Childhood trauma and abuse is the smoking of psychiatry. As a risk factor for mental illness it is comparable to how smoking a pack of cigarettes per day increases the risk of lung cancer and heart disease.
As an adult psychiatrist I see the consequences of poor starts to life and do my best to manage the consequences. However, doing my best often isn’t that effective or proves to be only a temporary solution. So the real question at hand is - what if we could do something to prevent child abuse from happening?
This is the question addressed in a systematic review published in the Annals of Internal Medicine in February this year. The authors update the US preventive services task force recommendations from 2004 on the prevention of child abuse and neglect. They reviewed the literature up until the middle of 2012 and found 11 randomised controlled trials which tested different interventions to prevent child abuse.
However, they only included English language studies and didn’t search outside MEDLINE, PsycINFO or the Cochrane Central Register of Controlled Trials which means non-English language studies were likely to be missed. (It seems strange that systematic reviewers ignore non-English language studies – is the implication that they are somehow less “good” than English language papers or that we can’t learn from “foreign” countries?).
The authors found one study in a paediatric clinic (although in other countries this would more likely be a family physician practice) which sought to identify and then refer those children up to age 5 at high risk of abuse and neglect. The program found that the intervention produced a significant reduction in child protective service reports up to four years after the child was seen. The evidence was less clear cut for various forms of home visits by nurses or “trained laypersons” up to three years after birth.
The conclusion of the review is that risk assessment and behavioural interventions in paediatric clinics reduced abuse and neglect for young children, but the evidence is inconsistent for home visitation programs. Plus, of course, it’s clear that additional research is needed.
This seems to be one of those areas where there is the choice between focusing on those at high risk or trying to address abuse at a population level – the classic Geoffrey Rose problem first articulated over salt and hypertension. Providing leadership through the development of infant mental health services may be one way forward.