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Systematic review of interventions for the secondary prevention and treatment of emotional abuse of children by primary carers

By Anita Schrader McMillan, Jane Barlow, Sarah L. Stewart-Brown, Yvonne Carter, Peter Sidebotham and Moli Paul


Background\ud Emotional abuse (or psychological maltreatment, as it is more commonly called in the US) is an inadequately researched and poorly understood concept, despite increasing awareness about the harm it can cause to children‟s lives. Although it unifies and underpins all types of maltreatment it also occurs alone and when it does, tends to elude detection and intervention. There have to date been no systematic reviews of the literature on the secondary prevention and treatment involving the parents or primary carers of emotionally abused children.\ud Objective\ud The objective of the review was to identify studies that evaluate the effectiveness of interventions in the secondary prevention and treatment of child emotional abuse involving the parents or primary carers of children aged 0 – 19 years.\ud Methods\ud Studies were included if they involved any intervention which was directed at emotionally abusive parenting and that measured change in (i) emotional unavailability (ii) negative attributions (i.e. that involve the parent attributing negative intentions, beliefs or attitudes toward the child); (iii) developmentally inappropriate interactions; (iv) lack of recognition of children‟s boundaries; (v) inconsistency of parenting role; (vi) missocialisation or consistent failure to promote the child‟s social adaptation. The primary outcomes evaluated involved proxy measures of a range of parent, family and child outcomes including parental psychopathology, parenting attitudes and practices, family functioning and/or child behaviour and the child‟s development and adaptation.\ud .\ud A broad search strategy was developed in order to identify as many relevant studies as possible. An electronic search of a wide range of databases was carried about. No study type was excluded. The search was augmented by direct contact with academics and practitioners known in this field. The search included studies written in English, Spanish, French and German. Studies were included if the intervention was described, and the impact on at least one indicator of emotional abuse was assessed. Included \ud studies were critically appraised by two reviewers using standard criteria. Data were extracted using a standard proforma, and a qualitative synthesis of results was carried out.\ud Results\ud The initial search yielded 4248 publications of potential interest. Of these, 175 were obtained for possible inclusion or as background material. A total of 21 studies of 18 interventions, met all the inclusion criteria. A further 43 studies were relevant, but did not meet all of the inclusion criteria. Studies were organised according to the type of emotional abuse targeted: emotionally abusive parenting; parents of infants with faltering growth; missocialisation: parenting interventions with substance-abusing mothers. Twelve included studies had quantitative designs. Of these, 6 comprised randomised controlled trials; 1 comprised a follow-up of a randomised controlled trial; 2 were controlled studies; and 3 had one-group pre- and post-designs. The remaining 9 were case studies.\ud Included studies involved a wide range of interventions. The 8 studies for parents which address emotionally abusive parenting (rejection, misattribution, parent-child role reversal and anger management) involved evaluations of cognitive-behavioural training (CBT), behavioural training and parent-infant psychotherapy. Two further case studies involved cognitive-behavioural training, mentalisation and family-based therapy. The 9 interventions with parents of infants with faltering growth evaluated CBT, behavioural training, parent infant psychotherapy and interaction guidance; lay home visitors, and a range of therapeutic options based on the diagnostic condition of the parents. The 3 studies of interventions for substance abusing mothers evaluated a relational psychotherapy group for mothers, and a residential treatment for substance abuse with a parenting component. The sample sizes for quantitative studies were small and ranged from 17 to 98 participants. Ten interventions involved mothers alone, while a further 11 included fathers, either at the outset or at a later stage, and in 3 cases extended family members.\ud Interventions for emotionally abusing parents\ud The findings from the 8 included studies evaluating CBT, psychotherapy, and behavioural approaches suggest that group-based CBT may be an effective means of intervening with this group of parents, although it cannot currently be recommended with parents experiencing symptoms of severe psychopathology. While one comparative study showed a psychotherapeutic intervention to be more effective than a CBT focused intervention, the outcomes measured in this study (i.e. parent and child representations) favoured the former. Behavioural case work involving the use of problem-solving techniques may also have a role to play with some parents, although further research is still needed.\ud Interventions to enhance parental sensitivity\ud The findings from a systematic review of 81 interventions that aimed at enhancing parental sensitivity and / or infant attachment found strong evidence that short term (less than 16 sessions) interventions, with a behavioural focus and aimed exclusively at enhancing maternal sensitivity were also most effective in enhancing infant attachment security. This supports the notion of a causal role of sensitivity in shaping attachment. Interventions that included fathers as well as mothers showed higher effect sizes but results are tentative since they are based on a small number of small scale trials.\ud Parental behaviours associated with faltering growth\ud Nine studies evaluated a range of interventions with parents of babies with faltering growth including interaction guidance, home visiting; parent-child psychotherapy, behavioural casework and multi-component interventions. The findings show that interaction guidance and parent-infant psychotherapy may be potentially effective means of working with this group of clients along with behavioural casework, but that further research is needed before these can be recommended.\ud Missocialisation: Parenting interventions for substance-abusing parents\ud 5 studies (one of which was a 6-month follow-up) evaluated interventions for substance abusing mothers, including a relational psychotherapy group and a residential treatment for substance abusing adults with a parenting component. The findings show that initial gains made in the former were not sustained at 6-months and few benefits from residential intervention.\ud Conclusions\ud Emotional abuse is a complex issue resulting in part from learned behaviours, psychopathology and/or unmet emotional needs in the parents, and often compounded by factors in the families‟ immediate and wider social environment. As such, a „one-approach-fits-all‟ is unlikely to lead to sustained change.\ud The evidence base is weak, but suggests that some caregivers respond well to cognitive behavioural therapy. However, the characteristics that define these parents are not clear. There is currently no evidence to support the use of this intervention alone in the treatment of severely emotionally abusive parents. Some of the evidence suggests that a certain form of emotional abuse (for example, highly negative parent affect, which may be expressed as frightened and frightening behaviours in the parent) stemming from unresolved trauma and loss, is less amenable to CBT. There is some evidence that interaction guidance and psychotherapeutic approaches can generate change in parents with more severe psychopathology.\ud Further research is urgently needed to evaluate the benefits of both psychotherapeutic and cognitive behavioural interventions, including those which take the form of family therapy, with parents at the more severe end of the spectrum, with fathers, and with older children. There is also a need to gain further understanding about which forms of emotional abuse respond best to different treatments

Topics: RC0321, HV
Publisher: Warwick Medical School
Year: 2008
OAI identifier:

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  1. 2002(b). Using recidivism data to evaluate project safecare: Teaching bonding, safety, and health care skills to parents. doi
  2. (1987). A comparison of multisystemic therapy and parent training in the brief treatment of child abuse and neglect. doi
  3. (2003). A family-based approach to the prevention of depressive symptoms in children at risk: evidence of parental and child change. doi
  4. (2005). A model-based intervention for depressed mothers' and their infants. doi
  5. (1979). A parental bonding instrument. doi
  6. (1968). A psychiatric study of parents who abuse infants and small children.
  7. (1968). A psychiatric study of parents who abuse infants and small children. In
  8. (1995). A randomized clinical trial of home intervention for children with failure to thrive.
  9. (2006). A Survey of Programs for Parents with Mental Illness and their Families: Identifying Common Elements to Build the Evidence Base. doi
  10. (2003). Achieving the goal of evidence-based psychiatric rehabilitation practices for mothers with mental illnesses. doi
  11. (1982). Administration Procedures:
  12. (1984). Adult Attachment Scoring and Classification System.
  13. (2004). Antenatal and postnatal home visiting a review of the review,
  14. (2007). Antenatal and Postnatal Mental Health. London: National Institute for Health and Clinical Excellence.
  15. (1990). Assessing internal working models of the attachment relationship: An attachment story completion task for 3 year olds.
  16. (1971). Assessing Language Skills in Infancy: A Handbook for the Multidimensional Analysis of Emergent Language. doi
  17. (1999). Assessment of Nonorganic Failure to Thrive, Infant-Toddler Intervention:
  18. (1999). Attachment Theory, Child Development and Family Support: a Practice and Assessment model. doi
  19. (1999). Atypical attachment in infancy and early childhood among children at developmental risk. VII. Danger and development: the organization of self-protective strategies. Monogr Soc Res Child Dev 64(3):145-71; discussion doi
  20. (2001). Atypical maternal behavior toward feedingdisordered infants before and after intervention. doi
  21. (1992). Behavioral assessment system for children (BASC). Circle Pines, MN: American Guidance Services. doi
  22. (1993). Behavioral Family Intervention. doi
  23. Behavioural social work intervention. doi
  24. (1987). Behavioural Treatment of Children with Problems: A Practice Manual. doi
  25. (2006). Beyond psychotherapy: Treating abused children by changing their social ecology. doi
  26. (1962). Centuries of childhood. Philippe Aries. doi
  27. (1996). Changes in psychopathology of parents of NOFT (non-organic failure to thrive) infants during treatment. doi
  28. (1986). Child abuse and unrealistic expectations: further validation of the parent opinion questionnaire. doi
  29. (1996). Child Abuse Treatment: A Fallow Land. doi
  30. (1993). Child Abuse. doi
  31. (2000). Child maltreatment in the United Kingdom: a study of the prevalence of child abuse and neglect, doi
  32. (1980). Child maltreatment: an ecological integration, doi
  33. (2006). Child-Parent Psychotherapy: 6-Month Follow-up of a Randomized Controlled Trial. doi
  34. (1996). Childhood matters report of the National Commission of Inquiry into the Prevention of Child Abuse,
  35. (1995). Children and young people on child protection registers year ending 31
  36. (1987). Children at Risk: In the Web of Parental Mental Illness. doi
  37. (2004). Children who fail to thrive: a practice guide. doi
  38. (1998). Children Who Prosper in Unfavorable Environments: The Relationship to Social Capital‟, doi
  39. (2007). Children, Schools and Families doi
  40. (1992). Children's Depression Inventory.
  41. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. doi
  42. (2001). CN with the Canadian task Force on Preventive Care Prevention and treatment of violence againstw women: Systematic review & recommendations.
  43. (1989). Cognitive foundations for parental care. doi
  44. (1986). Cognitive problem-solving training to improve the childcare judgment of child neglectful parents. doi
  45. (1999). Community-based approaches in preventing child maltreatment
  46. (2004). Core Standards - National Service Framework for Children, Young People and Maternity Services. doi
  47. (1978). Development and utility of the Parenting Sense of Competence Scale. Paper presented at the meeting of the doi
  48. (1993). Development of the alcohol use disorders identification test (AUDIR). WHO collaborative project on early detection of persons with harmful alcohol consumption – II. doi
  49. (1997). Disorganized mental processes in mother, frightening/frightened caregiving and disorganized behaviour in infancy. Paper presented at the meeting of the Society of Research in Child Development,
  50. (2004). Does parental attributional retraining and anger management enhance the effects of the Triple P-Positive Parenting Program with parents at risk of child maltreatment? doi
  51. (1983). Doing What Comes Naturally? An Evolutionary Perspective on Child Abuse‟. In Finkelhor
  52. (2003). Domestic violence is associated with environmental suppression of IQ in young children. doi
  53. (2000). Domestic Violence: A Resource Manual for Health Care Professionals. London: Stationery Office.
  54. (1998). Dyadic psychotherapy for early relationship disorders: a case study.
  55. (1995). Eastfield Ming Quong: Multiple-Impact In-Home Treatment Model.
  56. (2004). Education and Skills doi
  57. (2004). Education and Skills (2004a). Children Act
  58. (2001). Effective interventions for child abuse and neglect, doi
  59. (1996). Effects of Domestic Violence on Children and Adolescents: An Overview. The American Academy of Traumatic Stress.
  60. (1998). El dolor invisible de la infancia: una lectura ecosistémica del maltrato infantil
  61. (2001). Emotional abuse and emotional neglect: antecedents, operational definitions and consequences
  62. (2002). Emotional abuse and neglect (psychological maltreatment): a conceptual framework. doi
  63. (1997). Emotional abuse, the hidden form of maltreatment.
  64. (1986). Emotional abuse: The hidden crime in the classroom.
  65. (2000). Emotional Abuse: The Work of a Multidisciplinary Consultation Group in a Child Psychiatric Service. doi
  66. (1995). Emotionally abusive experiences. In Reder P and Lucey C (Eds) Assessment of parenting: Psychiatric and psychological contributions,
  67. (1997). Evaluating Parent Training for Emotionally Abusive and Neglectful Parents: Comparing Individual versus Individual and Group Intervention.
  68. (1997). Evaluating parent training for emotionally abusive and neglectful parents: comparing individual versus individual and group practice.
  69. (1998). Evaluating the effectiveness of multifamily group therapy in child abuse and neglect. doi
  70. (1988). Evaluation of changes in mother-infant brief psychotherapy: A single case study. doi
  71. Every Child Matters: Next Steps. London: HM Stationery Office.
  72. (2005). Expanding the Doula Model: An Illinois Replication Study. Zero to
  73. (1974). Families and Family Therapy. doi
  74. Fernyhough et al (2002). Maternal mind-mindedness and attachment security as predictors of theour of mind understanding. doi
  75. (2006). for Health and Clinical Excellence doi
  76. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships.
  77. Health (England) and the devolved administrations (2007) Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England) the Scottish Government Welsh Assembly Government and Northern Ireland Executive.
  78. (2005). Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database of Systematic Reviews doi
  79. (1984). Hospitalized cases of nonorganic failure to thrive: The scope of the problem and short-term lay health visitor intervention. doi
  80. (2007). Improving Family Functioning In Methadone Maintained Families: Results From a Randomised Controlled Trial. doi
  81. (2005). Interagency collaboration between child protection and mental health services: Practices, attitudes and barriers. doi
  82. (2003). Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. doi
  83. (1990). MacArthur StoryStem Battery.
  84. (1995). Manual for the Depression-Anxiety Stress Scales. Sydney, Psychological Foundation of Australia. doi
  85. (1998). Manual for the PAI: The Parental Anger Inventory.
  86. (1951). Maternal Care and Mental Health, Geneva, World Health Organisation. doi
  87. (1951). Maternal Care and Mental Health. Geneva, World Health Organisation. doi
  88. (2002). Meta-analysis of parenting programmes in improving maternal psychological health. doi
  89. (1991). Migrant Farm Child Abuse and Neglect within an Ecosystemic Framework‟, doi
  90. (2005). Minding the Baby: A Reflective Parenting Program.
  91. (2006). Models of care for alcohol misusers.
  92. (1998). Moran A doi
  93. (2001). Motivational Interventions in Prenatal Clinics.
  94. (2005). Motivational interviewing: a systematic review and meta-analysis.
  95. (1996). Niños de la calle y sus familias en Lima: una realidad en 852 variables..
  96. (1998). Niños maltratados.
  97. (2007). of Clinical Excellence doi
  98. (1990). Outcome evaluation in brief mother–infant psychotherapy: A preliminary report. doi
  99. (1987). Parent observation and report of child symptoms.
  100. (1994). Parent-Child Relationship Inventory (PCRI) manual. doi
  101. (1981). Parental acceptance-rejection and parental control: Cross-cultural codes. Ethnology 20:245-260. Rohner R, Rohner N doi
  102. (2002). Parental Psychopathology. In Bornstein M (Ed) Handbook of parenting: Social conditions and applied parenting,
  103. (2003). Parenting behaviors in parents with anxiety disorders, doi
  104. (2000). Parenting by men who abuse women: Issues and dilemmas. doi
  105. (1995). Parenting groups for men who batter. Ending the cycle of violence: Community responses to children of battered doi
  106. (2004). Parenting programs for women with mental illness who have ong children: a review. Australian and New Zealand doi
  107. (2004). Parenting programs for women with mental illness who have young children: a review. Australian and New Zealand doi
  108. (1995). Parenting Stress Index, 3 rd edition. FI: Psychological Assessment Resources.
  109. (1990). Parents' unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism? In
  110. (1978). Patterns of attachment: A psychological study of the strange situation. doi
  111. (2002). Predicting emotional abuse and neglect In Early prediction and prevention of child abuse, doi
  112. (1988). Problem-solving training with a multiply distressed abusive and neglectful mother: Effects on social insularity, negative affect, and stress. doi
  113. Process and evaluation of a group intervention for mothers with parenting difficulties. Child Abuse Review doi
  114. (1982). Project Thrive: A supportive treatment approach to the parents of children with nonorganic failure to thrive.
  115. (2002). Psychological maltreatment In
  116. (2001). Psychological maltreatment of children,
  117. (2004). Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews doi
  118. (2007). Psychosocial and psychological interventions for treating antenatal depression. Cochrane Database of Systematic Reviews doi
  119. (2007). Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions. Cochrane Database of Systematic Reviews doi
  120. (1984). Reaching the hard-to-reach: serving isolated and depressed mothers with infants in the community. New Directions for Mental Health Services(24): doi
  121. (2007). Relational Psychotherapy Mothers' Group: a randomized clinical trial for substance abusing mothers. doi
  122. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults The Adverse Childhood Experiences (ACE) Study. doi
  123. (2002). Relieving Parentified Children's Burdens doi
  124. (1997). Risk status and home intervention among children with failure-to-thrive: follow-up at age 4. doi
  125. (2004). Safeguarding children: a scoping study of research in three areas, Loughborough: Centre for Child and Family Research
  126. (1972). Screening depressed patients in family practice: A rapid technique.
  127. (2000). Six-month follow-up of two mother-infant psychotherapies. doi
  128. (1977). Social Learning Theory. doi
  129. (1985). Social work with failure to thrive children and their families Part
  130. (1985). Social work with failure to thrive children and their families Part 1: Psychosocial factors.
  131. (1996). Strait-trait anger expression inventory (professional manual). Lutz, FL, Psychological Assessment Resources. Spielberger C,
  132. (2006). Substance abuse treatment for mothers: Treatment outcomes and the impact of length of stay. doi
  133. Suchman N E (2000b). Clinical assessment of functioning.
  134. (1979). Superkids: Competent children of psychotic mothers. doi
  135. (2002). Talmi A doi
  136. (1999). The Adult-Adolescent Parenting Inventory- 2 handbook, Part City UT, Family Development Resources.
  137. (2000). The ALSPAC study team 'Patterns of child abuse in early childhood, a cohort study of the "Children of the Nineties'. doi
  138. (2002). The APSAC handbook on child maltreatment,
  139. (1969). The Bayley Scales of Infant Development. doi
  140. (1997). The cumulative effect of neglect and failure to thrive on cognitive functioning. doi
  141. (2002). The development of mentalizing and its role in psychopathology and psychotherapy
  142. (1979). The ecology of human development: Experiments by nature and design .
  143. (2006). The Effective Family Programme II: Clinicians' Experiences of Training in Promotive and Preventative Child Mental Health Methods. doi
  144. (2006). The Effective Family Programme: Preventative Services for the Children of Mentally Ill Parents in Finland. doi
  145. (2003). The effects of children's exposure to domestic violence: a meta-analysis and critique,
  146. The effects of maltreatment on the development of young children. Cicchetti D, Carlson V (Eds) Child maltreatment: theory and research on the causes and consequences of child abuse and neglect Cambridge: doi
  147. (2001). The efficacy of problem-solving communication training alone, behavior management training alone, and their combination for parent-adolescent conflict in teenagers with ADHD and ODD. doi
  148. (2007). The emotionally abused and neglected child: identification, assessment and intervention. doi
  149. (1990). The fifth edition of the Addiction Severity Index. doi
  150. (1986). The forms of capital‟, doi
  151. (1985). The Parent-Child Early Relational Assessment. doi
  152. (1993). The Parenting Scale: A measure of dysfunctional parenting in discipline situations. doi
  153. (2007). The psychological costs of unsustainable housing commitments. doi
  154. (1987). The Psychological Maltreatment Rating Scales. Child Abuse and Neglect doi
  155. (1993). The PTSD checklist Reliability, validity and diagnostic utility, doi
  156. (1991). The relationship of interparental conflict and global marital adjustment to aggression, anxiety, and immaturity in aggressive nonclinic children. doi
  157. (2002). The relative efficacy of two interventions in altering maltreated preschool children's representational models: Implications for attachment theory. doi
  158. (1994). The Social Context of Child Maltreatment. doi
  159. (1997). The strengths and difficulties questionnaire. doi
  160. (2000). The Triple-P Positive Parenting Program: A comparison of enhanced, standard and self directed behavioral family intervention. doi
  161. (2003). The Victoria Climbie Inquiry report of an inquiry, doi
  162. (2006). Thematic review of family therapy journals in doi
  163. (1997). Toddlers' internalizations of maternal attributions as a factor in quality of attachment. In
  164. Tomison A (1997a). Overcoming Structural Barriers to the Prevention of Child Abuse and Neglect: A Discussion Paper. NSW Child Protection Council,
  165. (1981). Treatment and outcome in an infant psychiatry program:
  166. (1981). Treatment and outcome in an infant psychiatry program: Part I.
  167. Trends in child maltreatment literature, Child Abuse and Neglect doi
  168. (1993). Understanding Child Abuse and Neglect. Washington,DC:
  169. (1970). Violence against Children. doi
  170. (1995). Voices from Childhood: A Survey of Childhood Experiences and Attitudes to Childrearing Among Adults in the United Kingdom, doi
  171. (1995). Voices from childhood. A survey of childhood experiences and attitudes to child rearing among adults in the United Kingdom, doi
  172. (2005). Women living in a drug (and violence) context-the maternal role. doi
  173. (1999). Working together to safeguard children, doi
  174. (2006). Working with parentification: Implications for clients and counselling psychologists. doi
  175. (2002). World Health Organisation doi
  176. (2004). World Health Organisation (2002). World Report on Violence and Health. doi
  177. Year Follow-Up of a Randomized Trail. doi

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