Background: Exposure to domestic violence and abuse (DVA) during childhood and adolescence increases the risk of negative outcomes across the lifespan.
Objectives: To synthesise evidence on the clinical effectiveness, cost-effectiveness and acceptability of interventions for children exposed to DVA, with the aim of making recommendations for further research.
Design: (1) A systematic review of controlled trials of interventions; (2) a systematic review of qualitative studies of participant and professional experience of interventions; (3) a network meta-analysis (NMA) of controlled trials and cost-effectiveness analysis; (4) an overview of current UK provision of interventions; and (5) consultations with young people, parents, service providers and commissioners.
Settings: North America (11), the Netherlands (1) and Israel (1) for the systematic review of controlled trials of interventions; the USA (4) and the UK (1) for the systematic review of qualitative studies of participant and professional experience of interventions; and the UK for the overview of current UK provision of interventions and consultations with young people, parents, service providers and commissioners.
Participants: A total of 1345 children for the systematic review of controlled trials of interventions; 100 children, 202 parents and 39 professionals for the systematic review of qualitative studies of participant and professional experience of interventions; and 16 young people, six parents and 20 service providers and commissioners for the consultation with young people, parents, service providers and commissioners.
Interventions: Psychotherapeutic, advocacy, parenting skills and advocacy, psychoeducation, psychoeducation and advocacy, guided self-help.
Main outcome measures: Internalising symptoms and externalising behaviour, mood, depression symptoms and diagnosis, post-traumatic stress disorder symptoms and self-esteem for the systematic review of controlled trials of interventions and NMA; views about and experience of interventions for the systematic review of qualitative studies of participant and professional experience of interventions and consultations.
Data sources: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, Applied Social Sciences Index and Abstracts, International Bibliography of the Social Sciences, Social Services Abstracts, Social Care Online, Sociological Abstracts, Social Science Citation Index, World Health Organization trials portal and clinicaltrials.gov.
Review methods: A narrative review; a NMA and incremental cost-effectiveness analysis; and a qualitative synthesis.
Results: The evidence base on targeted interventions was small, with limited settings and types of interventions; children were mostly < 14 years of age, and there was an absence of comparative studies. The interventions evaluated in trials were mostly psychotherapeutic and psychoeducational interventions delivered to the non-abusive parent and child, usually based on the child’s exposure to DVA (not specific clinical or broader social needs). Qualitative studies largely focused on psychoeducational interventions, some of which included the abusive parent. The evidence for clinical effectiveness was as follows: 11 trials reported improvements in behavioural or mental health outcomes, with modest effect sizes but significant heterogeneity and high or unclear risk of bias. Psychoeducational group-based interventions delivered to the child were found to be more effective for improving mental health outcomes than other types of intervention. Interventions delivered to (non-abusive) parents and to children were most likely to be effective for improving behavioural outcomes. However, there is a large degree of uncertainty around comparisons, particularly with regard to mental health outcomes. In terms of evidence of cost-effectiveness, there were no economic studies of interventions. Cost-effectiveness was modelled on the basis of the NMA, estimating differences between types of interventions. The outcomes measured in trials were largely confined to children’s mental health and behavioural symptoms and disorders, although stakeholders’ concepts of success were broader, suggesting that a broader range of outcomes should be measured in trials. Group-based psychoeducational interventions delivered to children and non-abusive parents in parallel were largely acceptable to all stakeholders. There is limited evidence for the acceptability of other types of intervention. In terms of the UK evidence base and service delivery landscape, there were no UK-based trials, few qualitative studies and little widespread service evaluation. Most programmes are group-based psychoeducational interventions. However, the funding crisis in the DVA sector is significantly undermining programme delivery.
Conclusions: The evidence base regarding the acceptability, clinical effectiveness and cost-effectiveness of interventions to improve outcomes for children exposed to DVA is underdeveloped. There is an urgent need for more high-quality studies, particularly trials, that are designed to produce actionable, generalisable findings that can be implemented in real-world settings and that can inform decisions about which interventions to commission and scale. We suggest that there is a need to pause the development of new interventions and to focus on the systematic evaluation of existing programmes. With regard to the UK, we have identified three types of programme that could be justifiably prioritised for further study: psycho-education delivered to mothers and children, or children alone; parent skills training in combination with advocacy: and interventions involving the abusive parent/caregiver. We also suggest that there is need for key stakeholders to come together to explicitly identify and address the structural, practical and cultural barriers that may have hampered the development of the UK evidence base to date.
Future work recommendations: There is a need for well-designed, well-conducted and well-reported UK-based randomised controlled trials with cost-effectiveness analyses and nested qualitative studies. Development of consensus in the field about core outcome data sets is required. There is a need for further exploration of the acceptability and effectiveness of interventions for specific groups of children and young people (i.e. based on ethnicity, age, trauma exposure and clinical profile). There is also a need for an investigation of the context in which interventions are delivered, including organisational setting and the broader community context, and the evaluation of qualities, qualifications and disciplines of personnel delivering interventions. We recommend prioritisation of psychoeducational interventions and parent skills training delivered in combination with advocacy in the next phase of trials, and exploratory trials of interventions that engage both the abusive and the non-abusive parent.
Study registration: This study is registered as PROSPERO CRD42013004348 and PROSPERO CRD420130043489.
Funding: The National Institute for Health Research Public Health Research programme.
Copyright © Queen’s Printer and Controller of HMSO 2016. This work was produced by Howarth et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
- Plain English summary
- Scientific summary
- Design and overview of methods
- Systematic review of interventions for children exposed to domestic violence and abuse: evidence from controlled trials
- Experiences of interventions following exposure to domestic violence and abuse: a qualitative synthesis of the views of children, parents and stakeholders
- Informing future research design: a network meta-analysis and cost-effectiveness analysis
- Extrapolating childhood outcomes into adult outcomes: analysis of longitudinal studies
- Understanding findings in the UK context: scoping review of current UK provision of interventions for children exposed to domestic violence and abuse
- Consultations with young people, mothers, service providers and commissioners
- Synthesis of study findings
- Conclusions and recommendations for strengthening the evidence base and directions for future research
- Search strategy
- Search strategy: supplementary updated search for randomised controlled trials
- Study identifier used, references to completed and included studies and references to ongoing studies
- List of excluded papers and reasons for exclusion
- Study details
- Details of ongoing study
- Risk of bias as assessed using the Cochrane risk-of-bias tool
- Outcome measures
- Characterisation of abuse
- Forest plots
- Translation of constructs: children
- Translation of constructs: parents
- Translation of constructs: stakeholders
- Complete study details: qualitative systematic review
- Useable outcome measures and predictors of interest (behavioural or mental health) reported by study
- Correlation between baseline and follow-up measures
- The additivity assumption for the Child Behaviour Checklist
- Network meta-analysis model
- WinBUGS code for intervention types for the primary analysis: randomised controlled trials only
- Estimate of intervention costs
- Summary of identified longitudinal studies and decision to include or exclude in analyses
- List of websites searched for relevant grey literature
- Papers obtained through grey literature search
- Programme descriptions
- List of professionals attending one or both expert stakeholder meetings
- Concepts of success for domestic violence and abuse interventions identified by stakeholder groups
- List of abbreviations
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