Research Brief

DCSF-RBX-09-08A
June 2009

SYSTEMATIC REVIEWS OF INTERVENTIONS FOLLOWING PHYSICAL ABUSE:

HELPING PRACTITIONERS AND EXPERT WITNESSES IMPROVE THE
OUTCOMES OF CHILD ABUSE

Dr Paul Montgomery, Prof Frances Gardner and Gretchen Bjornstad

Centre for Evidence-Based Intervention, University of Oxford
and
Dr Paul Ramchandani, Department of Psychiatry, University of Oxford

Introduction

This report was commissioned by the Department for Children, Schools and Families as part of the
Safeguarding Children research initiative. The aim was to undertake a series of systematic reviews to
investigate whether effective interventions exist for children and families where a child has experienced
physical abuse. The focus of this review is on secondary prevention of adverse child outcomes and
recurrence of abuse in children who have experienced maltreatment. The interventions that target these
outcomes have been grouped into three categories: child-focused, parent-focused and family focused
interventions.

Key Findings

• There are a number of well-designed studies investigating the effectiveness of interventions for children
who have experienced physical abuse. However, many interventions that are currently used in practice
have not been well-studied.

• The most consistent and promising evidence supported the effectiveness of parenting interventions such
as Webster-Stratton’s Incredible Years and Parent-Child Interaction Therapy for improving parent-child
interactions and child mental health outcomes. One study of Parent-Child Interaction Therapy measured
recurrence of abuse, showing positive results.

• Treatment Foster Care was found to be effective for improving child outcomes in one rigorous study.

• A therapeutic preschool intervention (Childhaven) that incorporated psychological services showed a

reduction in antisocial behaviour in a long-term follow-up of 12 years.

• Family therapy may be effective for improving parental discipline, reducing parent-child conflict, and
child abuse potential but was only compared to other types of family therapy or parent-child CBT, so the
size of the effects is unclear.

• Many interventions such as family preservation services, home visiting, psychodrama, therapeutic day
treatment, individual child psychotherapy, and art therapy do not have sufficient evidence to support
their effectiveness due to a lack of well-conducted studies and limited outcome measures. Residential
treatment and play therapy were not found to be effective, with comparison treatments showing better
outcomes.
• More research is needed to investigate the
effectiveness of the wide range interventions
that are currently being provided in this
population, using well-designed and
conducted randomised controlled trials.
• There is evidence to support parenting and
treatment foster care interventions. Training
and supervision for practitioners to be able to
deliver such interventions would have positive
benefits for many children and families where
a child has experienced physical abuse.
There is still a need for further research to
elucidate the role that many child and family-
focused interventions might play.
Background
Physical abuse is highly prevalent across the
world and is frequently a component part of
broader maltreatment afflicting children.
Prevalence rates are difficult to establish as it is
widely believed to be underreported. However,
in the UK, a leading charity estimated that 7% of
children were physically abused by their
caregivers (1). The consequences of abuse are
likely to lead to adverse emotional, social and
physical effects upon the child (2).
Child-focused interventions aim to help children
cope with adverse effects of maltreatment such
as stress, anxiety, and low self-esteem and
address their immediate and long-term
adjustment needs. Thus far, there has been little
systematic evaluation of these approaches in
the area of child physical abuse, but there is
some evidence that particular approaches such
as cognitive behavioural therapy (CBT) may be
effective for children who have experienced
other forms of child maltreatment, such as child
sexual abuse (3).
Parent-focused interventions focus on improving
parenting skills and parent-child interactions.
They aim to both prevent recurrence of abuse
and reduce parent-child conflict and coercive
interactions. There is a strong evidence base
from systematic reviews showing that parenting
interventions are effective in reducing harsh
parenting, improving positive parenting skills and
reducing child problem behaviour (4-6).
Family-focused interventions may aim both to
prevent recurrence of abuse and ensure better
outcomes for the child because they concentrate
on the interactions between all family members
as well as the mental health of each member
(7). There is a relatively limited evidence base
in this area, but these interventions are often
used in practice with families presenting with
multiple problems including child maltreatment.
Aims
The aims of this review were:
1. To conduct three reviews that will
synthesise the published literature and grey
literature for interventions for children who
have experienced physical abuse, in order to
present a complete picture of all of the
available evidence.
2. To draw out the implications of this
evidence for policy, practice and future
research.
Methods
Three separate electronic search strategies were
conducted for each category of intervention.
These searches aimed to identify all studies, both
published and unpublished, with no language or
geographical restrictions, investigating child-
focused, parent-focused, or family-focused
interventions for children who have experienced
physical abuse. This search was supported by
additional efforts to find studies in the grey
literature as well as contacting experts in the field.
We have reviewed all evidence of varying quality
and rigour so as to capture a complete picture of
what is known in this field. It is important to bear
in mind methodological quality when reading the
results of this review as some research
shortcomings may bias the results and can guide
future research in the wrong direction.
Findings
Quality of research
There are a number of well-designed and
executed research studies that assess the
efficacy of interventions for children who have
experienced physical abuse, and these have
been undertaken from a variety of perspectives.
Although this review found strong evidence for
some interventions, others still need considerably
more rigorous research before they can be
confidently employed with this population. There
is a limited amount of high quality evidence for
many interventions that are currently used in
practice and there is therefore an urgent need for
such evidence.
Child-focused interventions
There is very limited research on child-focused
therapies, particularly those that involve only the
child in treatment, although many different
interventions exist. There is some evidence that
individual child-parent CBT is effective, but only
for improving scores on proxy measures of child
maltreatment, and not for child mental health
outcomes (8, 9). This implies that the parent
component may be the more effective element
of this intervention, given that individual child
CBT alone would not be expected to impact on
parenting practices. For cases where the child is
placed in care, treatment foster care
interventions seem to be most promising for
improving outcomes for children who have
experienced maltreatment, although only one
randomised controlled trial (RCT) study has
investigated this - albeit a large and rigorous one
(10). Treatment foster care consists of training in
behaviour management and positive parent-
child interactions for the foster parents before
receiving the child, daily telephone support and
supervision, weekly group meetings, and 24-
hour on-call crisis interventions. In addition, the
children participated in a behavioural day
treatment programme and attended weekly
therapeutic playgroups. In addition, one study
found that a therapeutic preschool that provided
medical, developmental, psychological, and
educational services to promote healthy growth
and development reduced children’s antisocial
behaviour in the long term (11).
Parent-focused interventions
Overall, the findings from 7 RCTs suggest some
promising approaches based on well-structured
cognitive-behavioural parenting interventions
(12-18). In many cases the intervention included
additional components designed to address
needs of abusive parents, such as anger or
stress management. It is noteworthy that several
of the trials showing improvement on some
outcomes were based on well-known,
manualised interventions (e.g. Parent-Child
Interaction Therapy (PCIT); Webster Stratton
Incredible Years), which have a strong existing
evidence base for improving parent-child
interaction and reducing child conduct problems.
These interventions are based on a manualised
curriculum involving structured sessions to
promote positive relationships between parents
and children and to teach parents effective ways
to address behaviour problems that prevent
coercive interactions. The limited evidence from
the present review, when considered in
combination with evidence from the numerous
high quality trials based on somewhat different
(but nevertheless overlapping) samples of
troubled families, suggests promising avenues for
intervention with physically abused populations.
In particular, we found reasonable evidence that
the parenting interventions reviewed here were
effective in improving parent-child interactions
and some child mental health outcomes. We were
not able to draw definitive conclusions about their
potential to reduce the recurrence of abuse, as
only one study measured this (13), and given that
abuse reporting can be unreliable, it therefore
needs to be corroborated by other studies.
Family-focused interventions
Although it appears to be beneficial to involve the
parent or caregiver in treatment, family-focused
interventions such as family therapy or family
preservation services do not have such promising
outcomes. The stronger evidence for these
interventions in the form of the randomised trials
reported mixed results.
The effectiveness of family therapy is unclear
given that one randomised trial compared it with
CBT, showing family therapy to be equally or less
effective (8, 9). The other study found positive
results indicating that levels of physical abuse
had reduced according to both child and parent
report, but only as compared to another family
therapy intervention, thus limiting conclusions
(19).
Family preservation services, also known as
either 'Homebuilders' or 'Families First' aims to
keep families together but does not seem to
produce consistently good results. One study
measured improvements in reducing out-of-home
placement (20), three studies showed no
differences (21-23), and one showed negative
results (24). However, in one study, the families
who received this intervention seemed to have
fewer crises than did the families who were in the
'treatment as usual' groups (21). The implications
for children’s mental health and recurrence of
abuse were unclear from these studies.
Implications for practice, policy and research
Policy
Policy should prioritise funding for interventions
that are supported by strong evidence for
improving outcomes for children, and for
reducing recurrence of abuse in proxy outcome
measures. The evidence so far points to
parenting interventions being the most
promising. High quality training and supervision
will be required to deliver many of these
interventions.
Funding for research that includes measures of
recurrence of abuse as a primary outcome is
needed to determine the effects of parent and
family focused interventions, possibly using
proxy measures alongside referrals to social
services, hospital or medical records, or criminal
records.
Many interventions that are currently delivered
do not have strong evidence to support them.
Policy makers should reconsider funding for
interventions with weaker evidence, or
potentially combine funding with research
funding to develop the evidence base for
interventions that are currently used in practice.
Practice
Several of the evidence based interventions
reviewed here could be delivered by
practitioners in a range of settings because they
have been manualised with a clear training and
supervision scheme in place (e.g. Parent Child
Interaction Therapy, Webster Stratton’s
Incredible Years, Treatment Foster Care, child-
parent CBT). Indeed, the parent training and
treatment foster care interventions have been
tested using varying populations and settings
and have generally shown consistent results.
However, fidelity to treatment protocols would be
crucial for practitioners who wish to replicate
results in their own practices. This requires
investment in high quality training (for example,
as provided by the National Academy of
Parenting Practitioners). Importantly, to ensure
these skills are sustained and supported over
time, systems need to be in place for ongoing
supervision and quality control. In addition, few
of the reviewed studies provided details about
the settings in which they delivered treatment. It
was not always clear whether the therapists
were working as part of the research team, or
whether the research was conducted in an
existing practice. Some details about the
qualifications and training of the practitioners are
provided in the full review where available.
Practitioners will have to consider the effects that
compulsory or non-compulsory interventions
might have on participant retention and
motivation. Many studies did have high dropout
rates, which is likely to happen in practice
settings. Those that did manage to retain most
participants probably went to great lengths to do
so for the sake of the research, so practitioners
should be aware that they may need to employ
similar strategies.
It is important for practitioners to know about the
types of children or families for whom
interventions are effective. However the studies
reviewed provided little information about sample
characteristics and none conducted moderator
analyses to test if interventions were effective for
particular groups of children and families. Some
studies excluded parents with severe mental
illness and current drug addiction, whereas others
did not discuss these issues. Therefore, it is not
known whether these interventions are applicable
to families with multiple problems of this sort.
Research
One over-arching message from this series of
reviews is the limited amount of high quality
research in this area and the urgent need for such
evidence. In general, the evidence pointed to the
value of parenting and cognitive behavioural
approaches as having a stronger evidence base
than other interventions, and thus worthy of
further investigation. Studies conducted in future
need to be more robust and of higher quality.
They should be large and randomised, using
objective measures where possible. In addition,
the interventions should be manualised to allow
replicability and taking to scale, and the studies
need to be well supervised to ensure fidelity to
the intervention model.
Trials must take into account the characteristics
of the samples in their studies and provide more
detailed information about them. Moderator
analyses of these factors would be invaluable for
practitioners attempting to determine what works
best for whom. Future research, whether
specifically of children with physical abuse or,
perhaps more helpfully, of children with a range of
maltreatment types, needs to be generalisable to
meet the individual needs of presenting children.
All future studies must of course consider the
recurrence of physical abuse of the children
after treatment. Whether children benefit or are
harmed following these interventions is
ultimately the point of this research. Few parent
training or family therapy studies reported
outcomes related to the physical abuse of the
children. Outcomes related to the well-being of
the child, including internalising problems and
self-injurious behaviour were also not included
as outcomes in enough of these studies. Future
studies of these types of interventions need to
take this into account.
In addition, it would be very useful for policy
makers and practice managers to have more
data on the cost-effectiveness of these
interventions. Only one study measured the
costs of interventions. Many of these
interventions are likely to be quite costly, but it
would be very useful to know whether those
costs are justified by their benefits.
Additional Information
Further information about this research can be
obtained from Isabella Craig, 4 FL-ARD, DCSF,
Sanctuary Buildings, Great Smith Street, London
SW1P 3BT
Email: Isabella.craig@dcsf.gsi.gov.uk
The views expressed in this report are the
authors’ and do not necessarily reflect those of
the Department for Children, Schools and
Families.
Information about other studies which are part of
the Safeguarding Children Research Initiative
can be found at http://tcru.ioe.ac.uk/scri/
References
1. Cawson P, Wattam C, Brooker S, Kelly G.
Child Maltreatment in the UK: A Study of the
Prevalence of Child Abuse and Neglect. London:
NSPCC; 2000.
2. Dubowitz H, Bennett S. Physical abuse and
neglect of children. Lancet. 007;369(9576):
1891-9.
3. Macdonald GM, Higgins JPT, Ramchandani P.
Cognitive-behavioural interventions for children
who have been sexually abused. Cochrane
Database of Systematic Reviews 2006, Issue 4.
2006.
4. Barlow J, Johnston I, Kendrick D, Polnay L,
Stewart-Brown S. Individual and group-based
parenting programmes for the treatment of
physical child abuse and neglect. Cochrane
Database of Systematic Reviews, Issue 3. 2006.
5. Barlow J, Parsons J. Group-based parent-
training programmes for improving emotional and
behavioural adjustment in 0-3 year old children.
The Cochrane Database of Systematic Reviews.
2003;2003(2).
6. National Institute for Health and Clinical
Excellence. Parent-training/education
programmes in the management of children with
conduct disorders. London: NICE; 2006.
7. Carr A. Evidence-based practice in family
therapy and systemic consultation I: Child-
focused problems. Journal of Family Therapy.
2000;22:29-60.
8. Kolko DJ. Clinical monitoring of treatment
course in child physical abuse: Psychometric
characteristics and treatment comparisons. Child
Abuse and Neglect. 1996;20(1):23-43.
9. Kolko DJ. Individual cognitive behavioural
treatment and family therapy for physically
abused children and their offending parents: A
comparison of clinical outcomes. Child
Maltreatment. 1996;1:322-42.
10. Fisher PA, Burraston B, Pears K. The Early
Intervention Foster Care Program: Permanent
placement outcomes from a randomized trial.
Child Maltreatment. 2005;10(1):61-71.
11. Moore E, Armsden G, Gogerty PL. A twelve-
year follow-up study of maltreated and at-risk
children who received early therapeutic child
care. Child Maltreatment. 1998 1998;3(1):3-16.
12. Brunk M, Henlegger SW, Whelan JP.
Comparison of Multisystemic Therapy and
parent training in the brief treatment of child
abuse and neglect. Journal of Consulting and
Clinical Psychology. 1987;55:171-8.
13. Chaffin M, Silovsky JF, Funderburk B, Valle
LA, Brestan EV, Balachova T, et al. Parent-child
interaction therapy with physically abusive
parents: Efficacy for reducing future abuse
reports. Journal of Consulting and Clinical
Psychology. 2004 June 2004;72(3):500-10.
23. Walton E. Enhancing investigative decisions
in child welfare: An exploratory use of intensive
family preservation services. Child Welfare.
1997;76(3):447-61.
24. Schuerman JR, Rzepnicki TL, Littell JH.
Putting Families First: An Experiment in Family
Preservation. New York, NY: Aldine de Gruyter,
Inc.; 1994.

14. Egan K. Stress management and child

management with abusive parents. Journal of
Clinical Child Psychology. 1983;12:292-9.

15. Hughes J, Gottleib L. The effects of the

Webster-Stratton Parenting Program on
maltreating families: Fostering strengths. Child
Abuse and Neglect. 2004;28:1081-97.

16. Terao SY. Treatment effectiveness of

parent-child interaction therapy with physically
abusive parent-child dyads. Stockton, CA:
University of the Pacific; 1999.

17. Toth SL, Maughan A, Manly JT, Spagnola

M, Cicchetti D. The relative efficacy of two
interventions in altering maltreated preschool
children's representational models: Implications
for attachment theory. Development and
Psychopathology. 2002 Fal 2002;14(4):877-908.

18. Cicchetti D, Rogosch F, Toth S. Fostering

secure attachment in infants in maltreating
families through preventive interventions.
Development and psychopathology. 2006
2006;18(3):623-49.

19. Meezan W, O'Keefe M. Evaluating the

effectiveness of multifamily group therapy in
child abuse and neglect. Research on Social
Work Practice. 1998;8(3):330-53.

20. Walton E. In-home family-focused

reunification: An experimental study. Child
Welfare. 1993;72(5):473-87.

21. Walton E. Combining abuse and neglect

investigations with intensive family preservation
services: An innovative approach to protecting
children. Research on Social Work Practice.
2001;11(6):627-44.

22. Nelson JP. An experimental evaluation of a

home-based family-centered program model in a
public child protection agency. Minneapolis, MN:
University of Minnesota; 1984.