality and the response to families experiencing abuse. Finally, we make recommendations to researchers and COS guideline developers to support this broader application of COS methodology.

Polyvictimization and Adolescent Health and Well-Being in Ethiopia: The Mediating Role of Resilience

Interpersonal violence is a pervasive experience affecting one billion children and adolescents annually, resulting in adverse health and well-being outcomes. Evidence suggests that polyvictimization, the experience of multiple forms of violence, is associated with more harmful consequences for adolescents than experiencing individual types of violence, although data from low-and middle-income countries are limited. This study analyzed data on over 4100 adolescents from the Gender and Adolescence, Global Evidence Study in Ethiopia to examine the association between polyvictimization and adolescent mental and physical health and the mediating role of resilience using linear regression and path analysis. We hypothesized that adolescents experiencing polyvictimization would experience worse mental and physical health than those experiencing no types or individual types of victimization, and that resilience would mediate these relationships. Half of sampled girls and over half of boys experienced polyvictimization. Among both sexes, polyvictimization was associated with worse mental but not worse physical health. Resilience mediated the association between polyvictimization and mental health among girls only. Strengthening resilience among girls may be an effective avenue for mitigating polyvictimization's negative mental health effects, but additional research and programming for preventing and identifying polyvictimized adolescents and linking them to care is needed.

Adaptations of evidence-based trauma-focused interventions for children and adolescents: a systematic review

BACKGROUND

Rates of potentially traumatic events (PTEs) and other forms of adversity among children are high globally, resulting in the development of a number of evidence-based interventions (EBIs) to address the adverse outcomes stemming from these experiences. Though EBIs are intended to be delivered according to set parameters, these EBIs are frequently adapted. However, little is known about existing adaptations of EBIs for children who experienced PTEs or other adversities. As such, this review aimed to determine: (1) why existing EBIs designed to address PTEs and other adversities experienced by children are adapted, (2) what processes are used to determine what elements should be adapted, and (3) what components of the intervention are adapted.

METHODS

Nine academic databases and publicly available search engines were used to identify academic and grey literature. Initial screening, full-text review, data extraction, and quality determinations were completed by two members of the research team. Data were synthesized narratively for each adapted EBI by research question.

RESULTS

Forty-two studies examining the adaptations of nine different EBIs were located, with Trauma-Focused Cognitive Behavioral Therapy and Cognitive Behavioral Intervention for Trauma in Schools being the most commonly adapted EBIs. Most frequently, EBIs were adapted to improve fit with a new population and to address cultural factors. Most commonly, researchers in combination with others made decisions about adapting interventions, though frequently who was involved in these decisions was not described. Common content adaptations included the addition of intervention elements and the tailoring/tweaking/refining of intervention materials. Common contextual adaptations included changes to the intended population, changes to the channel of treatment delivery, and changes to who administered the intervention.

CONCLUSIONS

Most published studies of EBI adaptions have been developed to improve fit and address cultural factors, but little research is available about adaptations made by clinicians in day-to-day practice. Efforts should be made to evaluate the various types of adaptations and especially whether adaptations improve access to services or improve child outcomes in order to ensure that all children exposed to trauma can access effective treatment.

TRIAL REGISTRATION

The protocol for this systematic review was published with PROSPERO (CRD42020149536).

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis

BACKGROUND

It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability.

OBJECTIVES

This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes.

SEARCH METHODS

In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations.

DATA COLLECTION AND ANALYSIS

Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings.

MAIN RESULTS

We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

Child and family-focused interventions for child maltreatment and domestic abuse: development of core outcome sets

BACKGROUND

The current evidence for child maltreatment (CM) and domestic violence and abuse (DVA) interventions is limited by the diversity of outcomes evaluated and the variety of measures used. The result is studies that are difficult to compare and lack focus on outcomes reflecting service user or provider priorities.

OBJECTIVE

To develop core outcome sets (COSs) for evaluations of child and family-focused interventions for: (1) CM and (2) DVA.

DESIGN

We conducted a two-stage consensus process. Stage 1: a long list of candidate outcomes across CM and DVA was developed through rapid systematic reviews of intervention studies, qualitative and grey literature; stakeholder workshops; survivor interviews. Stage 2: three-panel, three-round e-Delphi surveys for CM and DVA with consensus meetings to agree with the final COSs.

PARTICIPANTS

287 stakeholders participated in at least one stage of the process (ie, either CM or DVA COS development): workshops (n=76), two e-Delphi surveys (n=170) and consensus meetings (n=43). Stakeholders included CM and DVA survivors, practitioners, commissioners, policymakers and researchers.

RESULTS

Stage 1 identified 335 outcomes categorised into 9 areas and 39 domains. Following stage 2, the final five outcomes included in the CM-COS were: child emotional health and well-being; child's trusted relationships; feelings of safety; child abuse and neglect; service harms. The final five outcomes in the DVA-COS were: child emotional health and well-being; caregiver emotional health and well-being; family relationships; freedom to go about daily life; feelings of safety.

CONCLUSIONS

We developed two COSs for CM and DVA with two common outcomes (child emotional health and well-being; feelings of safety). The COSs reflect shared priorities among service users, providers and researchers. Use of these COSs across trials and service evaluations for children and families affected by CM and DVA will make outcome selection more consistent and help harmonise research and practice.

Capturing the experiences of clinicians implementing a new brief intervention for parents and children who have experienced family violence in Australia

Family violence (FV) affects one in four families. While the evidence regarding therapeutic interventions for children and families who experience FV is expanding, little research has been conducted about clinicians' experiences of implementation. The current study aimed to capture the voices of clinicians delivering a brief dyadic intervention for women and their children after FV exposure. The Brief Relational Intervention and Screening (BRISC) is an evidence-informed intervention designed by Berry Street (Australia) for mothers and children with recent experiences of FV. Consisting of four sessions, BRISC was implemented across one regional and one metropolitan site. Thirteen BRISC clinicians participated in semi-structured interviews individually or in a focus group. Thematic analysis of transcripts was conducted using NVivo. Clinicians considered key strengths of BRISC to be related to the intervention principles, including the hopeful and relationship-focused approach, the intervention implementation such as the timing, structure and flexibility, as well as the systems and processes in place, such as intake and triage, supervision structure and their team environment. Challenges described by clinicians included aspects of delivery such as limited referral options and safety concerns, the nature of the program including the mechanics of delivery and specific role challenges such as vicarious trauma. Clinicians also shared suggestions for improvements for delivery, supervision and training. This study emphasises the importance of clinician perspectives when identifying factors that can promote the successful implementation of innovative interventions in real-world community settings.

Early developmental vulnerabilities following exposure to domestic violence and abuse: Findings from an Australian population cohort record linkage study

Early life exposure to Domestic Violence and Abuse (DVA) is associated with poor psychosocial and cognitive development in childhood. However, most prior research uses mother-reported involvement in DVA as a proxy indicator of child exposure; studies using direct measures of child exposure to DVA are scarce, especially among representative population-based samples. We address this gap by using longitudinal, population-based data from an Australian record linkage study of children to examine the associations between early life exposure to DVA and early childhood developmental vulnerability. Exposure to DVA was measured using police contact records for children involved in a DVA incident either as a victim or witness. Developmental vulnerability at school entry was measured using the Australian Early Development Census, providing indices of five broad domains of function and person-centred classes of developmental risk (referred to as 'mild generalized risk', 'misconduct risk', and 'pervasive risk', each compared to a group showing 'no risk'). Children exposed to DVA showed significantly greater odds of developmental vulnerability on all five domains and were more likely to be members of the three developmental risk classes. Girls who were victims of DVA (OR = 1.65) had significantly poorer developmental outcomes than boys who were victims (OR = 1.26) within the domain of communication skills and general knowledge (d = 0.29 [SE = 0.16], p = .04). No other sex differences were found. These preliminary findings hold important implications for policy regarding the early intervention and implementation of support services for young children exposed to DVA.

Childhood maltreatment mediates the effect of the genetic background on psychosis risk in young adults

Childhood maltreatment (CM) and genetic vulnerability are both risk factors for psychosis, but the relations between them are not fully understood. Guided by the recent identification of genetic risk to CM, this study investigates the hypothesis that genetic risk to schizophrenia also increases the risk of CM and thus impacts psychosis risk. The relationship between schizophrenia polygenetic risk, CM, and psychotic-like experiences (PLE) was investigated in participants from the Utrecht Cannabis Cohort (N = 1262) and replicated in the independent IMAGEN cohort (N = 1740). Schizophrenia polygenic risk score (SZ-PRS) were calculated from the most recent GWAS. The relationship between CM, PRS, and PLE was first investigated using multivariate linear regression. Next, mediation of CM in the pathway linking SZ-PRS and PLE was examined by structural equation modeling, while adjusting for a set of potential mediators including cannabis use, smoking, and neuroticism. In agreement with previous studies, PLE were strongly associated with SZ-PRS (B = 0.190, p = 0.009) and CM (B = 0.575, p < 0.001). Novel was that CM was also significantly associated with SZ-PRS (B = 0.171, p = 0.001), and substantially mediated the effects of SZ-PRS on PLE (proportion mediated = 29.9%, p = 0.001). In the replication cohort, the analyses yielded similar results, confirming equally strong mediation by CM (proportion mediated = 34.7%, p = 0.009). Our results suggest that CM acts as a mediator in the causal pathway linking SZ-PRS and psychosis risk. These findings open new perspectives on the relations between genetic and environmental risks and warrant further studies into potential interventions to reduce psychosis risk in vulnerable people.

'It felt like there was always someone there for us': Supporting children affected by domestic violence and abuse who are identified by general practice

One in five children in the UK are affected by domestic violence and abuse. However, primary care clinicians (GPs and nurses) struggle to effectively identify and support children and young people living in homes where it is present. The IRIS+ (Enhanced Identification and Referral to Improve Safety) training and advocacy support intervention aimed to improve how clinicians respond to children and young people affected by domestic violence and abuse. IRIS+ training was delivered as part of a feasibility study to four general practices in an urban area in England (UK). Our mixed method design included interviews and questionnaires about the IRIS+ intervention with general practice patients, including children and young people as well as with clinicians and advocacy service providers. We collected the number of identifications and referrals by clinicians of children experiencing domestic violence and abuse through a retrospective search of medical and agency records 10 months after the intervention. Forty-nine children exposed to domestic violence and abuse were recorded in medical records. Thirty-five children were referred to a specialist domestic violence and abuse support service over a period of 10 months. Of these, 22 received direct or indirect support. The qualitative findings indicated that children benefitted from being referred by clinicians to the service. However, several barriers at the patient and professional level prevented children and young people from being identified and supported. Some of these barriers can be addressed through modifications to professional training and guidance, but others require systematic and structural changes to the way health and social care services work with children affected by domestic violence and abuse.

Situational Characteristics Uniquely Associated With Children's Exposure to Intimate Partner Violence

Exposure to parental violence can have devastating consequences for children, including significant personal, social, and academic problems. The present study determined the situational factors that are associated with children's exposure to intimate partner violence (IPV) incidents. To examine whether these factors were unique to child witnesses' presence at IPV incidents, we also determined the factors that are associated with children's exposure to family violence (FV) and other family member witnesses' exposure to IPV incidents. Participants responded to an online panel survey investigating the role of alcohol and other drugs in family and domestic violence incidents in Australia. Nine hundred fifty-two respondents reported an IPV incident and 299 reported an FV incident; they provided details about their most recent incident. Results showed that child witnesses were more likely to be present during IPV incidents if the incident took place at home (odds ratio [OR] = 3.10), if a similar incident had occurred previously (OR = 1.66), if drugs were involved (OR = 1.60), and if a police report was made (OR = 2.61). There was some overlap with the other witness and violence combinations: The presence of a police report also predicted child witnesses' presence at FV incidents, and a home location also predicted other family member witnesses' presence at IPV incidents. These results enhance our understanding of the situations in which children might witness IPV incidents; future research is needed to determine whether these situational factors can be used to judge risk.

Protocol for developing core outcome sets for evaluation of psychosocial interventions for children and families with experience or at risk of child maltreatment or domestic abuse

INTRODUCTION

Recognition that child maltreatment (CM) and domestic violence and abuse (DVA) are common and have serious and long-term adverse health consequences has resulted in policies and programmes to ensure that services respond to and safeguard children and their families. However, high-quality evidence about how services can effectively intervene is scant. The value of the current evidence base is limited partly because of the variety of outcomes and measures used in evaluative studies. One way of addressing this limitation is to develop a core outcome set (COS) which is measured and reported as a minimum standard in the context of trials and other types of evaluative research. The study described in this protocol aims to develop two discrete COSs for use in future evaluation of psychosocial interventions aimed at improving outcomes for children and families at risk or with experience of (1) CM or (2) DVA.

METHODS AND ANALYSIS

A two-phase mixed methods design: (1) rapid reviews of evidence, stakeholder workshops and semistructured interviews with adult survivors of CM/DVA and parents of children who have experienced CM/DVA and (2) a three panel adapted E-Delphi Study and consensus meeting. This study protocol adheres to reporting guidance for COS protocols and has been registered on the Core Outcome Measures for Effectiveness Trials (COMET) database.

ETHICS AND DISSEMINATION

We will disseminate our findings through peer-reviewed and open access publications, the COMET website and presentations at international conferences. We will engage with research networks, journal editors and funding agencies to promote awareness of the CM-COS and DVA-COS. We will work with advisory and survivor and public involvement groups to coproduce a range of survivor, policy and practice facing outputs.Approval for this study has been granted by the Research Ethics Committee at University College London.

Hope, Agency, and the Lived Experience of Violence: A Qualitative Systematic Review of Children's Perspectives on Domestic Violence and Abuse

There is a large body of research on the impact of domestic violence and abuse (DVA) on children, mostly reporting survey data and focusing largely on psychological outcomes. Qualitative research on the views of children has the potential to enable a child-centered understanding of their experience of DVA, so their needs can be better met by professionals. This systematic review reports general findings from the ViOlence: Impact on Children Evidence Synthesis (VOICES) project that synthesized published qualitative research on the experiences of DVA from the perspective of children and young people. A thematic synthesis of 33 reports identified six themes: lived experience of DVA, children's agency and coping, turning points and transitions, managing relationships postseparation, impact of DVA on children, and children's expressions of hope for the future. We conclude that professionals working with children affected by DVA should be mindful of the diversity in children's experiences and listen carefully to children's own accounts.

A latent class analysis to identify how patterns of Intimate Partner Violence influence Early Childhood Development outcomes in Honduras

BACKGROUND

Intimate Partner Violence (IPV) against women is a complex phenomenon with long-term consequences for victims and their families.

OBJECTIVE

The goals of this study are two-fold: to identify common patterns of co-occurring and/or successive experiences with IPV; and to study the association between these IPV patterns and outcomes of Early Childhood Development (ECD) among the victim's children.

DATA AND PARTICIPANTS

Data was obtained from the 2011-12 Honduras Demographic Health Survey (DHS).

METHODS

A Latent Class Analysis (LCA) was conducted to define homogeneous patterns of experiences with IPV in terms of the type, severity, timing of the last event, and perpetrator of the violence. Outcomes of interest were binary variables indicating if a child is developmentally on track according to the ECD index and its four domains. LCA with distal outcomes and multivariate logistic regressions were used to measure the association between IPV patterns and ECD outcomes.

RESULTS

Five patterns of lifetime experiences with IPV were identified: (1)"no violence"; (2)"physical and sexual violence by an ex-partner"; (3)"current emotional violence"; (4)"current controlling, emotional and physical violence"; and (5)"past controlling, emotional and physical violence". Multivariate results show that children were less likely to be developmentally on track if their mothers were exposed to patterns of "physical and sexual violence by an ex-partner" or "current controlling, emotional and physical violence", relative to children whose mothers had not experienced violence. Further analysis of specific ECDI domains suggested that IPV hampers children's socioemotional development, but it is not associated with other domains of ECD.

CONCLUSION

Experiencing a pattern of co-occurrent forms of IPV negatively influences ECD and the socio-emotional development of the victim's children in low and middle-income countries. This study provides initial evidence about the complexity of this phenomenon and its long-lasting sequels.

A critical interpretive synthesis of the intersection of domestic violence with parental issues of mental health and substance misuse

A critical interpretive synthesis (CIS) methodology was used with the aim of informing practice with children and families when domestic and family violence (DFV) and parental issues relating to alcohol and other drugs (AOD) and mental health (MH) are also present. A CIS is grounded in the literature, but includes questioning of the literature in order to problematise gaps, contradictions and constructions of issues. A review of the literature from 2010 to 2018 was conducted with the structured search strategy identifying 40 relevant research articles. Synthesis and critique of these articles revealed three mutually informative themes through which to understand the literature and how it can inform practice. They were as follows: differences in theoretical approaches and client focus; complexity of system's collaboration; and practices converging on mothers. Taken together, these themes facilitated the development of the synthesising construct: strengthening intersection between DFV, AOD and MH sectors. Attention to practice at multiple levels that responds to the dynamics of gender and the differing impacts of violence was often lacking, particularly in the context of heightened child protection concerns where collaboration between sectors is needed. Both promising and problematic practices relating to gender dynamics and accountability converged on mothers. While there were exceptions, generally, there was an absence of engagement with, and recognition of, the impacts of fathers' patterns of using violence and control on adult and child survivors. Promising practice related to the strengthening of the mother-child relationship and attention to MH and its intersection with domestic violence. Strengthening the intersections between DFV, AOD and MH practices with attention to keeping the perpetrator of violence in view is critical to overcoming the poor practice that can occur when sectors are siloed from each other.

Child Welfare Responses Linked to Subtypes of Exposure to Intimate Partner Violence: Evidence From the Canadian Incidence Study of Reported Child Abuse and Neglect

Children exposed to intimate partner violence (CE-IPV) are at increased risk for later health and social difficulties. To date, studies have primarily focused on CE-IPV as a unitary construct; this may lead to the mistaken assumption that all subtypes of CE-IPV (i.e., exposure to direct or indirect physical abuse, or exposure to emotional abuse) are equally harmful requiring similar responses from child welfare services. The purpose of this study was to examine child welfare responses by CE-IPV subtype in a large Canadian child welfare sample. Using data from the Canadian Incidence Study of Reported Child Abuse and Neglect-2008 (N = 2,184), we examined child welfare responses to CE-IPV subtypes or their co-occurrence. Information was obtained from child welfare workers' reports. Cases with co-occurring subtypes of CE-IPV were more likely to be substantiated and involved multiple incidents compared with that with single CE-IPV subtypes. Cases with direct physical CE-IPV and co-occurring CE-IPV were also more likely to remain open and have an application considered or made to child welfare court. Exposure to emotional IPV was the least likely to warrant interventions by welfare services, including referrals to specialized services. These results suggest that within CE-IPV subtypes, there is evidence of different responses (recommendations and services) once a case has been opened by a worker. Future research is needed to examine the effectiveness of the responses and outcomes for children following child welfare interventions.

Interventions to support people exposed to adverse childhood experiences: systematic review of systematic reviews

BACKGROUND

Adverse Childhood Experiences (ACEs) such as abuse, neglect or household adversity may have a range of serious negative impacts. There is a need to understand what interventions are effective to improve outcomes for people who have experienced ACEs.

METHODS

Systematic review of systematic reviews. We searched 18 database sources from 2007 to 2018 for systematic reviews of effectiveness data on people who experienced ACEs aged 3-18, on any intervention and any outcome except incidence of ACEs. We included reviews with a summary quality score (AMSTAR) of 5.5 or above.

RESULTS

Twenty-five reviews were included. Most reviews focus on psychological interventions and mental health outcomes. The strongest evidence is for cognitive-behavioural therapy for people exposed to abuse. For other interventions - including psychological therapies, parent training, and broader support interventions - the findings overall are inconclusive, although there are some positive results.

CONCLUSIONS

There are significant gaps in the evidence on interventions for ACEs. Most approaches focus on mitigating individual psychological harms, and do not address the social pathways which may mediate the negative impacts of ACEs. Many negative impacts of ACEs (e.g. on health behaviours, social relationships and life circumstances) have also not been widely addressed by intervention studies.

A scoping review of network meta-analyses assessing the efficacy and safety of complementary and alternative medicine interventions

BACKGROUND

Network meta-analysis (NMA) has rapidly grown in use during the past decade for the comparison of healthcare interventions. While its general use in the comparison of conventional medicines has been studied previously, to our awareness, its use to assess complementary and alternative medicines (CAM) has not been studied. A scoping review of the literature was performed to identify systematic reviews incorporating NMAs involving one or more CAM interventions.

METHODS

An information specialist executed a multi-database search (e.g., MEDLINE, Embase, Cochrane), and two reviewers performed study selection and data collection. Information on publication characteristics, diseases studied, interventions compared, reporting transparency, outcomes assessed, and other parameters were extracted from each review.

RESULTS

A total of 89 SR/NMAs were included. The largest number of NMAs was conducted in China (39.3%), followed by the United Kingdom (12.4%) and the United States (9.0%). Reviews were published between 2010 and 2018, with the majority published between 2015 and 2018. More than 90 different CAM therapies appeared at least once, and the median number per NMA was 2 (IQR 1-4); 20.2% of reviews consisted of only CAM therapies. Dietary supplements (51.1%) and vitamins and minerals (42.2%) were the most commonly studied therapies, followed by electrical stimulation (31.1%), herbal medicines (24.4%), and acupuncture and related treatments (22.2%). A diverse set of conditions was identified, the most common being various forms of cancer (11.1%), osteoarthritis of the hip/knee (7.8%), and depression (5.9%). Most reviews adequately addressed a majority of the PRISMA NMA extension items; however, there were limitations in indication of an existing review protocol, exploration of network geometry, and exploration of risk of bias across studies, such as publication bias.

CONCLUSION

The use of NMA to assess the effectiveness of CAM interventions is growing rapidly. Efforts to identify priority topics for future CAM-related NMAs and to enhance methods for CAM comparisons with conventional medicine are needed. SYSTEMATIC REVIEW REGISTRATION: https://ruor.uottawa.ca/handle/10393/35658.

Children Exposed to Intimate Partner Violence: Association Among Battered Mothers' Parenting Competences and Children's Behavior

BACKGROUND

Exposure to violence perpetrated on a mother by her intimate partner (IPV or intimate partner violence) has an impact on the psychosocial adjustment of her children. In addition, the violence suffered by mothers could affect parental competences.

METHODS

Through the Child Behavior Checklist (CBCL), this work analyzes the psychosocial adjustment in children between 6 and 17 years old who live with their mothers in shelters after having experienced IPV situations. It also explores the association between mothers' parenting competences and children's adjustment in shelters.

RESULTS

The evaluation shows a negative correlation between the quality of mothers' care of their children during their stay in shelters and the rate of children's behavioral problems, so that the better the parental competences of mothers, the lower the rate of behavioral problems presented by children.

CONCLUSIONS

As a result of IPV, mother-child relationships can be affected. Children exposed to IPV may exhibit more externalizing behavior problems and their mothers may have difficulty demonstrating competent parenting behaviors while living in a shelter. Work should be aimed at reestablishing parenting competences in mothers and the quality of mother-child interactions while they remain in the shelters, in an effort to mitigate the psychosocial consequences of IPV for their children.

Swedish School Nurses' Experiences of Child Abuse

Child abuse recognition and the protection of children is a global concern. In Sweden, the role of the school nurse (SN) is to promote schoolchildren's health and development and to identify and prevent harm. The aim of this study was to describe Swedish SN experiences of suspecting, identifying, and reporting child abuse and to compare them with respect to (a) years of experience as SN, (b) age of SN, and (c) pupil population size. A descriptive design was used. Two-hundred and thirty-three SNs completed a survey detailing their experiences. Most SNs (96%) reported having suspected a child suffering from physical or psychological abuse. Approximately half of them reported occurrences of honor-related violence (54%) and of child sexual abuse (57%). SNs with less nursing experience reported significantly less recognition and reporting of child abuse. The findings indicate that experiences of child abuse are common. Thus, it is vital that SNs have the necessary competency and support to identify and report suspected child abuse.

Reconnecting mothers and children after violence (RECOVER): a feasibility study protocol of child-parent psychotherapy in Australia

INTRODUCTION

Intimate partner violence detrimentally affects the social and emotional well-being of children and mothers. These two populations are impacted both individually and within the context of their relationship with one another. Child mental health, maternal mental health and the mother-child relationship may be impaired as a consequence. Early intervention to prevent or arrest impaired mother-child attachment and child development is needed. Dyadic or relational mental health interventions that include mothers with their children, such as child-parent psychotherapy, are effective in improving the mental health of both children and mothers and also strengthening their relationship. While child-parent psychotherapy has been trialled overseas in several populations, Australian research on relational interventions for children and women recovering from violence is limited. This study aims to assess the acceptability and feasibility of implementing child-parent psychotherapy in Australian families.

METHODS AND ANALYSIS

Using a mixed methods, prepost design this feasibility study will examine the acceptability of the intervention to women with preschool aged children (3-5 years, n=15 dyads) and providers, and identify process issues including recruitment, retention and barriers to implementation and sustainability. In addition, intervention efficacy will be assessed using maternal and child health outcomes and functioning, and mother-child attachment measures. Young children's mental health needs are underserviced in Australia. More research is needed to fully understand parenting in the context of intimate partner violence and what works to help women and children recover. If the intervention is found to be feasible, findings will inform future trials and expansion of child-parent psychotherapy in Australia.

ETHICS AND DISSEMINATION

Ethics approval obtained from clinical sites and the La Trobe University Human Research Ethics Committee (ID: HEC17-108). Results will be disseminated through conference proceedings and academic publications.

Identifying and responding to child maltreatment when delivering family-based treatment-A qualitative study

INTRODUCTION

This study describes practitioner strategies, perceptions, experiences with identifying and responding to child emotional abuse (CEA) and child exposure to intimate partner violence (CEIPV) when providing Family-Based Treatment (FBT) to children and adolescents with eating disorders.

METHOD

Using qualitative interpretive description, this study recruited a purposeful sample of practitioners (N = 30, 90% female) implementing FBT for adolescent eating disorders. Semi-structured interviews focused on eliciting their perspectives regarding identifying and responding to CEA and CEIPV in practice. Interviews were conducted over the phone, were audio recorded, transcribed verbatim, and coded using conventional content analysis. Interim member checking, the thoughtful clinician test, and coding memos were used to ensure the integrity of the analysis.

RESULTS

Participants were 31-57 years old and practicing FBT in five countries. Three data patterns emerged: (a) perceptions of child maltreatment prevalence and identification; (b) complicating factors; and finally (c) strategies to support family-based work. Practitioners described important considerations for CEA and CEIPV identification, as well as possible FBT adaptations that can support the safety of children and adolescents while simultaneously ensuring the treatment of the eating disorder.

CONCLUSIONS

Practitioners describe a need for additional training to identify and respond to CEA and CEIPV within FBT and within practice more broadly. There is a need for trials that detail the appropriateness and efficacy of FBT for patients experiencing CEA and/or CEIPV.

Towards an ecological understanding of readiness to engage with interventions for children exposed to domestic violence and abuse: Systematic review and qualitative synthesis of perspectives of children, parents and practitioners

Children who grow up in homes affected by domestic violence and abuse (DVA) are at risk of poor outcomes across the lifespan, yet there is limited evidence on the acceptability and effectiveness of interventions for them. A recent review of child-focused interventions highlighted a gap in understanding the factors influencing the willingness of parents and children to engage with these programmes. We conducted a systematic review of qualitative evidence on the experiences of receiving and delivering interventions with the aim of identifying factors at different levels of the social-ecological context that may influence parent and child readiness to take up interventions. We searched literature till April 2016 and found 12 reports of eight programmes. Two authors independently screened papers for inclusion, extracted data and identified the first- and second-order constructs. The third-order constructs were derived and fitted to the ecological framework to inform a picture of readiness to engage with interventions. Three key findings emerged from this review: (a) parent and child readiness is influenced by a complex interplay of individual, relationship and organisational factors, highlighting that individual readiness to take up child-focussed interventions must be viewed in an ecological context; (b) the specific process through which women become ready to engage in or facilitate child-focussed interventions may differ from that related to uptake of safety-promoting behaviours and requires parents to be aware of the impact of DVA on children and to focus on children's needs; (c) there are distinct but interlinked processes through which parents and children reach a point of readiness to engage in an interventions aimed at improving child outcomes. We discuss the implications of these findings for both practice and research.

Synthesising quantitative evidence in systematic reviews of complex health interventions

Public health and health service interventions are typically complex: they are multifaceted, with impacts at multiple levels and on multiple stakeholders. Systematic reviews evaluating the effects of complex health interventions can be challenging to conduct. This paper is part of a special series of papers considering these challenges particularly in the context of WHO guideline development. We outline established and innovative methods for synthesising quantitative evidence within a systematic review of a complex intervention, including considerations of the complexity of the system into which the intervention is introduced. We describe methods in three broad areas: non-quantitative approaches, including tabulation, narrative and graphical approaches; standard meta-analysis methods, including meta-regression to investigate study-level moderators of effect; and advanced synthesis methods, in which models allow exploration of intervention components, investigation of both moderators and mediators, examination of mechanisms, and exploration of complexities of the system. We offer guidance on the choice of approach that might be taken by people collating evidence in support of guideline development, and emphasise that the appropriate methods will depend on the purpose of the synthesis, the similarity of the studies included in the review, the level of detail available from the studies, the nature of the results reported in the studies, the expertise of the synthesis team and the resources available.

Empowering young people who experienced domestic violence and abuse: The development of a group therapy intervention

This article describes the development of a group-based therapeutic intervention for young people (YP) who have lived with domestic violence and abuse. The intervention was informed by interviews with 107 YP, focused on their experiences of coping, resilience and agency. The intervention draws on resources from systemic, creative and narrative approaches to group work, and aims to facilitate YP's expression of distress in a way that recognizes that it is embodied, contextual and relational. The intervention also explores YP's existing strategies for coping and maintaining a sense of agency, and works to harness, enhance and further develop those skills. We report on the pilot of this intervention, and its development and application across four European countries (the United Kingdom, Greece, Italy and Spain). We outline the goals, strengths and limitations of this group intervention, as well as the main challenges, hindrances and ethical dilemmas experienced by the research and intervention team. Implications for therapeutic practice and training are addressed.

Domestic Violence and Education: Examining the Impact of Domestic Violence on Young Children, Children, and Young People and the Potential Role of Schools

This article examines how domestic violence impacts the lives and education of young children, children, and young people and how they can be supported within the education system. Schools are often the service in closest and longest contact with a child living with domestic violence; teachers can play a vital role in helping families access welfare services. In the wake of high profile cases of child abuse and neglect, concerns have been raised about the effectiveness of multi-agency responses to children living with abuse. In the United Kingdom, the case of 4-year-old Daniel Pelka who died in 2012 following abuse and starvation by his mother, who experienced domestic violence, and her partner, led to a serious case review. It found recording systems in Daniel’s school were not used consistently, and details held by different agencies were not collated to enable the formation of a coherent assessment. The lack of integrated working cited in the report echoes findings from previous serious case reviews. A strong correlation exists between domestic abuse and child abuse, with approximately half of all domestic violence situations involving direct child abuse. Children can also be affected indirectly by violence occurring in their home by seeing or hearing it taking place. This article examines the impact of domestic violence on the mental health of children, and the impact on their education. Violence in children’s lives often causes disruption to their schooling and harms the quality of their educational experiences and outcomes. The abuse children experience can result in emotional trauma, physical and psychological barriers to learning, and disruptive behavior in school, while the underlying causes of these problems remain hidden. Knowing when and how to seek advice from multi-agency professionals is an essential part of effective practice among school staff. Despite their vital role in identifying signs of abuse and signposting referral pathways, research indicates teachers often lack confidence and knowledge for such work. The article examines how the professional learning and professional confidence of teachers can be developed, and how recent policy and practice developments in the United Kingdom have the potential to influence work in this area.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Right from the start: protocol for a pilot study for a randomised trial of the New Baby Programme for improving outcomes for children born to socially vulnerable mothers

BACKGROUND

Children born to mothers who experience social complexity (e.g. substance misuse, intimate partner violence, mental ill health, a history of maltreatment) are at increased risk for a range of adverse outcomes at birth and during development. Home visiting programmes have been advocated as a strategy for improving outcomes for disadvantaged mothers and children, such as the Nurse-Family Partnership for young, socially disadvantaged first-time mothers. However, no evidence-based programme is available for multiparous women or older first-time mothers. The New Baby Programme was developed in Northern Ireland. It augments the universal health visiting service available in the UK with a content designed to promote maternal health and well-being in pregnancy, maximise secure attachments of children and parents and enhance sensitive parenting and infant cognitive development.

METHODS/DESIGN

This pilot study is designed to investigate whether it is possible to recruit and retain socially vulnerable mothers in a randomised trial that compares the effects of the New Baby Programme with standard antenatal and postnatal care. Feasibility issues include the referral/recruitment pathway (including inclusion and exclusion criteria), the consent and randomisation, the ability to maintain researcher blinding, the acceptability of the intervention to participants, and the feasibility and acceptability of the outcome measures. The results of the study will inform a definitive phase-3 RCT.

DISCUSSION

Trials of complex social interventions often encounter challenges that lead to the trial being abandoned (e.g. because of problems in recruitment) or present considerable analytic challenges relating to dropout, attrition and bias. This pilot study aims to maximise the chances of successful implementation.

TRIAL REGISTRATION

ISRCTN35456296 retrospectively registered.