There is a dearth of evidence-based interventions designed to prevent child maltreatment, or to support traumatized children who have been maltreated. When so much service provision is characterized by a paucity of evidence, it is not surprising that the few evidence-based interventions available in this area have struggled to gain traction [see: No green light for evidence from Munro report].

So why is the evidence base so limited? Sheree Toth and Jody Manly, researchers at the Mt Hope Family Center at the University of Rochester, USA, set out to explore some of the hurdles and offer an example of where these barriers have been overcome.

The first hurdle, they say, is that child maltreatment takes many forms and the negative consequences may also be expressed in an equally wide variety of areas of children’s health and development. As such, specific interventions targeted at preventing or reducing maltreatment need to be multi-faceted and flexible enough to respond in the most appropriate way. However, this represents a significant challenge when undertaking rigorous evaluations of such multifaceted interventions in order to build the evidence-base.

“Historically,” Toth and Manly state, “randomised control trials have had very clear and often quite narrow inclusion criteria… so, for example, a treatment for depression might exclude a child who had a co-morbid anxiety disorder.”

Maltreated children, however, do not form a narrow cohesive population. Their needs and difficulties will often be multiple and interconnected. As such, the often strict inclusion and exclusion criteria for the trials may be difficult to meet.

“To engage the ‘real world’ maltreatment client effectively,” believe Toth and Manly, “sufficient resources need to be available … to support the challenges in recruiting and retaining a population that is routinely confronted with multiple problems. In short, there is a need for increased research investment in studies that represent the complexities in the lives of maltreated children and their families.”

The second, and related, hurdle is that the variety of populations and needs of children suffering from maltreatment are diverse. Yet, as Toth and Manly state, “far too few evidence-based models of treatments have been developed with racially and ethnically diverse groups.” As such, “clinicians may feel ill equipped to evaluate the existing research evidence to determine which approaches are appropriate for the children in their practice.”

The authors argue that the direction of research should focus on “narrowing the learning list” and ensuring that evidence-based service provision is sensitive to diverse populations.

Third, where evidence does exist about effective prevention and treatment models, too often it is not made available and accessible to those responsible for providing and delivering services to children and families.

“It is not surprising,” say Toth and Manly, “that when confronted with an immediate and life-altering decision, research that is not easily accessible is not maximized in its usefulness to the clinician or policy advocate.”

They quote Jack Shonkoff as saying that “science is focused on what we do not know. Social policy and the delivery of health and human services are focused on what we should do.” Connecting practitioners and policy makers with what evidence is available, and making that evidence practical and within hands-reach is the challenge.

Finally, even when the above obstacles are overcome and policy advocates and service providers embrace evidence-based models of preventing and supporting maltreated children, numerous practical and logistical hurdles stand in the way of successful adoption.

Funding must be available to support training, time must be given to allow providers to master the evidence-base model, supervision arrangements must be in place and caseloads must be manageable. These practical obstacles arguably apply to most evidence-based interventions.

So is there hope for evidence-based prevention and treatment models focused on child treatment? “Given the impediments such as these” say Toth and Manly, “one might conclude that the challenges associated with the translation of evidence based models for child maltreatment into real world settings are nearly insurmountable.”

But hope should not be lost. The researchers argue that partnerships between policy-makers, practitioners, and researchers are the key to both building the evidence-base for interventions targeting maltreatment, and for their successful implementation and sustainability.

To illustrate they describe the Building Healthy Children initiative, a partnership between Monroe County Department of Human Services, United Way of Greater Rochester, the Mt. Hope Family Center at the University of Rochester, and the Society for the Protection and Care of Children.

This is an initiative targeted towards impoverished mothers who had their first child before they were 21. Primarily a preventative intervention, it initially works with families who have not been reported for maltreating their child. It is a tiered model of services ranging from outreach and educational and employment training through to the provision of evidence-based interventions such as Nurse Family Partnership, The Incredible Years, Parents as Teachers and Interpersonal Psychotherapy for Depression for Mothers.

Although Building Healthy Children has, and continues to face many challenges, Toth and Manly argue that it is possible to create a system where evidence-based interventions form the bedrock of service delivery. For this to occur “mutual respect and a spirit of collaboration” must be nurtured and the investment in the partnership must be long-term.

They write: “There can be no doubt that in order to prevent and treat issues related to child maltreatment adequately, increasingly we must adopt empirically supported initiatives … The exportation of evidence-based models for child maltreatment into real world settings ultimately rests on the development of a shared commitment to fostering the well-being of vulnerable children and families.”

Prevention Action will report upon the findings of the Building Healthy Children initiative as they become available.

Reference:
Toth, S., and Manly, J. 2011. Bridging research and practice: Challenges and successes in implementing evidence-based preventive intervention strategies for child maltreatment. Child Abuse and Neglect, 35, 633−636.