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Early Childhood Development: A report for the Royal Society of Canada

Early Childhood Development: A report for the Royal Society of Canada

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It is generally accepted that adolescent and adult mental health, effective function, and well-being are the outcomes of a complex interaction of biological, social and environmental factors. Acting on a request from the Norlien Foundation of Calgary, the Royal Society of Canada and the Canadian Academy of Health Sciences have established jointly a panel of experts to consider this important issue.
It is generally accepted that adolescent and adult mental health, effective function, and well-being are the outcomes of a complex interaction of biological, social and environmental factors. Acting on a request from the Norlien Foundation of Calgary, the Royal Society of Canada and the Canadian Academy of Health Sciences have established jointly a panel of experts to consider this important issue.

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Published by: The Province on Nov 15, 2012
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a. Physical abuse and neglect

Despite evidence that there are important epidemiologic differences between physical abuse and
neglect (English et al., 2005), reduction of these two subtypes of child maltreatment is a
combined focus in many prevention programs (MacMillan et al., 2009), and so we consider them
together.

Systematic reviews of programs aimed at prevention of child physical abuse and neglect have
yielded mixed results (Barlow, Simkiss, & Stewart-Brown, 2006). MacMillan et al. (MacMillan,
MacMillan, Offord, Griffith, & MacMillan, 1994) assessed six interventions reported in 11
studies: 1) home visitation (six studies) (Barth, 1991; Hardy & Streett, 1989; Larson, 1980; Olds,
Henderson, Chamberlin, & Tatelbaum, 1986; Siegel, Bauman, Schaefer, Saunders, & Ingram,
1980; Taylor & Beauchamp, 1988); 2) parent-training (Resnick, 1985; Wolfe, Edwards, Manion,
& Koverola, 1988); 3) intensive contact with a pediatrician coupled with home visitation (Gray,
Cutler, Dean, & Kempe, 1979); 4) early and/or extended postpartum hospital-based contact alone
or combined with home visits (O'Connor, Vietze, Sherrod, Sandler, & Altemeier, 1980; Siegel et
al., 1980); 5) use of a drop-in centre (Lealman, Phillips, Haigh, Stone, & Ord-Smith, 1983) and
6) free transportation for prenatal and well-child care (Olds et al., 1986). Evaluation was
restricted to outcomes defined by official reports of suspected or verified abuse and neglect as
well as three “proxy” measures (hospitalizations, emergency visits, and injury rates). The
reviewers concluded that there was insufficient evidence supporting the effectiveness of any of

the interventions in preventing physical abuse and neglect other than home visitation. “Home
visitation” programs were not all identical with each other, and the evidence for home visitation

effectiveness was mixed across the six studies. The most rigorous study of one home visitation
program showed positive results for the prevention of child maltreatment and associated
outcomes such as injuries (see below; (Olds et al., 1986)). This program has subsequently
undergone a much longer follow-up and two replications (further details below).

An update to the 1994 review by MacMillan et al (MacMillan, 2000) identified two additional
types of interventions: 1) a combination of home-based services that included case management,
education and psychotherapy (Huxley & Warner, 1993); and 2) provision of comprehensive
health services that included prenatal, postnatal and pediatric care provided in a clinic setting
(Brayden, Maclean, Bonfiglio, & Altemeier, 1993). Also, an additional parent-training program
had become available (Britner & Reppucci, 1997). However, the review concluded that the
evidence that any of these three programs were effective in preventing maltreatment was still
insufficient.

In a second review, MacLeod and Nelson (MacLeod & Nelson, 2000) conducted a meta-analysis
of programs aimed both at prevention of child maltreatment and at promotion of family wellness.
Using a measure of “effect size” (d) (that is, a measure of the proportion of those in treatment
who improve, compared to the untreated controls) that permits comparisons of effectiveness of
programs using different outcomes across studies, the authors reported that the most effective
preventive interventions with medium effect sizes were “multi-component” (d = .56) and home
visitation (d = .41) programs. However, their conclusions were difficult to interpret because they

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combined results across a very broad range of interventions and outcomes, and it was not clear if
individual study quality was taken into account when combining the results.

Geeraert and colleagues (Geeraert, Van den Noortgate, Grietens, & al., 2004) conducted a meta-
analysis of mixed study designs (that is, studies that included uncontrolled evaluations) of
programs for families with children up to age three years. They did not evaluate individual study
quality. Most of the interventions included were home visitation programs; others were hospital-
or clinic-based programs. The authors concluded that the effect size for these programs was
modest (d = .29), based on combining effect sizes across a range of outcomes (reports of abuse,
parent and child functioning, parent-child interactions, among others).

i. Home visitation

As suggested previously, the phrase “home visiting programs” does not always refer to a uniform

intervention. Home visitation programs may vary widely in regard to services delivered, content,
and/or staffing (Kamerman & Kahn, 1993). Although a wide range of early home visiting
programs to prevent child maltreatment have been promoted (American Academy of Pediatrics
& Council on Child Adolescent Health, 1998; Bull, McCormick, Swann, & Mulvihill, 2004),
most have not been shown to reduce physical abuse and neglect when evaluated by randomized
controlled trials (RCTs; (Olds, Sadler, & Kitzman, 2007b)). Although some systematic reviews
and meta-analyses reached the general conclusion that early childhood home visitation is
effective in preventing child abuse and neglect (Bilukha et al., 2005; MacLeod & Nelson, 2000),
these evaluations have not generally considered the substantial variability across programs
(Gomby, 2000). When considering the evidence for prevention of physical abuse and neglect
using objective outcomes such as child hospitalizations, emergency visits, and injury rates, only
two home visiting programs have shown significant benefits. These are the Nurse-Family
Partnership (NFP) developed in the USA and the Early Start Program developed in New Zealand.

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