Parenting Interventions for the Prevention of Child Abuse – Reviewing the Evidence

Rates of child abuse and neglect globally are difficult to gauge given the hidden and sensitive nature of the issue. Estimates indicate that 40 million children aged under 14 experience abuse and neglect annually (1). Child sexual abuse (CSA) in particular often goes unreported to professionals or adults, due to many complex reasons, including fear, stigma and shame associated with this type of abuse (2, 3). A global meta-analysis of child sexual abuse prevalence figures found self-reported CSA prevalence ranged from 164/1000 to 197/1000 for girls and 66/1000 to 88/1000 for boys (4). Differing methods and definitions across studies is said to explain variations in prevalence (1, 4). Even with these variations, it can be safely stated that child abuse is a global concern with millions of children growing up in toxic and dysfunctional family environments, regularly facing adversity and abuse (4).

For many children, homes in particular are not havens of safety, but places of anxiety and fear. Known and trusted family members are most frequently reported as the perpetrators of child abuse and neglect, with most perpetrators being male. Perpetrators of child sexual abuse are often close to the victim, including fathers, uncles, teachers, caregivers and other trusted members of the community (5). Experiencing abuse and neglect in childhood can have long lasting effects on brain development, psychological functioning, mental health, health risk behaviours, life expectancy and social functioning of both male and female survivors (6-12).

The profound impact child sexual abuse has on victims, families and communities, demands that we prioritise both responses and prevention efforts. Data on what works and how we stop child abuse however remains limited, particularly in developing countries (1). This article provides a summary of some of the research done to date on the prevention of child abuse, specifically focusing on parenting interventions, drawing on findings from two systematic reviews of the literature commissioned by the Sexual Violence Research Initiative with support from the Oak Foundation. For more detail on SVRI work funded by the Oak Foundation visit: http://www.svri.org/oakfoundation.htm

Prevention of Child Abuse

Risk Factors Child abuse and neglect happens most within family settings, and it is well known that what happens in childhood has long term implications for the future health and wellbeing of the child. Pithers and colleagues (21), for example, found that the families of children who rape other children were characterised by high levels of stress. The sources of the stress included low income, criminal arrest, family violence, sexual abuse, lack of social support, and poor parent-child attachment. As one group of researchers noted, “The evidence….points to family interactions as a primary source of the problem (i.e. children who sexually abuse other children)” (Araji 1997 cited in (21)). In our efforts to prevent child abuse, families are clearly important platforms for intervention. As McCloskey (2011), notes, “Child abuse is however not a stand-alone family problem, and is associated with multiple risk factors.” Some of these risk factors for child abuse are summarised in the table below: 

Table 1: Risk factors for child abuse

Demographic
  •  Low family income
  • Bearing a child before age 18
  • Unmarried mother
  • Low educational attainment
Psychosocial
  • Drug or alcohol dependency
  • Post-partum depression
  • Mental health problems
  • Intimate partner violence
  • Parenting Stress
  • Social isolation and / or weak or limited attachment to social institutions (e.g. health care, religious, civic)
Parenting Styles
  • Coercive
  • Poor or harsh parenting practices
  • Lack knowledge about child development and child rearing
  • Parenting beliefs e.g. blame children and infants for age appropriate behaviours
  • Poor parent-child relationships

Parenting Interventions: research highlights

The aim of parenting programmes is to strengthen or encourage effective parenting or some aspect thereof (13), e.g. strengthening parent-child bonding or parenting practices and knowledge. The two reviews that form the basis of this article included randomised control trials of parenting interventions from low-middle (14) and high income (13) countries. Twelve studies were included in the low-middle income review, and 22 were included in the high income review. Two studies undertaken in low and middle income countries stood out as high quality, showing parenting interventions can be effective in resource poor settings, whilst two-thirds of the studies from high income countries showed positive effects of parenting interventions on either child abuse rates in official records or according to parents’ self-reports. The types of interventions included in the two systematic reviews took different forms, ranging from psycho-educational to behavioural to attachment-focused interventions and included home visiting and clinic based programmes, safety training for parents to prevent unintentional injury, programmes to address specific health problems within the family, and to address child conduct problems (13, 14). A summary of noteworthy programmes identified in these reviews are provided in the following tables:

Table 2: Evidence from Interventions Implemented in High Income Countries

Risk Factor Child Bonding; Parenting
Programme  Summary of Intervention Evaluation Outcome  Reference Links
Infant Health and Development Project (IHDP)

Programme provides:

  • Counselling for mothers on how to improve and enhance an infant's development
  • Targets families from low-income backgrounds with low birth weight of infants
  • One year of home visiting
  • Two years free enriched day care for infants
Preschool education can make long-term changes in a diverse group of children who are at developmental risk.  (15) 
Healthy Start Hawaii Home visiting intervention for families who are at risk for maltreatment and abuse in order to enhance child health and development. The home-visits were carried out by para-professionals who model positive parent-child interactions and provide access to social services and parenting education.

Key Findings:

  • Lower rates of IPV victimization
  • Significantly lower rates of perpetration
  • During long-term follow-up, rates of overall IPV victimization and perpetration decreased
(16)
Nurse-Family Partnership (NFP)  The Nurse-Family Partnership is a home visiting programme developed by David Olds who has run different permutations of the programme for over 20 years. Nurses (not para-professionals) implement the programme through home visits. 15 year follow up, found fewer convictions of children in the homes where nurses have intervened.  (17)
Triple P Triple P is a ‘multilevel’ parent training intervention. At the 2-year follow-up: • Significant reductions in dysfunctional parenting behaviour • Mothers showed an increase in positive parenting behaviour • Mothers showed significant reductions in internalizing and externalizing child behaviour http://www1.triplep.net/

Source: (13)

Table 3: Evidence from Interventions Implemented in Low and Middle Income Countries

Risk Factor Child Bonding; Parenting
Programme  Summary of Intervention  Key Evaluation Outcome Reference Links
Home visiting programme, South Africa Intervention promoted sensitive and responsive parenting, and secure infant attachment to the mother. Targeted women in economically disadvantaged area of South Africa who were in late pregnancy up to six months postpartum. These women were visited in their homes by previously untrained lay community workers who provided support and guidance in parenting.  At both six and 12 months, mothers were significantly more sensitive and less intrusive in their interactions with their infants. The intervention was also associated with a higher rate of secure infant attachments at 18 months. (18) 
Learn Through Play parenting programme adapted for rural Pakistan   Aimed to improve parent knowledge of infant development.
  •  80% of the community health workers trained found the programme to be relevant and were able to integrate it into their routine work
  • Significant increase in mothers' knowledge and positive attitudes about infant development in the intervention group, compared with the control group.
(19)

 Source: (14)

The reviews on parenting interventions in both low-middle and high income countries to prevent child abuse and neglect show that parenting interventions which focus on strengthening responsive parenting and parent-child bonding are effective at decreasing child maltreatment or harsh parenting (14). Both systematic reviews identified very limited research done on interventions involving fathers or interventions to address parental gender socialisation and its effect on child behaviour. Given the links between future perpetration and violence and parenting styles, this gap is striking. However, studies from low and middle income countries do show that parent training with mothers, even in very resource poor settings can be integrated into existing health care systems, positively influence parent–child relationships and in turn reduce negative parenting practices (14).

This finding is very important for the prevention of sexual violence. Child abuse has been found to play a role in longer term anti-social behaviours. Growing up in dysfunctional families, for example, has been linked to child on child rape (20, 21). Research with children who sexually abuse other children found strong links between family dysfunction and the problem of child on child sexual abuse (21). Other studies have found links between early sexual victimisation and physical abuse and later rape perpetration. This link is however mediated by a variety of factors including the role of the family, drug and alcohol abuse and ways in which families resolve conflict (22, 23). It is important to highlight, that parenting programmes are not implemented in a vacuum and can only be effective if a country has child laws, policies, practices and procedures in place that are driven by human rights and guided by the Convention on the Rights of the Child and complemented by programmes that aim to address poverty and inequality. It is also essential that countries prioritise the adoption and adaptation of proven programmes that are cost effective and implementable within existing systems. Finally, if we truly want to encourage and strengthen parenting and help parents to be the best parents they can be, more resources are needed for primary prevention programmes and the evaluation of these interventions. We therefore urgently need more affordable and less complex methods for evaluating child abuse prevention programmes.

Note that the views expressed in this article are those of the author(s) and do not necessarily represent the views of PHASA.

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