WHO guidelines on parenting interventions to prevent maltreatment and enhance parent–child relationships with children aged 0–17: Report of the Systematic Reviews of Evidence
World Health Organization | University of Oxford
Authors:
Backhaus, S.*, Gardner, F.*, Schafer, M., Melendez-Torres, G.J., Knerr, W., Lachman, J.M.
*Joint first authors
Executive Summary
Child maltreatment is a global public health problem. It can have detrimental and longlasting effects on the development and health of a child. Prevention is crucial and can be carried out using multiple approaches. The World Health Organization (WHO) and other international stakeholders have led the response in reducing prevalence of abuse and neglect across the globe. The WHO INSPIRE package is an evidence-based resource that presents seven strategies to help countries and communities to accelerate their efforts to reduce child maltreatment. One of the seven strategies is the support of parents and caregivers in the form of parenting interventions. Parenting programmes contribute to a range of 2030 Sustainable Development Goals (SDGs), most prominently Target 16.2 (ending abuse, exploitation, trafficking and all forms of violence against and torture of children), in addition to Targets 5.2 (elimination of all forms of violence against all women and girls), 16.1 (reduction of all forms of violence and related death rates everywhere), 1.3 (implementation of social protection systems), 3.2 (preventing deaths of children under 5 years) and 4.2 (ensuring access to quality early childhood development (ECD) and care). This report provides evidence on the effectiveness of parenting interventions across different contexts and populations. The findings of this report will inform the decisions of the WHO Guideline Development Group for guidelines on parenting to prevent child maltreatment and promote positive development in children aged 0–17 years. We systematically summarized the evidence on the effectiveness of parenting interventions using systematic reviewing as the predominant method. In total, we conducted two main systematic reviews, two systematic sub- reviews and one narrative review. The first systematic review focused on parenting interventions in low- and middleincome countries (LMICs) for parents of children aged 2–17 years. The second systematic review examined the effectiveness globally of the most widely distributed parenting interventions focusing on ages 2–10. We then present findings of two sub-reviews of the main LMIC review, focusing on parenting interventions: i) for parents of adolescents aged 10–17 years; and ii) delivered in humanitarian settings in LMICs. Finally, we summarize the evidence for parenting interventions for the first three years of life, drawing on the recent evidence synthesis from the WHO nurturing care guidelines, while adding to this an updated search for the most recent evidence of parenting interventions for very young children. The systematic reviews presented represent the most comprehensive reviews to date, based on screening over 100,000 studies retrieved from highly sensitive searches in multiple electronic global, regional and grey literature databases in several languages. An included total of 435 randomized controlled trials (RCTs) from 65 countries suggests that parenting interventions improve a range of parent, child and family outcomes. Parenting interventions reduce negative parenting behaviours, including maltreatment, and improve positive and nurturing parenting behaviours across all contexts and types of interventions examined. We found strong evidence in the majority of reviews that parenting interventions 3 effectively reduce child behaviour problems. The findings suggest that effects on both negative and positive parenting are sustained over the long term, at least in the global review. This finding could not be replicated for maltreatment, suggesting a fade-out effect of maltreatment, albeit with a small number of trials, suggesting the possible need for booster sessions and more research. Despite the large number of RCTs included in the reviews, effectiveness analyses included only those trials that reported on the outcome, leaving a large body of trials aside. We found very little evidence of differential effects on different subgroups of families across all reviews. Thus, the effect of parenting interventions on maltreatment and negative parenting did not vary by poverty level of the country, gender of the children, education level of the parents, family-level poverty or the age of the children or parents in the trials. We found evidence of some differential effect by ethnicity, with trials that included mostly ethnic minority families showing smaller improvements in negative parenting and child behaviour problems compared to mostly majority families. Additionally, trials that focused on children with higher levels of behaviour problems showed stronger effects on improving behaviour problems and positive parenting. Moderator findings should be interpreted with caution, given that moderators may be confounded with unmeasured trial-level factors, and that only a small subset of the trials could be included in subgroups, representing only a small portion of the overall effectiveness in the analyses. Almost a third of the studies were conducted in the Pan-American Region, followed by a quarter conducted in both the European Region and the Western Pacific Region, with the final quarter shared by trials from the Eastern Mediterranean Region, the African Region and the South-East Asian Region. Most trials were conducted in high-income countries, leaving many gaps on the world map for effectiveness trials. However, the evidence base from LMICs was still substantial: we included 131 trials from all regions of the world in the LMIC review for children aged 2–17, an additional 26 LMIC trials in the ECD and humanitarian review, and 28 trials from LMICs in the global review. Despite the need for more trials from LMICs, we observed a promising trend, with more evidence coming from LMICs in the past decade. In addition, more trials examining the effectiveness of trials for subpopulations are needed, including families living in humanitarian settings, parents of adolescents, and parents living in extreme poverty. To fully understand the effects of parenting interventions on maltreatment, trials should: a. target parents based on their maltreatment levels; b. use measures of maltreatment consequently including subtypes; and c. examine the effectiveness on proxy measures of maltreatment, including attitudes to corporal punishment, intimate partner violence between parents, and experience of dating violence in adolescents. Moreover, there is a strong need for LMIC trials to measure the long-term effects of trials. Finally, most trials examined the effects of parenting interventions using self-report from mothers. When possible, observational measures should be used, and measures should include other important primary caregivers such as fathers, grandparents, older siblings or other family members.
Keywords: Parenting, Child Maltreatment, Guidelines
