The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

Abstract

BackgroundChild maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.ObjectivesTo synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.Study designFor effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.ParticipantsChildren and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.InterventionsAny psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.Main outcome measuresPsychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.MethodsYoung Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.ResultsWe identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive–behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) –0.44 (95% CI –4.43 to –1.53)], depression [mean difference –2.83 (95% CI –4.53 to –1.13)] and anxiety [SMD –0.23 (95% CI –0.03 to –0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist–child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.ConclusionsIt is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.LimitationsStudies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.Future workStudies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.Study registrationThis study is registered as PROSPERO CRD42013003889.FundingThe National Institute for Health Research Health Technology Assessment programme.

Interventions to support people exposed to adverse childhood experiences: systematic review of systematic reviews

“…Cognitive Behavioural Therapy. Seven reviews investigated CBT for a range of ACE populations [15][16][17][18][19][20][21]. The most substantive results come from Macdonald et al's review, which found that CBT improved mental health outcomes for people who had experienced abuse or neglect [19].…”

“…Other psychological therapies. A range of other psychological therapies, such as brief motivational interviewing, family therapy and psychodynamic psychotherapy, were evaluated in six reviews [15,18,19,[21][22][23]. The findings do not provide strong evidence of effectiveness, although the interventions are heterogeneous.…”

“…Psychoeducation. Three reviews included psychoeducation [18,19,24]; the findings are mixed, although one meta-analysis finds evidence of effectiveness for mental health outcomes in children of parents with depression [24].…”

Variability in Developmental Outcomes of Foster Children: Implications for Research and Practice

“…However, we warn against too much optimism about the effects of interventions for foster children and foster families. There are several overview studies indicating the limited effects of interventions aimed at foster children and foster parents (Benesh & Cui, 2016;Dorsey et al, 2008;Macdonald et al, 2016;Rork & McNeil, 2011;Turner, Macdonald, & Dennis, 2007). It is therefore important to further develop and examine new interventions for foster care (Dorsey et al, 2008;Hambrick, Oppenheim-Weller, N'zi, & Taussig, 2016).…”

Editorial perspective: Treatment of complex maltreatment – beyond the NICE guideline? Manuals, muddles or modules

“…These include the fact that much of the research on the manuals’ effectiveness has been carried out in the United States, generally on single forms of maltreatment. A recent systematic review (Macdonald et al., ) concluded that ‘it is difficult to draw very firm conclusions about which interventions are effective for which children, with what maltreatment, in what circumstances’ and ‘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’ ( pp. vii and 38 ) .…”