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The efficacy of family support and family preservation services on reducing child abuse and neglect: what the literature reveals Rebecca O'Reilly, Lesley Wilkes, Lauretta Luck and Debra Jackson J Child Health Care 2010; 14; 82 originally published online Nov 20, 2009; DOI: 10.1177/1367493509347114 The online version of this article can be found at: http://chc.sagepub.com/cgi/content/abstract/14/1/82

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The efficacy of family support and family preservation services on reducing child abuse and neglect: what the literature reveals

JCHC Journal of Child Health Care © The Author(s), 2010 Reprints and Permissions: http://www.sagepub.co.uk/ jounalsPermissions.nav Vol 14(1) 82–94 DOI: 10.1177/1367493509347114

REBECCA O’REILLY PhD Candidate, School of Nursing and Midwifery, Family and Community Health Research Group (FaCH), University of Western Sydney, New South Wales, Australia

LESLEY WILKES Professor and Dean of Research Studies, School of Nursing and Midwifery, Family and Community Health Research Group (FaCH), University of Western Sydney, New South Wales, Australia.

LAURET TA LUCK Associate Head of School and Senior Lecturer, School of Nursing and Midwifery, Family and Community Health Research Group (FaCH), University of Western Sydney, New South Wales, Australia.

DEBRA JACKSON Professor and Director Higher Degree Research, School of Nursing and Midwifery, Family and Community Health Research Group (FaCH), University of Western Sydney, New South Wales, Australia.

Abstract Globally, child protection services are under-resourced and unable to meet the demands associated with the increasing numbers of families who are being exposed to child abuse and neglect. Family support and family preserva­tion interventions are the methods cited within the literature as those employed by child protection services to address this issue. Intensive family preservation services and cognitive behavioural therapy are discussed as the most effective interventions currently used by child protection services. This article presents a review of the literature on the efficacy of family-centred interventions for child abuse and neglect. Revealed in this review is that such efficacy remains controversial, with literature affirming that the most successful practice is a combination of interventions applied simultaneously. The literature reviewed suggests that more contemporary

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research around family-centred interventions for child abuse and neglect is required.

Keywords   child abuse    child neglect    child protection    family centred care ●





Introduction Child protection services are faced with the challenges of reducing child abuse and neglect, protecting the child and maintaining the family unit. Increasing numbers of families are being exposed to child abuse and neglect globally (Adams, 2005; Australian Institute of Health and Welfare [AIHW], 2006; Watson, 2005; World Health Organization, 1997), yet child protection services are finding themselves under-resourced and unable to meet the demands associated with this increase (DePanfilis and Zuravin, 2002; McCowskey and Meezan, 1998). Child protection services are focused on family-centred interventions, referred to within the literature as family support and family preservation services (Katz and Hetherington, 2006; McCowskey and Meezan, 1998; Statham, 2000). Family support services are primarily community-based services intended for families coping with the normal stressors of parenting, with the aim of alleviating stress and promoting parental capacity to prevent child abuse and neglect (Chaffin et al., 2001; McCowskey and Meezan, 1998). Family preservation services are aimed at families in crisis and at serious risk of child abuse and neglect and who are already known to child protective services (Chaffin, et al., 2001; McCowskey and Meezan, 1998). Both of these services share the goal of reducing future child abuse and neglect (Chaffin, et al., 2001; McCoswkey and Meezan, 1998). The family-centred interventions that fall under both family support and family preservation services that will be addressed in this paper include home ­visiting, cognitive behavioural therapy (CBT), group therapies and intensive family preservation services (IFPS). Home-visiting interventions encompass visitation of parents and children in their home by child welfare workers who convey information, offer training and support, or perform a combination of activities with the family (Duggan et al., 2000; Hahn et al., 2003). Cognitive behavioural therapy involves modifying parenting and children’s behaviours through education and learning and encourages positive interactions between parents and children (Dufour and Chamberland, 2004). Group therapy provides the parents of abused and neglected children with education on parenting and opportunities for social skills enhancement and the development of social support networks (Gaudin et al., 1990–1991; Marziali et al., 2006). Intensive family preserva­tion services are brief, intensive services for high-risk families in crisis with the goal of



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preventing removal of a child from the family home (Berry et al., 2000; Kirk and Griffith, 2004; McCowskey and Meezan, 1998) and includes case management, home-based counselling, anger management and provision of concrete services (Chaffin et al., 2001; Littell, 2001). While extensive literature exists around these family-centred interventions, their efficacy remains controversial. This paper will review research studies that have examined the effectiveness of home visiting, CBT, group therapy and IFPS in reducing child abuse and neglect. Further, the review will identify implications for research and practice.

Identification of relevant literature The following databases were searched for literature that focused on family­centred interventions for child protection: CINAHL, EMBASE, Journals at Ovid, MEDLINE, PsycINFO, PsycARTICLES, Academic Search Premier, Health source, Blackwell Synergy, Psychology and Behaviour Sciences Collection, Professional Development Collection and ERIC. The keywords that were used to search for relevant studies included ‘family-centred interventions’; ‘child protection services’; ‘family preservation services’; ‘family support services’; ‘home visiting’; ‘cognitive behavioural therap*’; ‘group therap*’; ‘intensive family preservation services’; ‘child abuse interventions’; ‘child neglect interventions’. The initial search was limited to the years 2000 to 2008 however this resulted in only a small amount of relevant literature being found. In addition to the database searches, reference lists of the identified suitable literature were also searched. This identified that there was a vast amount of literature relevant to the search terms published in the 1980s and 1990s. Therefore, the same search strategy was applied but the years of the search extended to 1980 through to 2008. The literature identified that each family-centred intervention has controversial findings related to their efficacy.

The efficacy of the family-centred interventions The efficacy of family-centred interventions is determined by a variety of outcome measures, namely child hospitalization for injury, number of child protective service reports, removal of the abused/neglected child from the family home, child health and development, parental risk factors, parenting behaviours, the home environment and customer satisfaction with service delivery. The findings reported on in this paper will address the efficacy of home visiting, CBT, group therapy and IFPS relevant to these outcome measures.

Home visiting Home visiting was the largest area discussed within the literature with the majority of the research being from before the year 2000. The literature presents evi84 Downloaded from http://chc.sagepub.com at University of Western Sydney on May 4, 2010

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dence of the effectiveness of early childhood home visitation in reducing child abuse and neglect (Bilukha et al., 2005; Hahn et al., 2003) as is measured by decreased hospitalization for child injury (Gray et al., 1979) and decreased child protective services reports (Olds et al., 1986). Conversely, Duggan, McFarlane et al. (2004) and Duggan et al. (2007) found that home visiting had no impact on hospitalization rates or the number of substantiated child abuse reports after home visitation. Parental behaviours that have been measured to determine home visiting efficacy, such as use of corporal punishment and knowledge related to the holistic health of a child, suggest that there were no changes to the outcome measures with home visitation (Armstrong et al., 1999; Duggan, McFaralane et al., 2004; Duggan et al., 2007; Lyons-Ruth et al., 1990). Similarly, the outcome measure of the home environment, including domestic violence, maternal depression, parenting stress and substance abuse, revealed no significant changes with home visitation (Duggan, Fuddy et al., 2004; Duggan et al., 2007; Fraser et al., 2000; Marcenko et al., 1996). Of the studies reporting positive results of home visiting to home environment outcome measures, there was no evidence of lasting effects of this intervention (Armstrong et al., 1999; Fraser et al., 2000). However, Eckenrode et al. (2000) found that while home visiting demonstrated little effect on domestic violence levels, the treatment group receiving home visiting during pregnancy and infancy had significantly fewer child maltreatment reports. Also proving favourable for home-visiting efficacy were the outcome measures of ­parent–child interaction (Armstrong et al., 1999; Fraser et al., 2000; Lyons-Ruth et al., 1990), child health and development (Bugental et al., 2002; Lyons-Ruth et al., 1990) and customer satisfaction with service (Armstrong et al., 1999; Fraser et al., 2000; Marcenko et al., 1996). However, one study did report no significant difference for an infant’s physical development with home visiting (Lyons-Ruth et al., 1990). Research on the efficacy of home visiting remains ambiguous and largely outdated with more contemporary research of this area required. Existing studies reporting on home visiting are of various designs, such as mixed methodology (Bugental et al., 2002), comparison method (Lyons-Ruth et al., 1990), systematic reviews (Bilukha et al., 2005; Hahn et al., 2003), and one longitudinal design (Duggan et al., 2000). Randomized control trials however, was the preferred method for this research topic (Armstrong et al., 1999; Duggan et al., 2007; Duggan, Fuddy et al., 2004; Duggan, McFarlane et al., 2004; Eckenrode et al., 2000; Fraser et al., 2000; Marcenko et al., 1996). Randomized control trials are stated to be the most reliable and preferred design for testing the effectiveness of social service outcomes (Rossi, 1992; Statham, 2000; Stevenson, 1999). Nevertheless, given that there has been mixed results from reliable studies, reasons for the lack of consistency in the outcomes of home visiting need to be explored.



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Cognitive behavioural therapy (CBT) There is some research that supports CBT as an effective intervention for child protection. However, such research is mostly from the 1980s and 1990s. Furthermore, this research is largely focused around the adult perpetrators rather than the child victims (Dufour and Chamberland, 2004; Verduyn and Calam, 1999). In CBT research focused around abusive parents, there was a decrease in anger and anxiety levels (Brunk et al., 1987), improvements in parenting and problem-solving behaviours (Dawson et al., 1986; Denicola and Sandler, 1980; Jinich and Litrownik, 1999) and improved family interaction (Denicola and Sandler, 1980). In research around child outcomes from CBT, positive results were demonstrated for increased social responses of children receiving CBT (Fantuzzo et al., 1988), improvements in developmental competence (Davis and Fantuzzo, 1989), perceived parental supportive behaviours and self-concept (Culp et al., 1991), behavioural problems and a decrease in sexually inappropriate behaviours (Cohen and Mannarino, 1996). However, a study on the child’s perceptions of parental ­support following child sexual abuse showed no significant differences between the CBT group and control group on perceptions of social support, self-attribution, negative reactions by others and empowerment (Jinich and Litrownik, 1999). Literature on CBT in reducing child abuse and neglect indicates positive changes for families immediately after the intervention process for all types of abuse and neglect (Gaudin, 1993; Iwaniec et al., 2007; Jinich and Litrownik, 1999). Demonstrated in early literature, the positive effects of CBT were shown to be longer lasting than other interventions (Dawson et al., 1986; Gaudin, 1993) which may have been due to the emphasis of long-term skill acquisition and behaviour change where other interventions improvements may be lost at termination as supportive services are removed (Gaudin, 1993). While CBT has been an effective family-centred intervention in reducing child abuse and neglect, the outdated nature of the literature demonstrates a need for more contemporary research around this area. The majority of ­studies on the effectiveness of CBT fall under the umbrella of experimental designs (Brunk et al., 1987; Culp et al., 1991; Davis and Fantuzzo, 1989; Dawson et al., 1986; Fantuzzo et al., 1988; Jinich and Litrownik, 1999) with only a single observational study noted in the literature (Denicola and Sandler, 1980). While the literature supports the effectiveness of CBT in reducing or preventing child abuse and neglect, studies have been criticized as not being rigorous – for example the use of small sample sizes – and therefore more evaluation is required around this intervention (Dufour and Chamberland, 2004; Stevenson, 1999). Group therapy Research around group therapy in the context of child protection reveals that group therapy allows for cost effective interventions to be implemented while 86 Downloaded from http://chc.sagepub.com at University of Western Sydney on May 4, 2010

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simultaneously meeting the high demand for child protection services (Howing et al., 1989; Silovsky and Hembree-Kigin, 1994). Furthermore, research into group therapy use in child protection is distinct in the separation of groups for the child victim and groups for the parent perpetrator. However, as in home visiting and CBT research findings are limited by the older age of the research. Outcome measures in the research for group therapy for children who had experienced sexual abuse, demonstrated benefits of improvements in stress and anxiety levels (Cohen and Mannarino, 1996; McGain and McKinzey 1995), decrease in anger levels (Cohen and Mannarino, 1996) and improvement in self-esteem (Linden and Nourse, 1994). Significant improvements with group therapy for behavioural problems were also found by Cohen and Mannarino (1996) and McGain and McKinzey (1995). Conversely, an earlier study on group therapy revealed no improvement in behavioural problems (Hack et al., 1994). Furthermore, the study by Hack et al. (1994) reported there were no changes evidenced for children undergoing group therapy in depression or anxiety levels. For adult perpetrators in group therapy, research found consistently less child maltreatment behaviours than those adults who did not participate in this intervention (Cohn and Daro, 1987). Furthermore, studies around group therapy have shown an increase in parents’ social skills and a reduction in social isolation, plus increased problem-solving ability and stress-management (Brunk et al., 1987; Gaudin et al., 1990–1991; Iwaniec, 1997), significant increases in parenting skills (Gaudin et al., 1990–1991; Golub et al., 1987), knowledge and techniques, along with increased empathy towards their child, decreased use of corporal punishment and a reduction in inappropriate expectations of child behaviour (Golub et al., 1987). Positive outcome measures were also found in a recent qualitative study of group therapy for parent perpetrators of child abuse and neglect. These included that the parents were more educated in practical parenting skills, appreciated being able to share similar parenting experiences and their own negative childhood experiences with other parents, and felt validated and listened to (Marziali et al., 2006). Furthermore, this study demonstrated an increase in parent-initiated contact with welfare workers, other family members and community resources (Marziali et al., 2006). Group therapy is addressed in descriptive papers and literature reviews (Dufour and Chamberland, 2004; Finkelor and Berliner, 1995; Howing et al., 1989). However, the majority of research around the effectiveness of group ­therapy in reducing or preventing child abuse and neglect are experimental designs such as pre- and post-test studies (Brunk et al., 1987; Golub et al., 1987; Hack et al., 1994; Iwaniec, 1997; Lindon and Nourse, 1994; McGain and McKinzey, 1995), and comparative studies (Cohen and Mannarino, 1996; Cohn and Daro, 1987). Clearly further qualitative research as well as research with a more contemporary view of group therapy as a family-centred intervention for child protection is required.



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Intensive family preservation services (IFPS) Research findings around the efficacy of IFPS are largely determined by the outcome measures of out-of-home child placement and re-occurrences of child abuse and neglect once IFPS are in place. Such findings range from no impact to substantially positive impacts There are contradictory findings for IFPS efficacy on the outcome measure of out-of-home child placement. Early research reports no difference in placement rates between experimental and control groups (Berry, 1992; Fraser et al., 1997; Pecora et al., 1995; Wells and Whittington, 1993). However, more recent research reports IFPS as outperforming traditional child welfare services when efficacy is defined as out-of-home child placement prevention (Berry et al., 2000; Blythe and Jayaratne, 2002; Kirk and Griffith, 2004; Nelson and Nash, 2008). Furthermore, findings demonstrated that length of service and intensity of service, as well as reason for referral of service, impacted on the abused or neglected child’s placement outcome (Berry et al., 2000). Specifically, IFPS participants who received a short duration of service and low intensity of services experienced higher rates of child removal from the home (Berry et al., 2000). Additionally, IFPS was found to impact less positively on child neglect than physical abuse (Berry et al., 2000; Chaffin et al., 2001). On the contrary, Nelson and Nash (2008) found that child neglect referrals declined substantially in the 12 months following termination of IFPS, that factors contributing to child well-being improved significantly, and there was an increase in family support and family resources with IFPS. While research around IFPS has a more contemporary focus than other ­traditional interventions such as home visiting, CBT and group therapy, there still exists inconsistency in efficacy findings. Numerous authors have suggested this is due to research that applies the study to an inappropriate population (not highrisk children), inaccurate assessment of risk factors that control out-of-home child placement and varying degrees of study reliability (Kirk and Griffith, 2004; Rossi, 1992). Furthermore, the existing research is largely quantitative, resulting in a lack of knowledge about the experiential aspects of the clients of child protection services, as well as the workers’ perspectives in delivering such services. Studies such as random control trials (Blythe and Jayaratne, 2002), experimental pre-test post-test design (Nelson and Nash, 2008), comparative studies (Kirk and Griffith, 2004), and descriptive studies (Berry et al., 2000) are used in defining the efficacy of IFPS.

Conclusion The literature reviewed suggests that family-centred interventions are used by child protection services in an attempt to reduce and prevent child abuse and neglect. All interventions reviewed indicated mixed findings in their use, however, the

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more traditional interventions of home visiting and group therapy ­demonstrated more inconsistency in efficacy than did IFPS and CBT. Furthermore, while home visiting had the largest amount of research, IFPS represented the most contemporary research and reported more positive results in the outcome measures. However, while IFPS demonstrates more positive results in child welfare outcome measures, the large focus on out-of-home child placement may be considered a research limitation (Raschick and Critchley, 1998).

Implications for research A number of areas that require further attention have been revealed by this literature review. As shown by Dufour and Chamberland (2004), Howing et al. (1989) and Verduyn and Calam (1999), the majority of research around child abuse and neglect has focused on outcome measurements for adults, with limited data on the effectiveness of interventions specific to children. It is therefore proposed that more research on the outcome measures of children receiving family-centred interventions is considered. This literature review has demonstrated a paucity of qualitative research around the effectiveness of child abuse and neglect interventions. This is supported by Dufour and Chamberland (2004) in their recognition of the absence of qualitative studies in the literature around CBT research. Furthermore, it is ­ recognized that the experiential insight from qualitative research, into the ­efficacy of family-centred interventions by the service users (the parents and children) and the service providers (the child protection workers), would provide important information for child protection services (Dufour and Chamberland, 2004; Fernandez, 2004). Numerous authors have reported on the benefits of qualitative research in complementing quantitative findings, thereby providing further insight into the meaning of the child protection services (Dufour and Chamberland, 2004; Fernandez, 2004; Pecora et al., 1995; Raschick and Critchley, 1998). Further qualitative research on the efficacy of child protection services is therefore justified. Another area of note is that much of the research reports on child protective service interventions in the United Kingdom and the United Sates of America, with little research carried out in other countries. Finally, the majority of research around the effectiveness of family-centred interventions for child abuse and neglect was published in the 1980s and 1990s. There is clearly a need for more global and contemporary research to be implemented in this area. Implications for practice The literature reviewed has revealed that IFPS and CBT are the forerunners in the most effective intervention evaluated for preventing and reducing child abuse and neglect amongst high-risk families. This implies that the use of CBT and IFPS



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would be favourable for child protective services and their clientele. Conversely, home visiting, while largely evaluated, has inconsistent results, ­raising the question of its effectiveness for use with families considered as at high risk for child abuse and neglect. Further evaluation of home visiting in this context is required. The literature review reveals that family-centred interventions are the means of choice for child protective services to address child abuse and neglect. However, the literature also affirms that for family-centred interventions to be effective in reducing child abuse and neglect, and for a more comprehensive approach to child protection, a combination of interventions need to be applied simultaneously (Chaffin et al., 2001; Dufour and Chamberland, 2004; Howing et al., 1989). This is emphasized by an analysis of three models of family-centred placement prevention services (crisis intervention model, home-based model and the ­family treatment model), which utilize multi-intervention approaches (Nelson et al., 1990). While the authors of this study report that their findings cannot address the effectiveness of these models, they do demonstrate high prevention rates for out-of-home child placements. These were reported as 87.3 percent prevention for family treatment programmes, 79.6 percent for home-based programmes and 76.5 percent for crisis intervention programmes, suggesting the use of ­multiple interventions within these models is a successful approach to working with child abuse and neglect in families (Nelson et al., 1990). However, Nelson et al. (1990) believe that further research around the effectiveness of these models is required. Finally, as the aetiology of child abuse and neglect is multi-causal, family­centred interventions need to be adapted to address such multiple causes (Howing et al., 1989; Kirk and Griffith, 2004). It is therefore suggested that child protective services initiate the use of multiple family-centred interventions simultaneously rather than a single, ineffective intervention. Finally, to support multiple interventions being utilized, Katz and Hetherington (2006) have called for interagency collaboration when caring for families experiencing or at risk of experiencing child abuse and neglect. It is therefore suggested that child protection services work together to provide multiple family-centred interventions according to family risk factors and needs, thereby working collaboratively to reduce child abuse and neglect.

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Department of Community Services. URL (consulted 20 March 2008): http://www. community.nsw.gov.au/DOCSWR/_assets/main/documents/research_child_ neglect.pdf Wells, K. and Whittington, D. (1993) ‘Child and Family Functioning after Intensive Family Preservation Services’, Social Service Review 67: 55–83. World Health Organization (WHO)(1997) ‘WHO Recognizes Child Abuse as a Major Public Health Problem’ (press release, WHO/20, 1999), URL (consulted 14 September 2007): www.who.int/inf-pr-1999/en/pr99-20.html REBECCA O’REILLY is an associate lecturer at the University of Western Sydney, a registered nurse and midwife and novice researcher. Rebecca has completed her Masters of Clinical Nursing at Charles Sturt University and is currently a PhD candidate and member of the Family and Community Health Research Group at the University of Western Sydney. Rebecca has numerous publications in peer reviewed journals and an interest in research around Women’s and Family Health. LESLEY WILKES holds a conjoint appointment as Professor of Nursing with the Clinical Nursing Research Unit, Sydney West Area Health Service and the University of Western Sydney, as well as the position of Dean of Research Studies at UWS. She is an active researcher and an expert in both qualitative and quantitative research methods. She has a strong track record of publications in national and international peer-reviewed journals. LAURETTA LUCK is a senior lecturer and Associate Head of School in the School of Nursing and Midwifery, University of Western Sydney. Lauretta’s current research interests include workforce issues, in particular violence towards nurses, and mixed methods and case study research designs. DEBRA JACKSON was awarded a PhD in 2000 and since that time her teaching and research interests have focused on women’s health, family health, nursing leadership and adolescent health. She is the Director of Higher Degree Research and the leader of the Family & Community Health (FaCH) Research Group at the School of Nursing and Midwifery, University of Western Sydney. Debra has published extensively and has authored or co-authored over 150 publications including journal articles, books and book chapters.

Correspondence to: Rebecca O’Reilly, School of Nursing & Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia. [email: [email protected]]

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