Comparative Effectiveness of Interventions Addressing Child Maltreatment

In April 2013, RTI International-University of North Carolina Evidence-based Practice Center issued a report, Child Exposure to Trauma:  Comparative Effectiveness of Interventions Addressing Maltreatment.  This report reviews “the comparative efficacy and effectiveness of interventions that address child well-being and/or promote positive child welfare outcomes (safety, placement stability, and permanency) for maltreated children ages birth to 14 years.”

What is particularly striking about the studies reviewed for the report was the paucity of evidence-based interventions that address child well-being or child welfare outcomes in maltreated children.  Investigators found that few head-to-head (an intervention is compared with an alternative approach), multiple, or independent (an investigator that is not associated with the intervention’s development) trials existed.  Sample sizes were typically small, with no attention paid to dose.  Parents or caregivers struggling with substance abuse, domestic violence, and mental illness were usually excluded from the study sample.

The review was based on studies published since 1990 that addressed the researchers’ analytic framework, key questions, and inclusion/exclusion criteria identified by PICOTS (populations, interventions, comparators, outcomes, timing, settings).  For each study, investigators rated the risk of bias (selection, performance, attrition, detection, confounding, reporting) and the strength of evidence for each key question.  Strength of evidence was based on risk of bias, consistency, directness, and precision of the evidence.  Thus, strength ranged from “high confidence that the evidence reflects the true effect” to insufficient evidence.  Although the initial literature search resulted in 6,282 unduplicated citations, this list was winnowed down to a total of 25 studies based on the exclusion criteria.

For key question 1, comparative effectiveness of interventions for improving child well-being outcomes, 21 studies were reviewed.  Only one—Keeping Foster Parents Trained and Supported (KEEP)—received a moderate strength of evidence grade for mental and behavioral health and caregiver-child relationship outcomes.

For key question 2, comparative effectiveness of interventions for improving child welfare outcomes, 9 trials were reviewed.  Moderate strength of evidence was found for a home-visiting approach with maltreating parents (SafeCare) and the foster parent training program KEEP.

For key question 3, comparative effectiveness of interventions with different characteristics, no studies were found that addressed the question.

For key question 4, comparative effectiveness of interventions for improving child well-being or child welfare outcomes in population subgroups, SafeCare and KEEP were again identified as having moderate strength of evidence.  SafeCare received this grade for safety for early childhood, neglect, and the maltreating parent.  KEEP received this grade for mental and behavioral health, caregiver-child relationship, and permanency.

For key question 5, comparative effectiveness of interventions with children exposed to maltreatment for engaging children and/or caregivers in treatment, only Parent-Child Interaction Therapy (PCIT) addressed this measure. PCIT, combined with motivational interviewing, was found to have moderate strength on treatment engagement and retention.

For key question 6, adverse events associated with interventions for children exposed to maltreatment, only one study examined active surveillance of adverse events.  These investigators found that sexually-abused preschool children receiving trauma focused-cognitive behavioral therapy were less likely to experience the adverse event of removal from treatment than those children receiving nondirective supportive therapy.

The RTI International-University of North Carolina Evidence-based Practice Center urged that the report not be used as a guide to selecting interventions.  Rather, they asked policymakers to consider funding more collaborative multisite clinical research trials and to incentivize the collection of implementation and outcome data that would be used for both research and decision-making at the program and clinical levels.