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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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In comparison to the two programs discussed above, most of the home visitation studies
evaluating effectiveness for preventing physical abuse and neglect have focused on models in
which the service is delivered by paraprofessionals (Geeraert et al., 2004). The two that have
undergone the most extensive evaluations have been the Hawaii Healthy Start Program (HSP)
and Healthy Families America (HFA; based on HSP) (Duggan et al., 2007; Duggan et al., 2004;
Duggan et al., 1999). The Healthy Start Program served as the basis for the subsequent Healthy
Families America program. Both programs have been evaluated with randomized designs.
However, the intervention was disseminated to other implementation sites based on the results of
the earlier, less rigorous, studies. In a follow-up of the original Healthy Start Program, there were
few effects on outcomes such as hospitalizations for trauma, verified child protection reports or
parental reports of abusive caregiving. Mothers in the Healthy Start Program were less likely to
self-report neglectful behaviours on a revised Conflict Tactics Scales (CTS) subscale, but the
traditional CTS approach to measuring neglect showed no effect of the intervention. Subsequent
follow-ups of the derived Health Families America randomized controlled trials in Alaska and
San Diego showed few or no effects, respectively (Duggan et al., 2007; Landsverk et al., 2002).

Two-year findings from a New York Healthy Families America trial showed no differences
between groups in either occurrence or frequency of verified child protection records or the
occurrence of abusive or neglectful behaviours reported by mothers (Caldera et al., 2007). There
were some benefits in maternal self-reported outcomes, such as fewer acts of very serious
physical abuse, minor physical aggression and psychological aggression at one-year follow-up.
However, when one takes account of the fact that these few positive results emerged from more
than 14 outcomes and that they were all self-reports by the mother, their value remains
questionable.

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ii. Parent-training programs

A number of parent-training programs are being used with the stated goal of preventing child
maltreatment (Krugman, Lane, & Walsh, 2007), but only the Triple P program has been
evaluated for its effectiveness by using actual child maltreatment outcomes. One trial examined
the effectiveness of the Triple P program to prevent child abuse and neglect in a community-
based study in which 18 counties within a southeastern state in the USA were randomly assigned
to an intervention or a control group (that is, services as usual) (Prinz, Sanders, Shapiro,
Whitaker, & Lutzker, 2009). It involved the implementation of professional training for the
workforce, in addition to universal media and communication strategies addressing positive
parenting strategies, as the first level of a multilevel system that included five intervention
categories of increasing intensity (see Textbox 5.3). Three population-level indicators were used
to determine intervention effectiveness: rates of verified child maltreatment; out-of-home
placement; and hospitalizations or emergency room visits for child maltreatment injuries.
Positive effects in the counties that implemented the Triple P program were found for all three
indicators. However, it is important to note that the effect sizes reported were between-cluster
differences rather than individual differences. This means that we cannot be sure that these
community-level results apply to the individual. Furthermore, information that would have been
helpful in interpreting the results of the statistical analyses, such as standard deviations, was not

provided. The authors state that this population trial was based on “a large body of evidence” that

includes intervention fidelity, thereby justifying the lack of individual-level data (Prinz et al.,
2009). However, previous clinical trials did not asses—nor was the intervention aimed at—
prevention of child maltreatment. This intervention shows promise, however, so it would be
important for a future replication to include individual-level data.

iii. Abusive head trauma education programs

Abusive head trauma (AHT, also known as shaken baby syndrome [SBS];(Christian & Block,
2009)) is a distinctive form of infant abuse in that it is increasingly clear that there is a specific
stimulus (crying) and a specific risk factor (shaking) that results in the abuse. Because the
increased crying is a reflection of normal behavioural development (Barr, Trent, & Cross, 2006;
Lee, Barr, Catherine, & Wicks, 2007; Talvik, Alexander, & Talvik, 2008) and AHT/SBS occurs
primarily within the first six months, prevention has focused on targeting education to caregivers
during the newborn period, as a primary caregiver universal prevention program. This strategy
differs from other prevention programs in targeting the whole population of parents of newborns

rather than just “at risk” groups.

The first such program was developed and evaluated by Dias and colleagues (Dias et al., 2005).
The core concept is that delivering prevention materials during the immediate postpartum period

exploited a “teachable moment” that would make the intervention most effective if delivered by

nurses. The intervention was provided by nurses to parents on the postpartum ward in 16
hospitals in western New York State. It consisted of providing a one-page educational leaflet and

posters, showing a brief video, and having parents sign a ‘commitment statement’ that they had

received the materials. The materials focused on the dangers of violent infant shaking and on
suggestions about how to handle persistent crying. The incidence of abusive head injuries in
children less than 36 months of age was tracked prospectively for 66 months and compared with

282 Somerset Street West, Ottawa ON, K2P 0J6 • Tel: 613-991-6990 • www.rsc-src.ca | 92

the incidence in the previous 66 months. The incidence of AHT identified following introduction
of the program (22.2 cases per 100,000 births) represented a significant reduction relative to the
incidence prior to the study period (41.5 cases per 100,000 births). A similar program introduced
in Utah between 2001 and 2007 using videos, written materials, posters and magnets with a
“don’t shake” message was evaluated in an observational case control study (Keenan &
Leventhal, 2010). Although there was a decreased risk of AHT occurrence similar in size to the
New York program, the study design did not support a causal connection of AHT cases with
exposure to the program.

The encouraging results from the Dias study have stimulated additional efforts to prevent
AHT/SBS, taking account of previous limitations in materials and methods of distribution. New
materials have been designed and tested that reflect evidence supporting positive teaching
materials (Russell, Trudeau, & Britner, 2008). In two randomized trials, a DVD and booklet from
the National Center on Shaken Baby Syndrome (NCSBS) in the USA, focusing on improving
understanding of normal crying in the first months of life, has been shown to increase knowledge
and some behaviours relevant to preventing SBS (Barr et al., 2009a; Barr et al., 2009b). Current
trials include an attempted replication by Dias and colleagues in every hospital in Pennsylvania
with the addition of reminder messages in approximately one-third of pediatric practices in the
state. In British Columbia, Canada, and in North Carolina, USA, jurisdiction-wide trials of the
NCSBS materials have been implemented as part of a comprehensive “three dose” program that
includes delivery of education at the birth of the baby, reinforcement before and/or after delivery,
and public education directed to society at large. Outcomes will include incidence of AHT/SBS
hospitalizations and deaths, effects on emergency room visits and after-hours nurse-line calls,
and changes in knowledge and behaviours of the general public.

iv. Enhanced pediatric care for families at risk

Dubowitz et al. (Dubowitz, Feigelman, Lane, & Kim, 2009) examined the efficacy of the Safe
Environment for Every Kid (SEEK) model of pediatric primary care in a university-based,
pediatric resident, continuity clinic serving primarily a low income urban community of single
mothers in Baltimore, Maryland. Clinics were randomized to receive routine pediatric care
provided by the pediatric residents (250 families) or Model care (308 families). In Model care,
residents received special training, used the Parent Screening Questionnaire to identify family
problems, and had a social worker available for referral. Prior to the intervention, 12% of
families in each group had been reported to Child Protective Services (CPS). During the
intervention, there were fewer CPS reports in the Model care group (13.3%) than in the routine
care group (19.2%) (p=0.045 [one-tailed]). In addition, there were fewer problems related to
possible medical neglect (non-adherence to medical care [4.6% vs. 8.4% P = 0.05] and delayed
immunizations [3.3% vs. 9.6%; P = 0.002]) and fewer severe or very severe physical assaults
reported by parents (P = 0.04). The results suggested that enhancing primary care physicians’
abilities to identify risks and help families decrease risk factors for child maltreatment may be
effective; however, further evaluation, especially with pediatricians in private practice settings, is
needed.

282 Somerset Street West, Ottawa ON, K2P 0J6 • Tel: 613-991-6990 • www.rsc-src.ca | 93

b. Sexual abuse

Education programs have been the main approach to preventing sexual abuse (Davis & Gidycz,
2000; Zwi et al., 2007). Systematic reviews conducted since 1994 (Davis & Gidycz, 2000;
MacMillan et al., 1994; Rispens, Aleman, & Goudena, 1997; Zwi et al., 2007) have examined an
increasing number of randomized controlled trials evaluating universal school-based programs.
In the most recent systematic review, Zwi and colleagues (2007) considered the evidence from
15 trials that examined the effectiveness of school-based curricula for children from kindergarten
through to high school, primarily in the USA. The programs involved combinations of
film/video, discussion and role-play that varied in session duration from fewer than 90 minutes to
a cumulative maximum of about five and a half hours. Most commonly, the control groups were
children randomly assigned to the wait list or those who received the standard curriculum; in a
minority of studies, control subjects received a program with no child abuse content. A
significant improvement in measures of knowledge was reported in most studies; a smaller
proportion that evaluated protective behaviours (e.g. running away from a stranger) under
simulated conditions found significant gains in this area as well. Only three studies measured
disclosures of past or current sexual abuse. Because of methodological limitations, such use of
quasi-experimental design in one study and failure to distinguish disclosures from the control
versus experimental group in another, it was not possible to determine whether such disclosures
were affected by the intervention. Three studies reported unfavourable outcomes such as
increased anxiety. Many of the studies suffered from major methodological weaknesses that
included absence of blinding, analyses that failed to take into consideration cluster
randomization, and follow-up that was very short, typically for only three months following the
end of the program. In their review, Zwi and colleagues (2007) reached the same conclusions as
did three earlier systematic reviews (Davis & Gidycz, 2000; MacMillan et al., 1994; Rispens et
al., 1997); namely, that it is still unknown whether increased knowledge and use of protective
behaviours translate into reduced sexual abuse. Therefore, it remains unknown whether education
programs aimed at children actually prevent sexual abuse (Zwi et al., 2007).

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