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Systematic review

Which signs that can be observed by personnel in kindergartens and schools might be associated with maltreatment of children? A systematic overview of reviews

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  • Year: 2018
  • By: Norwegian Institute of Public Health
  • Authors Reinar LM, Vist GE, Kirkehei I, Kornør H.
  • ISBN (digital): 978-82-8082-919-1

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Key message

The Norwegian Directorate of Health is conducting a national guideline on how to respond to worries about children in nurseries/kindergartens and schools. We were in May 2017 asked to conduct a systematic review on signs and warnings that can be associated with maltreatment, abuse and neglect in children and adolescents.

We found that:

  • Delayed speech development  is possibly more common in children exposed to maltreatment than in other children
  • More teenagers who have been exposed to physical or sexual abuse possibly get pregnant more often than other teenagers
  • Boys who have been exposed to sexual abuse are possibly more often involved in teenage pregnancies than other boys
  • Children with disabilities are possibly more likely to be exposed to maltreatment than other children
  • Depression is possibly associated with maltreatment and neglect
  • Fecal incontinence is possibly associated with sexual abuse in children under twelve years of age
  • Low intelligence is possibly associated with maltreatment in children with post traumatic stress syndrome (PTSD).

For many other signs and warnings, the evidence is of very low quality. We are unsure of their association with maltreatment.

The fact that we are unsure does not mean that there is no association.

While conducting this overview of reviews we found that there is extensive research on maltreatment and its consequences. We also found that many published reviews have methodological limitations and weaknesses.

Summary

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Background

Maltreatment can be an important risk factor for the total burden of diseases in the population. Knowledge about serious long-term consequences of maltreatment, abuse and neglect, and how they manifest themselves, should be given a lot of weight in strategies on how to protect children from maltreatment, abuse and neglect.

Personnel in nurseries, kindergartens and schools have a unique opportunity to observe early signs of maltreatment because they see children and adolescents on a daily basis over time. They are also obliged to, by the Act of child welfare (Lov om barnevern) to report worries. In this systematic review we aim to find to what extent signs and warnings that can be observed by people working in nurseries, kindergartens and schools are associated with maltreatment. This knowledge base can be used when authorities advise when the personnel should report to the child welfare services or other instances or investigate a worry further themselves. Maltreatment includes physical and sexual abuse, psychological abuse, and neglect. 

Data from 24 Nordic studies show that 0.2 to 1.2% of all children are being sexual abused by their parents, and between three and four percent are physically abused. Reliable data on the prevalence of neglect and psychological abuse are missing. 

Objective

Our objective was to conduct a systematic review on signs and warnings that can be associated with maltreatment, abuse and neglect in children and adolescents.

Method

We searched for systematic reviews in the following databases (June 2017): MEDLINE, Embase, PycINFO, Epistemonikos, ERIC, Campbell Library, CINAHL, ISI Web of Science, Social Services Abstracts, Sociological Abstracts, Scopus, Cochrane Database of Systematic Reviews, Database of Reviews of Abstracts of Effects (DARE), HTA Database and Prospero.

Two reviewers independently screened the search findings, selected studies and assessed the methodological quality of all included reviews. . We extracted data from relevant reviews. The findings from included systematic reviews of high or moderate methodological quality were summarised in text and in summary of findings tables. Reviews of low methodological quality were not summarised. We judged our confidence in the result for each association between signals and warnings and type of maltreatment by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). As this is a systematic overview of reviews we extracted results from meta-analysis and narratives of included reviews. We did not perform our own analyses. 

Results

The search in databases gave 1320 references and we received one review from an expert. We read 94 reviews in full text and quality assessed 31. Of these, 15 were of low methodological quality and were therefore not included in our summary of findings.  We included four reviews of high quality and 12 twelve reviews of moderate quality. Our confidence in the results was mostly low or very low.

One study that included 34 749 children in age groups 5-6 and 11-12 years investigated the prevalence of sexual abuse amongst children with faecal incontinence compared with other children. Amongst the boys the prevalence of faecal incontinence was 3.7 percent and amongst the girls 2.4 percent. There is possibly a moderate association between faecal incontinence and sexual abuse (adjusted OR 4.32; 95% CI 1.68 to 11.1).

Boys involved in teenage pregnancies are possibly more likely to have been exposed to sexual abuse than other boys (OR 4.81; 95% CI 4.39 to 5.28). Pregnant teenagers are possibly more likely to have been exposed for physical and sexual abuse than other teenage girls (OR 3.83; 95% CI 1.78 to 2.05). It is unclear if boys who have unprotected sex or have had several sexual partners, are more likely to have been sexually abused than other boys. It is also unclear if pregnant teenage girls are more likely than other girls to have been exposed to sexual abuse, physical abuse, psychological abuse or neglect. It is also unclear if there is an association between drug abuse and physical abuse.

It is unclear if anti-social behaviour amongst adolescents is associated with general maltreatment, sexual abuse, psychological abuse, physical abuse or neglect. It is also unclear if aggressive behaviour amongst adolescents is associated with general maltreatment, sexual abuse, psychological abuse, physical abuse or neglect. It is further unclear if children who bully and/or are bullied are more likely to have been exposed to maltreatment than other children.

Depression is possibly associated with general maltreatment (d 0.77; 95% CI 0.62 to 0.92) and neglect (d 0.73; 95% CI 0.73 to 0.73). It is unclear if depression is associated with psychological abuse or physical abuse. It is also unclear if psychological challenges as low self- esteem and emotional problems are associated with physical abuse.  It is further unclear if there is any association between eating disorders and sexual, psychological or physical abuse.

Delayed speech development in children aged 2.5 to 11 years is possibly associated with maltreatment (SMD 0.46; 95% CI 0.29 to 0.63). It is unclear if low cognitive function is associated with physical abuse. Low intelligence in children with PTSD is possibly associated with maltreatment.

Children with physical or mental disabilities are possibly more likely to be exposed to maltreatment than other children (OR 3.68; 95% CI 2.56 to 5.29), psychological abuse (OR 4.36; 95% CI 2.42 to 7.87), physical abuse (OR 3.56; 95% CI 2.80 to 4.52). It is unclear if they are more likely to be exposed for sexual abuse or neglect.

We did not find systematic reviews on the following signs and warnings that were defined in the protocol: Cuts/wounds, fractures, genital damage, headaches or tummy pain, malnutrition, bad hygiene, untreated health problems, inappropriate clothing, «head-banging and body-rocking», parents unrealistic expectations, parents threats, parents’ lack of involvement, children in care, school absence, school refusal, and lack of concentration.

Discussion

We could not conclude with certainty on any signs or warnings and the association with maltreatment. On some signs (speech/language development, sexual behaviour, depression, disabilities, faecal incontinence) research findings indicated that they possibly are associated with maltreatment.  The fact that we are unsure about the other signs or warnings does not mean that there is no association. There are questions regarding population, study design, the conduct of studies, review process and reporting, all are factors that contribute to our reduced confidence in the estimated association or lack of association.

There is a need to update reviews on the following signs and warning: Bruises, bites, burns, self-harm, problems with adjusting, suspicious parent behaviour, uncritical friendliness and children’s drawings.  There is a need for new reviews on cuts/wounds, fractures, genital damage, headaches or tummy pain, malnutrition, bad hygiene, untreated health problems, inappropriate clothing, «head-banging and body-rocking», parents unrealistic expectations, parents threats, parents’ lack of involvement, children in care, school absence, school refusal, and lack of concentration.

Conclusion

There exists a big research-base on maltreatment and its consequences. Many published reviews have methodological limitations and weaknesses. We found that there possibly is an association between maltreatment and low intelligence, delayed development in speech/language in children, depression and teenage pregnancies. In addition, boys who have been sexually abused are possibly more often involved in teenage pregnancies than other boys. Children with disabilities are possibly more likely to be exposed to maltreatment than other children. Faecal incontinence is possibly associated with sexual abuse in children under twelve years of age.  For all other signs and warnings, we are unsure about the associations. The fact that we are unsure does not mean that there is no association.

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