The Norwegian Directorate for Children, Youth and Family Affairs works to improve services for vulnerable infants and toddlers. This report is an overview of systematic reviews that have examined the effects of interventions for at-risk families with children aged 0-6 years. We included nine systematic reviews. The results of our systematic review shows that:
• Psychotherapy for mothers with depression leads to better interaction between mother and child and better mental health of both mother and child. The documentation is of low quality.
• Psychotherapy for mother and infant has a positive effect on the child's attachment to the mother. The documentation is of low quality.
• Parent training/guidance to parents struggling with parenting has a positive effect on the parent-child relationship. The documentation is of low quality.
• Home visits for mothers with substance abuse problems have little or no effect on maternal substance abuse, behavioral problems in the child or outcomes related to child abuse/neglect. The documentation is of low quality.
• Small financial interventions have little or no effect on whether children are exposed to physical harm in the family. The intervention shows no effect on the child's behavior or development. The documentation is of medium to low quality.
Both psychotherapy for mothers, psychotherapy for mothers and infants, and parent training/guidance improve interaction and attachment between mother and child. Parental training/guidance that is well adapted to the group receiving the intervention seems to have a better effect on child outcomes than more general parenting interventions. Home visits seem to have better effect on outcomes for the child and parents if it’s started early, the provider is well trained to assist the relevant families, the intervention is delivered over a period of time and focus on a few challenges rather than a range of challenges. Small financial interventions do not seem promising. A larger amount of money could perhaps have better effect.
The number of children under six years old who receive assistance from the child welfare system because of neglect and abuse has been steadily increasing over the period 1995-2008. This is clear from a report of the extent of neglect of infants and young children in Norway. In 2008, there were 8256 children under six years who received child-welfare. The increase has been greatest for children under one year. The report reveals that failure to provide care is the most common reason why kids come under official supervision. Substance abuse and mental disorders are other frequent reasons for the initiation of interventions. We need more knowledge about which interventions are effective for children in so-called risk families.
We searched for systematic reviews in 13 international databases. The search was completed in March 2015. Two people independently screened all titles and abstracts and assessed relevant publications in full text. We included all systematic reviews that we rated as having high methodological quality and that met our inclusion criteria for the population, intervention, and outcomes. We used the authors' assessment of risk of bias. Quality of the evidence was rated either high quality (⨁⨁⨁⨁), medium quality (⨁⨁⨁ ◯), low quality (⨁⨁ ◯◯), or very low quality (⨁ ◯◯◯).
We included nine systematic reviews of high methodological quality. The population in the systematic reviews have in common that they are in various ways vulnerable families with young children. The interventions that have been investigated in the included systematic reviews are partially overlapping and partially different. We grouped the results in five categories of similar interventions: 1) Psychological, psychoeducational and psychosocial interventions (3 reviews), 2) Parenting interventions/training/guidance (2 reviews), 3) Home visits (2 reviews), 4) Mother- child units (1 review), 5) Financial assistance (1 review).
One systematic review looked at the effectiveness of psychotherapy for mothers with depression. The authors found a positive effect on the mental health of both mother (SMD 0.66, 95% CI: 0.46 to 0.84) (⨁⨁ ◯◯) and children (SMD 0.40, 95% CI: 0 .22-0.59) (⨁⨁ ◯◯), as well as a positive effect on co-play between mother and child (SMD 0.35, 95% CI: 0.17 - 0.52) (⨁⨁ ◯◯). One systematic review looked at the effectiveness of community-based interventions provided families with parental depression. The authors found no effect on the child's emotional health (SMD 0.06, 95% CI: -0.2 - 0.33) (⨁⨁ ◯◯). A systematic review looked at the effectiveness of psychotherapy for mothers and infants. The authors found a strong positive effect on the attachment style in the infant (RR 3.30, 95% CI: 1.82 - 6.00) (⨁⨁ ◯◯).
One systematic review looked at the effectiveness of parenting interventions given families who are in contact with the child welfare system because of abuse/neglect. The authors found that the interventions have a positive effect on parent-child relationship (effect sizes and confidence intervals are missing) (⨁⨁ ◯◯), while the results for the child's behavior and mental health varies (⨁⨁ ◯◯). One systematic review looked at the effectiveness of parental training for parents with mental retardation. The authors found that the interventions have a positive effect on the ability to handle dangerous situations (MD 1.95, 95% CI: 0.46 to 3.44 (⨁⨁ ◯◯). But they found no effect on outcomes related to health understanding (MD -0.7, 95% CI: -1.29 to 0.11) (⨁⨁ ◯◯). They found, however, an effect of the intervention on mother-child interaction, but here we lack effect size and confidence intervals (⨁ ◯◯◯).
One systematic review looked at the effectiveness of home visits given to families defined as being at risk of neglect and abuse of children. The authors found inconsistent results for outcomes related to abuse and neglect. This was also the case for outcomes such as child behavior and child's cognitive and linguistic development (we lack effect sizes and confidence intervals) (⨁⨁ ◯◯). One systematic review looked at the effectiveness of home visits for mothers with drug problems. The authors found that the interventions have no effect on maternal drug use (RR 1.18, 95% CI: 0.96 to 1.46) (⨁⨁ ◯◯). They found no effect on outcomes related to abuse/neglect (RR 0.36, 95% CI: 0.02 to 8.77) (⨁⨁ ◯◯) or behavioral problems in the child (RR 0.46, 95 % CI: 0.21 to 1.01) (⨁⨁ ◯◯).
One systematic review looked at the effectiveness of small financial interventions provided families with low socioeconomic status. The authors found that the intervention have no effect on whether the child is exposed to physical harm (OR 1.06, 95% CI: 0.82 to 1.35) (⨁⨁⨁ ◯). They also found no effect of the intervention on positive behavior in the child (OR 0.96, 95% CI: 0.79 to 1.17) (⨁⨁ ◯◯). When it comes to outcomes related to child psychomotor- and cognitive development, results are somewhat inconsistent (we lack effect sizes and confidence intervals) (⨁⨁ ◯◯).
Because of risk of bias, drop out of participants from the studies, and small sample sizes we generally have low confidence in the documentation. This does not mean that the interventions don’t work, but that the documentation is too limited for us to draw solid conclusions. Specific issues for each of the five categories of interventions worth highlighting are:
• Psychological interventions seem to have a better effect on parents and children's mental health than psychoeducational and psychosocial interventions. Psychotherapy for mother and infant appears to have a strong positive effect on attachment style in the child, compared to standard treatment. Compared to another active parenting intervention this intervention shows as good effect. Parenting interventions may have as good an effect on attachment style in the child.
• Parenting interventions seem to have a positive effect on the parent-child relationship, but the intervention shows mixed results for other outcomes. The effect of the interventions might be better if the intervention is more tailored.
• Home visits seem to have little effect for families at great risk. The intervention could possibly work better if it is started early (in the child’s life), the provider is well trained to meet the challenges of the families, the intervention is delivered over a period of time and focus on a few challenges rather than a range of challenges.
• Small financial interventions appears to have little effect on matters concerning abuse or behavioral problems in children. This intervention alone is probably not enough to change the life conditions of families with low socioeconomic status, especially not if the amount of money is to small to make a real change in the family’s budget.
• For mother- and child units we have no documentation.
The studies we have summarized results from here are largely conducted in the USA, Great Britain or other countries with far greater poverty and socioeconomic challenges than we have in Norway. Perhaps Norwegian families - living in a welfare state - to a greater extent could benefit from some of the interventions because the amount of stress associated with socioeconomic challenges in families may be less.
We found nine systematic reviews of high methodological quality that met our inclusion criteria. We grouped the interventions in five categories. Of these, three main categories of interventions showed a possible effect on at least one outcome: Psychological, psychoeducative and psychosocial interventions, parenting interventions and home visit. There were no reports of negative outcomes. Small financial interventions probably have no effect. No studies were included in the review of mother-child units, so for this intervention we cannot draw any conclusions.