Richard Cotmore

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

BACKGROUND Child 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. OBJECTIVES To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment. STUDY DESIGN For 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. PARTICIPANTS Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months. INTERVENTIONS Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment. MAIN OUTCOME MEASURES Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability. METHODS Young 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. RESULTS We 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. CONCLUSIONS It 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. LIMITATIONS Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses. FUTURE WORK Studies 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 REGISTRATION This study is registered as PROSPERO CRD42013003889. FUNDING The National Institute for Health Research Health Technology Assessment programme.

A Feasibility Randomised Controlled Trial of the New Orleans Intervention for Infant Mental Health: A Study Protocol

Child maltreatment is associated with life-long social, physical, and mental health problems. Intervening early to provide maltreated children with safe, nurturing care can improve outcomes. The need for prompt decisions about permanent placement (i.e., regarding adoption or return home) is internationally recognised. However, a recent Glasgow audit showed that many maltreated children “revolve” between birth families and foster carers. This paper describes the protocol of the first exploratory randomised controlled trial of a mental health intervention aimed at improving placement permanency decisions for maltreated children. This trial compares an infants mental health intervention with the new enhanced service as usual for maltreated children entering care in Glasgow. As both are new services, the trial is being conducted from a position of equipoise. The outcome assessment covers various fields of a childs neurodevelopment to identify problems in any ESSENCE domain. The feasibility, reliability, and developmental appropriateness of all outcome measures are examined. Additionally, the potential for linkage with routinely collected data on health and social care and, in the future, education is explored. The results will inform a definitive randomised controlled trial that could potentially lead to long lasting benefits for the Scottish population and which may be applicable to other areas of the world. This trial is registered with ClinicalTrials.gov (NC01485510).

Recovering from Domestic Abuse, Strengthening the Mother–Child Relationship: Mothers' and Children's Perspectives of a New Intervention

Domestic Abuse: Recovering Together (DART) is a 10-week programme that supports families who have experienced domestic abuse. It focuses on strengthening the mother–child relationship and helps with other aspects of their recovery from the experience of abuse. As part of a mixed-method evaluation, interviews were conducted with mothers and children following their attendance at DART. The interim findings are reported in this paper. Mothers and children interviewed were, on the whole, positive about DART and felt it had helped their recovery and relationship with one another. Elements identified that facilitated the programme included: activities that helped participants to deal with difficult feelings related to the abuse; sessions where mothers and children worked together, which helped to improve their relationship; and supportive staff and peers who enabled participants to feel less alone. Some aspects of the programme, such as re-living painful memories, were described as distressing. However, participants believed it was important to address these experiences as part of their recovery process. There were instances of mothers resuming relationships with the perpetrator for a short period following the programme, which had a detrimental impact on their childs behaviour. However, some mothers asserted that the programme convinced them never to return to an abusive relationship.

Randomisation before consent: avoiding delay to time-critical intervention and ensuring informed consent

Abstract Obtaining informed consent can be challenging in stressful and urgent circumstances. One example is when potential participants have recently had their child removed into care; intervention is urgent and mandatory whereas participation in associated research is voluntary. Using a nested qualitative study, we examined experiences of consent processes in a randomised controlled trial of a family assessment and intervention service for maltreated young children. Some potential participants found it difficult to use information; some believed consenting might influence the return of their child. In response to these ethical challenges, we propose reversing the typical process of securing consent, so that randomisation to an intervention occurs before inviting potential participants to consider the trial. This will avoid delays, delineate research from intervention, and make it easier to consider information. We suggest that this innovation could be useful in trials across service areas that incorporate urgent and complex interventions.

Partnership approaches to the evaluation of complex policy initiatives: qualitative research as key to building effective relationships

We argue that major health and social care policy initiatives are not too complex for randomised controlled trial (RCT) methodology and illustrate this using the example of the Best Services Trial (BeST?): a RCT of an infant mental health intervention for maltreated children. We suggest that qualitative research, as a core part of the trial process from conception and development through to implementation and evaluation, is crucial in building, understanding and strengthening the partnership required to drive such a complex trial. Data pertinent to trial implementation demonstrate the iterative nature of the process whereby stakeholders are consulted and their views influence the conduct of the trial. Here we reflect on the bi-directional relationship between qualitative data collection and partnership-working in a trial. For very complex trials to be possible, significant resource needs to be available for the qualitative component. Key Practitioner Message: • Qualitative research is key to understanding, building and strengthening partnership approaches to researching complex interventions; • Qualitative research is vital to supporting randomised controlled trials involving multiple sectors; • Qualitative research provides essential explanatory power to outcome data in research.