Child maltreatment is a serious public health issue and a major cause of health inequality.1 Children who experience serious or persistent maltreatment are at risk of a range of social, emotional, behavioural and economic adversities, alongside the impact of maltreatment on their physical and mental health. The major focus of UK policy has been on preventing serious abuse and neglect, triggered and sustained by periodic reports of the circumstances surrounding child deaths.2–4 Little attention has been given to how best to address the consequences of maltreatment for those who have experienced it or been adversely affected by it. While prevention is preferable to dealing with the consequences of maltreatment, the reality is that in 2014 almost 50,000 children in England were subject to a child protection plan because of maltreatment or risk of significant harm. Behind those 50,000 children are many more who also experience maltreatment, but who either do not come to the attention of social services or whose maltreatment falls below the undoubtedly high thresholds of harm currently operated by Children’s Services Departments. In 2012, the Health Technology Assessment (HTA) programme commissioned two evidence syntheses that were relevant to the needs of maltreated children. One was a review of interventions aimed at improving outcomes for children exposed to domestic violence (PHR 11/3007/01).5 The second was an evidence synthesis of psychosocial interventions aimed at improving outcomes for children who experienced maltreatment, and this is the focus of this report.
Categories of maltreatment
Child maltreatment has been defined as any act or series of acts of commission (physical abuse, sexual abuse, emotional/psychological abuse) or omission (neglect) by a parent, caregiver or other person, which leads to harm, the potential for harm, or threat of harm to a child (someone under 18 years). Most child maltreatment takes place within the family home, but it can also occur in an institutional or a community setting. The perpetrators of maltreatment are usually known to the children concerned, but more rarely they may be strangers. Although most maltreatment is attributable to adults, child-to-child maltreatment is also a concern. Some forms of maltreatment can take place on the internet.
Detailed definitions can be found in a number of guidelines.6–9
Briefly:
Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child.
Emotional/psychological abuse is the persistent emotional abuse of a child such as to cause severe and persistent adverse effects on the child’s emotional development. Emotional maltreatment may take the form of age or developmentally inappropriate expectations on children. It may involve conveying to children that they are worthless or unloved; not giving them opportunities to express their views or ‘making fun’ of what they say or how they communicate; seeing or hearing the ill-treatment of another; being seriously bullied (including cyberbullying), or exploited or corrupted. Emotional abuse is involved in all types of maltreatment, although it may occur alone. Children who are the subject of fabricated illness are also subject to emotional abuse, either as a result of being brought up in a fabricated sick role, or because of an abnormal relationship with their carer, or disturbed family relationships.
10–15 More recently, domestic violence has been recognised as maltreatment, and is a common cause of emotional or psychological harm to children.
Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. Activities may involve physical contact, including assault by penetration or non-penetrative acts and non-contact activities, such as involving children in watching sexual activities, encouraging them to behave in sexually inappropriate ways, or grooming them in preparation for abuse (including via the internet). Sexual abuse is perpetrated by men and women, although the majority of sexual abuse of children is by male perpetrators against female children, typically someone known to them (i.e. a family member or family friend). Abuse by a stranger is less common. Sexual abuse can occur between children.
Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of his or her health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to provide a child with adequate food, clothing and shelter (including exclusion from home or abandonment); failing to protect him or her from physical and emotional harm or danger; or failing to ensure access to appropriate medical care or treatment. It may include neglect of, or unresponsiveness to, a child’s basic emotional needs.
Most children experience more than one form of maltreatment, and there is growing recognition of the need to better take into account children’s profiles of maltreatment in order to improve policy and practice.16–18 Although maltreatment can result in death, serious injury or impairment (see below), it is not itself a disorder but an event or exposure; not all maltreated children experience impairment.
Prevalence, aetiology, contributory factors
Child maltreatment poses significant threats to children’s health, development and well-being. It is recognised that statistics on the number of referrals to child protection services, and the numbers of children for whom there is a child protection plan, let alone the number of criminal offences against children, are an underestimate of the scale of the problem within the UK. The term ‘registration’ is used here to describe children for whom there is a child protection plan (England) or whose names are on child protection registers (Wales, Scotland and Northern Ireland). As at March 2009, registrations in the UK were England, 34,100; Wales, 2512; Northern Ireland, 2488; and Scotland, 2682. It is important to note that these data may not be measuring precisely the same thing in each jurisdiction. Data on trends in child maltreatment are difficult to interpret,19 but, overall, the numbers of children registered in each jurisdiction has increased steadily since 2002, although there is some evidence of a fall in the numbers of violent child deaths in infancy and middle childhood within the UK.20 The 2014 figure for children subject to a child protection plan in England as at 31 March was 48,300 (excluding unborn children), an increase of 12.1% on the numbers at the same time in 2013. This represents an increase of 23.4% since 31 March 2010. In 2011 the National Society for the Prevention of Cruelty to Children (NSPCC) published a cross-sectional, self-report survey of 2275 children aged 11–17 years and adults aged 18–24 years. Their findings indicated that 18.6% of the 11- to 17-year-olds ‘had been physically attacked by an adult, sexually abused, or severely neglected’ and 25.3% of the 18- to 24-year-olds reported severe maltreatment during childhood.21
Consequences of maltreatment
A growing body of evidence suggests that being exposed to maltreatment may result in structural and functional changes to the developing brain,22–24 as well as long-lasting changes in the way genes are expressed in the brain.25–27 The adverse effects of maltreatment can be found across multiple domains of functioning, including physical and mental health and well-being, security of attachment, cognitive and emotional development, aggression, violence and criminality, and socioeconomic attainment.28–33 Maltreatment is a non-specific risk factor for a wide range of adverse long-term health and social care outcomes, and children who experience multiple forms of maltreatment are at increased risk.34–36 There is also some evidence of maltreatment type-specific risks, although generally this is stronger for sexual abuse than other forms of child maltreatment. Widom et al.37 found that both child physical abuse and neglect, but not sexual abuse, were associated with an increased risk for lifetime major depressive disorder in young adulthood, with children exposed both to physical abuse and neglect being most at risk. A longitudinal study by Kotch et al.38 concluded that neglect within the first 2 years of life, in the absence of other forms of maltreatment, predicted levels of aggression at ages 4, 6 and 8 years. Preschool children exposed to severe physical neglect have been found to evidence increased rates of internalising symptomatology and withdrawn behaviour compared with other maltreated children.39 Generally though, the fact that few children experience only one form of maltreatment makes it difficult to link particular forms of maltreatment with specific risks or adverse outcomes.
The impact of maltreatment may depend on the interaction of a number of factors, including the child’s genetic endowment, age, gender, type(s) of abuse, severity, frequency and duration of maltreatment, and the availability of protective factors that function to enhance a child’s resilience.40–45 Children who appear to be ‘asymptomatic’ following maltreatment may, nonetheless, be at risk for the development of later psychosocial problems, triggered by subsequent stressors and the need to negotiate key developmental tasks, for example forming intimate relationships, managing interpersonal conflict, becoming a parent and so on.
For the child who is removed from their birth parents or other primary carers under relevant legislation, the adverse effects of maltreatment may be compounded by delays arising from lengthy care proceedings and instability of placements. For infants and young children, these factors may exacerbate attachment difficulties or disorders. In developing effective interventions, it is therefore important to understand how and why maltreatment impacts throughout the life course, and the variables that either mediate or moderate adverse sequelae.
Economic consequences of maltreatment
The economic costs of maltreatment, both to individuals46–50 and to society,51–55 are well documented. Costs to individuals include adverse effects on physical and mental health; social and emotional development; cognitive development and levels of educational attainment; and employment status and earnings. Societal costs include the health and social care costs of illness or injury; the intergenerational costs of teenage pregnancy and poor parenting; criminal justice system costs; and losses in productivity.
Psychosocial interventions
There is a wide range of psychosocial interventions currently available to children and young people who have experienced maltreatment, although availability varies enormously.56–58 These are based on a variety of theoretical underpinnings and include:
interventions based on cognitive theories, including cognitive–behavioural therapy (CBT), trauma-focused CBT (TF-CBT) and abuse-focused CBT
eye movement desensitisation and reprocessing (EMDR)
interventions based primarily on forms of expression and communication drawn from the arts, including art therapy, drama therapy, music therapy, play therapy and narrative group therapy
attachment-based interventions
interventions based on psychoanalytic theories, offered to the child or parent–child dyad.
family/systemic interventions.
multisystemic therapy (MST)
peer mentoring.
enhanced foster care, including treatment foster care
residential care, including models of therapeutic residential care, such as CARE® (Cornell University, Ithaca, NY, USA) and Sanctuary® (Sanctuary Institute, Philadelphia, PA, USA).
Interventions may be delivered in one or more of a range of contexts, for example clinic, school, community. Interventions may be individual or group based, or a combination, and may involve only the child or the child and his or her primary carer(s). Some entail a change of caregiver, as in adoption, kinship care, foster care or residential care. Most are commissioned, or provided by, the UK NHS. Some are available from a range of voluntary and private sector providers, and some are primarily social care or education based.
Timing of, and pathways to, treatment
For some forms of maltreatment, treatment can be offered appropriately only after the child is protected from further abuse. This applies to sexual abuse and serious physical injury, and here protection can be ensured only when the contact between the child and the abuser is constantly supervised or halted. In the more persistent or chronic forms of maltreatment – emotional abuse and neglect – treatment may be offered to the child and caregivers simultaneously to deal both with the effects of the maltreatment and with the harmful parent–child interactions.
Maltreatment per se may be the trigger for some referrals to Child and Adolescent Mental Health Services (CAMHS). For example, a child may be referred following recognition of a specific form of maltreatment, most commonly sexual abuse. Sometimes children are referred as a result of maltreatment although the precise nature of that maltreatment may not be known. Other children may be referred because they have experienced several forms of maltreatment. Emotional maltreatment is often seen as integral to other forms of abuse or neglect.
Some children will be referred for help with specific symptoms, for example post-traumatic stress disorder (PTSD), depression or anxiety. In some cases this will be clearly identified as the results of exposure to maltreatment, such as physical or sexual abuse or intimate partner violence (IPV). Others will be referred when there is no mention or initial awareness of the existence or relevance of previous maltreatment, but where a causal link is subsequently found. This review focuses on those children whose pathways to referral are clearly linked with maltreatment.
Treatment acceptability and engagement
Children who have experienced abuse and neglect can be difficult to engage, not least because of the adverse impact of maltreatment on their ability and willingness to engage with, or trust, adults. Evidence from a NSPCC survey21 indicated that some 80% of young adult women who reported abuse by a caregiver said they had talked to a professional following the abuse taking place, compared with just 18% of boys. However, those who sought help from a professional did not always think that it had brought about a better outcome. Carers too can feel excluded from some therapeutic approaches, when their involvement may be critical.
But many children do not have the opportunity of help. Historically, child maltreatment has been seen as a problem for social care, rather than CAMHS,59 and effective interagency working between CAMHS and social services continues to be elusive. Referral pathways to CAMHS are long and complex,60,61 and, for those referred, acceptance thresholds are high and waiting lists are often extremely long. Little, if anything, is known about what maltreated children want from health-care professionals or what kinds of intervention or service arrangements they find acceptable, and possible to engage with, or unacceptable.
Importance of this evidence synthesis
Reviews in this area suffer from a number of weaknesses.62 These include (1) searches that are out of date, have restricted search dates or language restrictions; (2) the predominance of research conducted in North America, with little or no consideration of the generalisability of evidence to other policy contexts; (3) a lack of adequate consideration of the maltreatment profiles of study participants; (4) a lack of consideration of the logic models underpinning included interventions; (5) inadequate, and sometimes no, consideration of the risk of bias of included studies; (6) heterogeneity of outcomes and measures used; and (7) a lack of consideration of issues of acceptability or accessibility of interventions for children and their families.
Most reviews, for good methodological reasons, restrict their inclusion criteria to randomised or quasi-randomised trials. Although it is arguably unethical to expose maltreated children to interventions of unknown effectiveness, the technical challenges of implementing randomised trials of maltreatment interventions are considerable, sometimes resulting in studies with high risk of bias63,64 or little useful information. Other types of study may provide valuable information about interventions not yet subjected to more rigorous evaluation, and may provide a picture of the evidence gaps when compared with the profile of available services.
As with studies and reviews of interventions, most studies of the cost-effectiveness of interventions appear to have focused on primary prevention rather than secondary and tertiary prevention, or the treatment of children who have experienced maltreatment.65–67 A review by Goldhaber-Fiebert et al.68 identified 19 reviews and 30 original papers reporting research on the costs and effectiveness of interventions for children at risk of (the majority), or already involved in, child welfare (protection) services. They observe that existing model-based evaluations of secondary prevention have, so far, used ‘relatively simple multiplicative decision trees’ that do not reflect the variety of pathways that children follow, how these may impact on the effectiveness of subsequent interventions or adequately address factors such as the child’s age (p. 737). They concluded that current epidemiological data, combined with evidence from well-conducted outcome studies and improved modelling techniques, make it timely to revisit the cost-effectiveness of interventions for maltreated children.
Research aims and objectives
This review aimed to bring high standards of evidence synthesis to bear in this important but challenging area of public health. It provides an up-to-date overview of research on interventions aimed at addressing the adverse consequences of child maltreatment, and a synthesis of what we know about their effectiveness and cost-effectiveness. The objectives of the research were to answer the following questions:
Which interventions are effective, for which children, with what maltreatment profiles, in what circumstances?
When two or more interventions might be appropriate, which is most likely to be effective?
Which interventions are of no benefit or may result in harm?
Which interventions are most accessible and acceptable to carers, children and young people?
What do we know about the economic benefits of interventions, and the potential value of undertaking future research?
