Can Children be Protected Against Violence and Violations From Parents? A Randomized Controlled Study of Safer Kids: A Manualized Intervention to Prevent Child Abuse

BACKGROUND:

International studies have shown prevalence rates of child abuse globally, with around 20 percent of all children being exposed to violent or abusive parenting (Stoltenborgh, Bakermans Kranenburg, Ijzendoorn, & Alink, 2013). A Swedish study showed that 15 percent of children living in Sweden sometime had experienced physical violence from a parent or close relative, from which half had been exposed several times (Annerbäck, Wingren, Svedin, & Gustafsson, 2010). Apart from the suffering caused by the abuse in itself, does the experience of child abuse act as a risk-factor for future problems. It has for example been shown that children who have experienced child abuse run a greater risk for developing depression, anxiety disorders, eating disorders, conduct disorders and substance abuse problems (Norman et al., 2012).

Despite the apparent need for effective interventions to prevent child abuse, few well-designed studies of intervention effects have been published. In a recent meta-analysis including all randomized trials of all types of interventions to prevent or treat child abuse, only 23 studies were included (Euser, Alink, Stoltenborgh, Bakermans-Kranenburg, & van IJzendoorn, 2015). The results of that analysis was also a disappointment, since the overall effect in terms of reducing or preventing child abuse was d=0.13, an effect that turned out to be non- significant after taking publication bias into account. However, a moderation analysis showed that interventions based on parent training (N=10) showed significantly larger effects than other types of interventions. In support of that result, another meta-analysis including studies of parent training interventions only, did show a significant overall effect of 11 percent absolute reduction in risk of reabuse (Vlahovicova, Melendez-Torres, Leijten, Knerr, & Gardner, 2017). Thus, even if parent training interventions show some promise, the small to non-existent intervention effects found in the meta-analyses also point to the need of developing more effective interventions.

The application of manualized interventions is rare within the social services in Sweden, but there have been a few projects in recent years with the purpose of implementing interventions that previously have been evaluated in foreign studies. One example is the iRisk-project (Broberg et al., 2015). The main purpose of that project was to investigate the ability of regular service providers to implement the interventions fith fidelity and sustainability. The effects of the interventions were also measured, but only with pre-post design without a matched control group. Both parents and the practitioners appreciated the interventions. There were also positive effects on outcome measures between pre and post the interventions, but since no matched control group was included, no safe conclusion of intervention effects could be drawn. However, several challenges were also identified in terms of implementation and sustainability. First, it was found that it was harder than expected to recruit and engage caregivers in the interventions. Secondly, several of the included service units had difficulties getting started with interventions and many reported that contacts were terminated prematurely. A third conclusion was that several practitioners described difficulties in sustaining the work with the more time consuming interventions at their service unit. A final conclusion was that practitioners found it difficult to maintain continuity in the longer interventions, due to logistic challenges for the practitioner and the families.

In summary, most previously evaluated interventions demand considerable time and resources, and there have consequently been reports of challenges in terms of implementation. In view of the prevalence of child abuse, it is therefore apparent that many families that are investigated within the services never will get access to such interventions. Furthermore, a condition in several of the existing interventions is that the suspected caregiver acknowledges the abusive act that has been committed, either in the investigation that precedes the intervention, or as a part of the intervention itself. This may pose challenges in terms of stigma and motivation to engage in the intervention. In light of these challenges, it is important to develop interventions that a) readily can be implemented with fidelity and sustainability in regular social service units, b) is less demanding and time consuming - both to be able to serve a larger number of investigated families, but also to prevent fatigue and premature termination in participating families, c) that minimize stigma and therefore can engage reluctant caregivers.