Interventions to Improve the Response of Professionals to Children Exposed to Domestic Violence and Abuse: A Systematic Review
Deanne Mitchell
Monday, April 29, 2019
Despite the major public health and clinical impact of domestic violence and abuse, the response of health care professionals to women experiencing domestic abuse is often poorly informed and inappropriate. This systematic review looks at educational and structural or whole-system interventions that aim to improve professionals' understanding of, and response to, survivors and their children.
Interventions to Improve the Response of Professionals to Children Exposed to Domestic Violence and Abuse: A Systematic Review
Report by William Turner et al, Child Abuse Review, 26 (2017)
The majority of the studies were conducted in paediatric settings in the USA. A total of 2018 participants were included in the 18 studies, the majority being clinicians. Three of the 18 studies were randomised controlled trials (RCTs). Twelve studies used a pre-/post-test survey design and three used a post-test only design.
Findings
The review included eight training, and three system-level interventions. Training interventions generally have had positive effects on participants' knowledge and attitudes towards domestic violence and abuse and clinical competence. The results from the RCTs were consistent with the before/after studies.
Elements of effective interventions include: an added experiential or post-training discussion component, alongside the didactic component, incorporating "booster" sessions at regular intervals after the end of training; advocating and promoting access to local domestic abuse agencies or other professionals with specific issue expertise; and drawing from a clear and well-articulated protocol for intervention.
Programmes studied covered multiple topics and used teaching strategies in combination such as discussion, modelling, role-play, rehearsal and feedback. Integrated active/passive and behavioural/instructional approaches were used in one session.
There was some evidence that improvements in perceived competence can be translated into changes in clinical practice, as documented by clinical record audits. However, perceived competence gains were not sustained consistently over time, suggesting the need for reinforcement, such as booster sessions. Consistency of results is unclear for similar outcome measures evaluated in the three RCTs. It is also not clear whether these training programmes may also have harmful consequences in the form of parental anxiety and child fear or anxiety. It is also uncertain whether the interventions result in greater odds of disclosures of past or current abuse from mothers and children who have contact with professionals.
System-level interventions aim to effect changes in organisational practice and inter-organisational collaboration between child welfare and domestic violence service providers to implement strategies in the prevention of abuse. All system-level intervention studies used a pre-/post-test survey design. With the exception of the New Zealand study by Wills et al., 2008, they were all conducted in the USA. The Greenbook demonstration initiative is reported in three papers (Banks et al., 2008b, 2008a, 2009) looking at the rationale and results of the initiative's multisite evaluation. This aimed to put into practice the Greenbook principles and recommendations over a five-year period. The Greenbook principles relate to guiding reforms in child welfare systems in the USA.
Strengths and limitations
This study about training programmes is primarily focused on improvements in participants' knowledge, both factual and applied, and practice - that is, screening behaviours. To a lesser extent the focus is on assessing harm - child anxiety or fear - and disclosures of past or current domestic violence. None of the primary studies evaluated online programmes. There remains uncertainty about whether these training and system-change interventions improve outcomes for parents and children. Further evidence is required to assess the effectiveness of training and system change programmes aiming to improve the response of professionals to the exposure of children to domestic violence.
Implications for practice
- This research suggests that for practitioners interested in improving the way they respond to children exposed to domestic violence, training programmes can improve participants' knowledge, attitudes and clinical competence up to a year after it has been delivered.
- In terms of the elements that will help make training successful, these include: interactive discussion, booster sessions and the involvement of specialist domestic violence practitioners in the training.
- When it comes to whole-system approaches aimed at promoting co-ordination and collaboration across agencies, this approach appears promising but requires funding and high levels of commitment from partners to succeed.
- The commitment for continuous work by all partners was highlighted as one of the most challenging aspects of collaborative initiatives aiming to deliver integrated domestic violence policies and practices; and improve outcomes for families. Further studies are needed to identify the optimal operational parameters of such strategies.
Deanne Mitchell is information specialist, the Social Care Institute for Excellence (SCIE)