Interventions that Address Institutional Child Maltreatment: An Evidence and Gap Map

Institutional settings

Institutional settings were defined as any public or private body, agency, association, club, institution, organisation or other entity or group of entities of any kind (whether incorporated or unincorporated), that also provides, or has at any time provided, activities, facilities, programs or services of any kind that provide the means through which adults have contact with children, including through their families (adapted from Australian Government, 2017). This included but was not limited to settings in education, health, residential care, detention, sports and recreation and religion. All geographic locations were included, and covered low-, middle- and high-income countries.

Target population

The key target population were children who were aged under 18 years, and living in or engaging in activities in institutional settings. However, although children were the key target group, study participants could also be adults. This EGM also included evidence on interventions that targeted perpetrators of institutional child maltreatment, as well as interventions aimed at improving the professional practice of staff and organisational standards of child and youth serving organisations. Target populations therefore included child victims, adult perpetrators, child/youth offenders and adult participants of eligible interventions.

Child maltreatment

Any type of maltreatment that may occur in an institutional setting, including sexual and physical violence/abuse, neglect and emotional abuse. This may encompass: adults abusing children; children abusing other children; or institutions enabling child maltreatment.

Interventions

Any intervention that aimed to prevent, support the disclosure of, respond to or treat the consequences of child maltreatment within institutional settings (see Table 1). These interventions could be targeted at the primary, secondary or tertiary level, with a focus on victims, perpetrators or institutions.

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Table 1.

The Four Intervention Categories Within Scope of This EGM, With Examples.

Intervention	Target	Examples
Prevention	Victim	• Universal/primary interventions (e.g. educational interventions used in school settings and maternal-child health screening) • Indicated/tertiary interventions (e.g. advocacy and social supports)
	Perpetrator	• Universal/primary interventions (e.g. traditional or social media campaigns) • Targeted/secondary therapeutic interventions (e.g. CBT group therapy and education interventions) • Indicated/tertiary interventions (e.g. criminal justice and pre-employment screening/criminal background checks)
	Institution	• Legal or regulatory mechanisms aimed at introducing new procedures for institutions to follow (e.g. response framework) • Particular institutions aimed at enhancing safeguarding practices of other institutions and outcomes in institutional settings (e.g. Child Advocacy Centres) • Organisational guidelines and/or practices • Staff education or training programs/initiatives
Disclosure	Victim	• Universal/primary interventions (e.g. traditional or social media campaigns and abuse helplines) • Targeted/secondary therapeutic interventions (e.g. play therapy)
	Perpetrator	• Universal/primary interventions (e.g. traditional or social media campaigns) • Legal or regulatory mechanisms aimed at introducing new procedures for institutions to follow (e.g. mandatory reporting)
	Institution	• Legal or regulatory mechanisms aimed at introducing new procedures for institutions to follow (e.g. response framework) • Particular institutions aimed at enhancing safeguarding practices of other institutions and outcomes in institutional settings (e.g. Child Advocacy Centres) • Organisational guidelines and/or practices (e.g. guidelines for reporting abuse) • Staff education or training programs/initiatives
Response	Victim	• Indicated/tertiary interventions (e.g. Legal avenues for criminal redress, advocacy and social supports)
	Perpetrator	• Indicated/tertiary interventions (e.g. criminal justice, arrest and removal of credentials, imprisonment)
	Institution	• Legal or regulatory mechanisms aimed at introducing new procedures for institutions to follow • Organisational guidelines and/or practices (e.g. response framework, perpetrator accountability) • Particular institutions aimed at enhancing safeguarding practices of other institutions and outcomes in institutional settings (e.g. Child Advocacy Centres) • Staff education or training programs/initiatives
Treatment	Victim	• Targeted/secondary therapeutic interventions (e.g. trauma-focussed interventions)
	Perpetrator	• Indicated/tertiary interventions (e.g. criminal justice, arrest, removal of credentials and imprisonment)
	Institution	• Legal or regulatory mechanisms aimed at introducing new procedures for institutions to follow • Organisational guidelines and/or practices (e.g. response framework and perpetrator accountability)

Outcomes

Studies were included where they evaluated and reported outcomes that could be grouped under the following six outcome categories within the scope of the EGM framework: institutional safeguarding practice; disclosure; child maltreatment occurrence/reoccurrence (child safety), child wellbeing, adult perpetrator; child or youth offender; and parent/caregiver outcomes. Each of these broad outcome groupings were further broken down into subcategories (see Table 2). Studies that reported adverse outcomes that were explicitly evaluated were also included in the EGM.

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Table 2.

The Six Outcome Categories Included in the EGM.

Outcome Category	Subcategory	Examples
Institutional safeguarding practice	Culture	• Leadership behaviour (e.g. role modelling of safeguarding behaviour) • Staff perceptions or views associated with safeguarding practices or risk awareness/minimisation
	Operations	• Outcomes related to staff recruitment policy/practice • Outcomes related to the implementation of child safeguarding policies and practices • Outcomes related to adult institutional caregiver competencies, including:   – Knowledge and skills relating to institutional policies and practices required to safeguard children – Knowledge about child maltreatment and its impact on children – Knowledge about risk factors for child maltreatment, observation and interview skills related to identifying child maltreatment – Ability to handle child maltreatment disclosure including listening, supporting, documenting and actioning a response – Competencies associated with supporting and working with children who have been maltreatment
	Environment	• Outcomes associated with the design of, or modifications to, the institution’s physical environment
Child maltreatment disclosure	Disclosure rates	• The disclosure of maltreatment through the victim, caregivers, institutional staff or others involved in the child’s life
Child maltreatment occurrence or reoccurrence (child safety)	Maltreatment type (i.e. physical, sexual, emotional abuse, neglect)	• The occurrence or reoccurrence of child maltreatment within the institutional setting, for study participants – measured through, for example, self-reports, informant-reports
Child health and wellbeing	Knowledge/awareness	• Knowledge about child maltreatment and potential responses to offending behaviour • Risk-aware/risk-targeting behaviour
	Physical health	• Normative standards for growth and development • Gross motor and fine motor skills • Overall health • Body mass index • Risk-avoidance behaviour related to health
	Mental health	• Self-control, emotional management and expression • Internalising and externalising behaviours • Trauma symptoms • Self-esteem • Emotional intelligence • Self-efficacy • Motivation • Prosocial behaviour • Positive outlook • Coping
	Socioemotional functioning	• Social competencies and skills • Attachment and caregiver relationships • Adaptive behaviour • Social connections and relationships
	Cognitive functioning	• Language development • Pre-academic skills (e.g. literacy/numeracy) • Approaches to learning • Problem-solving skills • Academic achievement • School engagement/school attachment
Adult perpetrator/child or youth offender	Desistance	• The degree of cessation of the maltreating behaviour
	Recidivism	• The occurrence of relapse into maltreating behaviour
	Maltreatment behaviours	• Harmful coercive behaviours • Problem sexual behaviour (children under 10) • Harmful sexual behaviour (children aged from 10 up to 18) • Sexually offending behaviour (children aged between 10 and 18 years receiving treatment through a juvenile justice intervention)
Parent/caregiver	Behaviour/knowledge/attitudes	• Parental normative beliefs relating to institutional maltreatment related policies and practices • Parent perceptions about their child’s understanding of protective behaviour concepts • Behavioural responsiveness to lack of institutional standards

Study type

Primary effectiveness studies (primary studies) and systematic reviews were included. Primary studies were included if they used a randomised controlled trial design, or a quasi-experimental design with a control/comparison group. Reviews were eligible if they reported a systematic literature search strategy, and a subset of studies reported met the eligibility criteria of this EGM. The following study types were excluded: noncontrolled pre-post evaluations; case studies; cross-sectional studies; observational studies; opinion pieces, editorials; studies solely employing qualitative methods. Both finalised and ongoing studies were included. No limitations were placed on the year of publication. Studies reported in the following languages were included: English, German, French, Spanish, Italian, Portuguese, Dutch, Danish, Swedish and Norwegian. Studies in other languages were excluded due to a lack of further available translation resources.

Information sources

Comprehensive electronic database searches were undertaken in July 2019, using key words relating to ‘institutional settings’ and ‘child maltreatment’, and included the following 10 databases: Medline, PsycINFO, CINAHL, ERIC, Informit Families and Society Collection (Australian), Sociology Source Ultimate, Sociological Abstracts, Scopus, The Campbell Collaboration Library and Proquest-Dissertations and Theses. Further searches were undertaken to identify grey literature. This included searches of four trial and systematic review registries; nine organisational websites; and the websites and reference lists of inquiry reports from seven international inquiries into child abuse. The search for grey literature was also expanded based on input from multiple subject matter experts and project stakeholders. All reference lists of included systematic reviews were also screened for additional studies. Further details of the complete search strategy, including individual database search syntax, can be found in the published report (Finch et al., 2021).

Screening and study selection

Seven reviewers were involved in the screening and study selection process. Each title/abstract identified by the search strategy was screened against the selection criteria, by at least two reviewers working independently. The full text of studies that were deemed potentially relevant at the title/abstract screening stage were further assessed by two reviewers working independently. Any discrepancies in the decisions made by reviewers were resolved by an additional reviewer, or by discussion/consensus. Authors who were involved in any of the identified studies did not take part in the screening and selection of those studies. The Covidence platform (Veritas Health Innovation, 2020) was used for literature screening. No automation or text-mining was used to identify studies.

Language, publication year, country

One primary study was published in German (Feldmann, Storck, & Pfeffer, 2018) and one primary study was in Spanish (del Campo Sánchez & Sánchez, 2006), with the remaining studies published in English. The earliest primary study included in the EGM was published in 1985. No more than four studies were published per year before or during 2011. Of the total studies, 54% were published between 2012 and 2020, with the peak number of completed primary studies published in 2018 (n  =  10). The first systematic review was published in 1994, 9 years after the first primary study was published, with the four most recent reviews published in 2017. Just over half of the primary studies were conducted in the United States (n  =  32). Canada produced four studies, three studies each came from Germany and the United Kingdom (one from Northern Ireland and two from Scotland), six countries produced two studies each (Turkey, Ireland, China, Spain, The Netherlands and Uganda) and a further eight countries contributed one study each (Australia, Ecuador, Indonesia, Jamaica, Malaysia, Romania, Taiwan and Tanzania).

Institutional settings

Most primary studies (n  =  48) were conducted in school settings, including: primary/elementary school (n  =  40), middle school (n  =  1), secondary/high school (n  =  7), kindergarten to year 12 (K-12) educational settings (i.e. schools inclusive of all years) (n  =  1) and out-of-school-hours care programmes (n  =  2). Two studies included more than one of these school settings (Barron & Topping, 2013; Ssenyonga et al., 2018). Eleven primary studies were conducted in early childhood settings (e.g. kindergarten, preschool and day-care), and three of these also included primary/elementary school settings (Fryer et al., 1987; Kraizer et al., 1988; Kraizer, 1991; Wurtele et al., 1986). Two primary studies were conducted across multiple settings, which included: health, school and social services agencies who respond to child maltreatment (Cerezo & Pons-Salvador, 2004), and organisations delivering services that children access or attend (e.g. schools, day-care and church organisations) (Rheingold et al., 2014). Three were conducted in out-of-home care, including foster care and orphanages (the BEIP study and associated publications), a residential school for the deaf (Sullivan et al., 1992) and group homes (Van Lieshout et al., 2019). No studies were identified where the primary setting was sports clubs, religious organisations, summer camps, detention centres or primary and secondary health care facilities.

Most of the 11 systematic reviews reported on studies conducted exclusively in school and/or early childhood settings (i.e. kindergartens, preschool and day-care) (n  =  5). Of these, one systematic review (plus, one update) included studies reporting both primary/elementary and secondary/high school settings (Walsh et al., 2015; Zwi et al., 2008), one systematic review included early childhood and primary/elementary settings (Heidotting, 1996), one included middle and secondary/high school settings (Ricardo, Eads, & Barker, 2011), one systematic review included several settings (across early childhood, primary/elementary and secondary/high school) (Topping & Barron, 2009) and one included only early childhood settings (Pitts, 2015). Of the remaining five systematic reviews, four focused on residential care (e.g. orphanages and out-of-home care) (Hermenau et al., 2017; McKibbin, 2017; Sherr, Roberts, & Gandhi, 2017; South et al., 2015). Two systematic reviews included studies conducted across various settings (Quadara, Nagy, Higgins, & Siegel, 2015; Radford, Foster, Barter, & Stanley, 2017), including school and early childhood settings, voluntary and faith-based organisations and sports clubs (coded as ‘multiple settings’).

Target population

Among the completed and ongoing primary studies, most evaluated interventions for children in organisations (n  =  45). Six studies assessed interventions solely for institutional staff and/or adult care providers (e.g. teachers, after-school-hours care staff, day-care staff, youth service organisation staff and health and social services agency staff) (Baker-Henningham et al., 2016; Cerezo & Pons-Salvador, 2004; Gushwa, Bernier, & Robinson, 2018; Nkuba, Hermenau, Goessmann, & Hecker, 2018; Rheingold et al., 2014; Ssenyonga et al., 2018). Nine studies assessed interventions for both children and institutional care staff and/or adult care providers (GST study; Baker et al., 2012; del Campo Sánchez & Sánchez, 2006; Edwards et al., 2019; Kolko et al., 1987, 1989; Kraizer, 1991; MacIntyre & Carr, 1999a; Taal & Edelaar, 1997).

Most reviews (n  =  7) examined interventions solely for children, one included evaluations of interventions targeting only institutional staff and/or adult care providers (e.g. teachers) (Hermenau et al., 2017), and four reviews included studies assessing interventions for either or both of these populations (Quadara et al., 2015; Radford et al., 2017; Sherr et al., 2017; South et al., 2015).

Types of maltreatment

Most completed and ongoing primary studies included interventions that had a singular focus on sexual abuse (n  =  46), with 10 additional studies focussing on sexual abuse alongside other maltreatment types (total sexual abuse: n  =  57). Four primary studies assessed interventions specifically addressing physical abuse, and a further 10 incorporated physical abuse alongside other maltreatment types (total physical abuse: n  =  14). Child neglect was the primary focus of the BEIP study, and three other studies also addressed neglect alongside other maltreatment types (total neglect: n  =  4). No study focussed exclusively on emotional abuse, but emotional abuse was considered in the GST study and four others (total emotional abuse: n  =  5).

Of the 11 systematic reviews, eight (plus one update) included studies that reported on interventions relating solely to sexual abuse. The other three systematic reviews included primary studies that reported on one or more types of child maltreatment. Hermenau et al. (2017) and Sherr et al. (2017) included studies assessing physical and emotional abuse, as well as neglect, and Ricardo et al. (2011) included studies reporting on sexual, physical and emotional abuse.

Prevention

The overwhelming majority of studies assessed the effectiveness of prevention interventions (n  =  58 primary studies; n  =  5 systematic reviews), and a smaller number included prevention approaches alongside other intervention types (n  =  2 primary studies; n  =  5 systematic reviews). Prevention interventions were defined as any intervention where the primary aim was to decrease the likelihood or risk of child maltreatment occurring or recurring in the future. This encompassed universal interventions for any child or adult, as well as interventions aimed at specific populations. Examples of the types of prevention interventions that could be included were school-based safety programmes, organisational guidelines/practices and interventions to reduce perpetrator reoffending.

Most prevention interventions were delivered in an educational setting and were curriculum-based, with a focus on increasing child awareness and understanding of sexual abuse, and teaching self-protection skills (n  =  54). For most (n  =  43), the main intervention involved workshops or lessons, alongside written, audio-visual or other resources (e.g. films or plays, images, activity books and parent resources), and was delivered directly to children in groups via an external agency or existing trained institutional staff or students. The intensity of these sessions varied from brief standalone educational programs involving single sessions (Daigneault, Hebert, McDuff, & Frappier, 2012; Pulido et al., 2015); delivery of between two to eight lessons over the course of 1–2 weeks (Cecen-Erogul & Hasirci, 2013; Conte, 1985; Dake, Price, & Murnan, 2003; Fryer et al., 1987; Jin, Chen, Jiang, & Yu, 2017; White et al., 2018; Wurtele, Gillispie, et al., 1992), and more intense delivery with multiple lessons delivered over longer periods ranging from 5 to 10 weeks (Citak Tunc et al., 2018; Dryden, Desmarais, & Arsenault, 2014; Taylor, Stein, & Burden, 2010; Van Lieshout et al., 2019; Weatherley et al., 2012). One additional study assessed a school-based rape prevention intervention consisting of three 45-min sessions (Hillenbrand-Gunn, Heppner, Mauch, & Park, 2010).

Twelve primary studies reported on interventions that aimed to improve the knowledge, attitudes and practices of the organisation’s staff via training – some with and some without follow-up support – in educational settings (n  =  9), and multiple youth service organisations (n  =  2). Among these interventions, training for staff ranged from a brief 1 hour session (Gushwa et al., 2018), up to 5 days (Ssenyonga et al., 2018), with inclusion of follow-up support strategies such as in-school coaching (Baker-Henningham et al., 2016; Dryden et al., 2014), performance feedback and text messaging (Baker-Henningham et al., 2016), and supervision and peer networks (Ssenyonga et al., 2018). Two of these interventions involved online or web-based delivery (Rheingold et al., 2014; Gushwa et al., 2018).

Four school-based prevention interventions used more comprehensive approaches, seeking to embed the programme across the broader school community, and included multiple strategies (combined with curriculum approaches) delivered over a longer timeframe (from two terms, up to a year) (Baker-Henningham et al., 2016; GST study; McElearney et al., 2018; Ratto & Bogat, 1990). For example, the GST was aimed at multiple levels within the schools including head teachers, administration, classroom teachers and students with multilayered training, processes and school-led activities for each level.

Ten systematic reviews included studies reporting on prevention interventions. Most systematic reviews included studies that evaluated programmes in educational settings (e.g. schools and early childhood settings) to prevent sexual abuse, either as sole focus or reported alongside studies assessing other intervention types (n  =  7) (Heidotting, 1996; Pitts, 2015; Quadara et al., 2015; Radford et al., 2017; Ricardo et al., 2011; Topping & Barron, 2009; Walsh et al., 2015; Zwi et al., 2008). The remaining three reviews (McKibbin, 2017; Sherr et al., 2017; South et al., 2015), included prevention interventions delivered in out-of-home care settings.

Disclosure

Disclosure interventions were defined as any intervention that aimed to facilitate, support or promote the disclosure of child maltreatment. This encompassed a range of universal interventions, such as traditional or social media campaigns, or child helplines, as well as therapeutic interventions for children that aimed to promote disclosure (e.g. play therapy). It included tertiary interventions relating to perpetrators, such as mandatory reporting, and also included any intervention that aimed to promote disclosure within an organisational context (e.g. staff training and organisational guidelines).

No primary studies were evaluations of interventions aiming solely to facilitate disclosure of child maltreatment. However, multiple prevention interventions included components that aimed to provide children with knowledge and/or skills to disclose maltreatment to a trusted adult. Nine studies evaluating these interventions included participant rates of disclosure either during or directly after participation (Czerwinski, Fine, Alfes, & Kolip, 2018; Daigneault et al., 2015; Devries et al., 2015; Barron & Topping, 2013; del Campo Sánchez & Sánchez, 2006; Hazzard et al., 1991; Kolko, 1987; Kolko et al., 1989; Oldfield, Hays, & Megel, 1996), and two studies specifically assessed disclosures rates of children currently suspected of experiencing abuse, who had at some point in the past taken part in one of these programs (MacIntyre & Carr, 1999b; Elfriech et al., 2020).

Two reviews searched for primary studies assessing interventions aiming to increase disclosure (Quadara et al., 2015; Radford et al., 2017). However, these reviews either did not identify primary studies, or did not identify primary studies that met our inclusion criteria for disclosure interventions.

Response

Response interventions were defined as any intervention that aimed to improve institutional responses to the occurrence of child maltreatment in relation to each of the target populations. Response interventions included legal or regulatory mechanisms aimed at introducing new procedures for institutions to follow, organisational guidelines and/or practices (e.g. response framework), support for the victim and/or family, working with child protection agencies and providing training and/or crisis support to staff within organisations. Response interventions were evaluated by fewer studies (n  =  2 primary studies; n  =  5 systematic reviews), and for all bar one systematic review (Hermenau et al., 2017), these were reported alongside, or combined with, prevention-focused interventions.

Cerezo and Pons-Salvador (2004) used a quasi-experimental approach to assess a largescale intervention that aimed to increase detection of child maltreatment across a single territory in Spain. The intervention involved professional training based on motivational interviewing approaches and support. It was delivered in multiple settings to professionals from all frontline health and social services agencies, and schools, in the territory. An RCT reported by Rheingold et al. (2014) compared a web-based and in-person training versions of an intervention with a dual focus on preventing and responding to child sexual abuse among children (ranging from 0 to 18 years). It was delivered to staff from youth service organisations including schools, churches, day-care, extracurricular activity agencies, state agencies, group home/residential settings and healthcare settings. The programme included education about child sexual abuse, ways to minimise child sexual abuse, how to recognise the signs and how to respond appropriately when a child discloses (Rheingold et al., 2014).

Only one of the five reviews focussed solely on interventions relating to institutional responses to child maltreatment (Hermenau et al., 2017). This review investigated the effects of structural interventions and caregiver trainings on child development, for children living full time in institutional care environments across the world (e.g. orphanages and residential care). It included interventions that aimed to change the organisational structure and culture of the institutions, as well as the ways in which caregivers interact with children. The four remaining reviews included studies assessing response interventions alongside other intervention types (Quadara et al., 2015; Radford et al., 2017; Sherr et al., 2017; South et al., 2015).

Treatment

Treatment interventions were assessed by fewer studies still (n  =  2 primary studies; n  =  2 systematic reviews). Treatment interventions were defined as any intervention that aimed to provide a therapeutic response to a target population. This included therapeutic interventions provided to children who experienced child maltreatment in institutions, and interventions targeted at perpetrators of institutional child abuse.

Two primary studies assessed the effectiveness of treatment interventions, including the six reports describing the BEIP. The BEIP study randomly assigned children in Romanian orphanages to remain in institutional care or be removed and placed in high-quality foster care (the treatment intervention). Sullivan et al. (1992) used a quasi-experimental approach to assess the effectiveness of a treatment intervention for hearing-impaired children between the ages of 12 and 16 years, who had been sexually abused while attending a residential school for the deaf. The psychotherapeutic intervention was offered to the children by the school and involved 2 h of individual therapy per week for 36 weeks, delivered by a clinical psychologist and a supervising psychiatrist with expertise in the psychology of deafness and fluency in sign language (Sullivan et al., 1992).

A scoping review by McKibbin (2017) examined treatment interventions focused on harmful sexual behaviour and child sexual exploitation among children and young people living in out-of-home care. This review included 17 papers describing interventions, including treatment interventions, for young people who display harmful sexual behaviour. The authors concluded that evidence about the elements of a successful tertiary prevention response, including trauma-informed therapeutic treatment was well-developed particularly in the UK. The review by Quadara et al. (2015) examined prevention, early intervention and therapeutic responses to child sexual abuse and described one study comparing children in institutions with home-based care as a form of treatment.

Institutional safeguarding practice

Twelve primary studies reported outcomes related to institutional safeguarding practice: eight focused on operational practice (Baker-Henningham et al., 2016; Cerezo & Pons-Salvador, 2004; del Campo Sánchez & Sánchez, 2006; Gushwa et al., 2018; Kolko et al., 1987; 1989; MacIntyre & Carr, 1999a; Rheingold et al., 2014) and four on institutional culture (McElearney et al., 2018; Merrill et al., 2018; Nkuba et al., 2018; Ssenyonga et al., 2018). Operational practice outcomes were reported in studies evaluating both prevention and response interventions targeting staff in schools (Baker-Henningham et al., 2016; del Campo Sánchez & Sánchez, 2006; Gushwa et al., 2018; Kolko et al., 1987; 1989; MacIntyre & Carr, 1999a) and youth service agencies and organisations (Cerezo & Pons-Salvador, 2004; Rheingold et al., 2014). Specific outcomes reported included: teachers’ knowledge and awareness of child sexual abuse, child abuse prevention behaviours by staff, and detection and reporting of child maltreatment. The four studies reporting on changes in institutional culture each evaluated school-based interventions (McElearney et al., 2018; Merrill et al., 2018; Nkuba et al., 2018; Ssenyonga et al., 2018). Specific reported outcomes included: teacher willingness to teach sexual health and safety, change in teachers’ attitudes to violent discipline and use of violent disciplinary methods, and student and teacher assessed attitudes toward emotional and physical violence toward children.

Two recently published systematic reviews included interventions delivered in out-of-home care settings (Hermenau et al., 2017; McKibbin, 2017). Hermenau et al. (2017) included studies that assessed interventions aimed at improving the quality of care in institutional environments, reporting a broad range of outcome measures and measurement instruments used to assess changes in caregiving and institutional quality and attachment. They included institutional safeguarding practice outcomes relating to both operational practice (e.g. measures assessing changes in caregiving quality, child-caregiver ratios) and the institutional environment (e.g. measures of environmental quality and structural changes to the institutional environment). A scoping review by McKibbin (2017) included studies reporting on interventions addressing harmful sexual behaviour and child sexual exploitation for children and young people living in residential care. The reported institutional safeguarding practice outcomes were related to operational practice, and included outcomes measuring staff members' knowledge about, and skills relating to, recognising children’s problematic sexual behaviour (McKibbin, 2017).

Child maltreatment disclosure

Eleven reports of primary studies reported outcomes relating to child maltreatment disclosure (Czerwinski et al., 2018; Elfreich et al., 2020; Daigneault et al., 2015; Devries et al., 2015; Barron & Topping, 2013; del Campo Sánchez & Sánchez, 2006; MacIntyre & Carr, 1999b; Hazzard et al., 1991; Oldfield et al., 1996; Kolko et al., 1987, 1989). All of these studies evaluated school-based interventions aiming to prevent child maltreatment. Outcome measures included: participant, teacher and/or parent reported disclosure of sexual abuse over the course of the intervention and evaluation (Barron & Topping, 2013; del Campo Sánchez & Sánchez, 2006; Hazzard et al., 1991; Kolko et al., 1987; 1989; Oldfield et al., 1996); child reported courses of action in response to hypothetical scenarios, including: possible disclosure options (Czerwinski et al., 2018), child-reported likelihood of future disclosure (Kolko et al., 1989), youth recognition of sexual assault and response to a hypothetical disclosure of sexual assault (Daigneault et al., 2015), and students’ self-reports of physical violence from school staff (assessed in a follow-up survey) (Devries et al., 2015). Two studies (Elfreich et al., 2020; MacIntyre & Carr, 1999b) specifically assessed disclosure rates of children who were suspected of experiencing maltreatment and who had at some point in the past taken part in a school-based prevention programme. MacIntyre and Carr (1999b) reported children’s disclosure of sexual abuse after they had been referred to a sexual abuse assessment unit, and Elfreich et al. (2020) assessed child disclosure of abuse during forensic interviews.

Three systematic reviews included studies reporting on interventions' impact on disclosure-related outcomes. A high-quality review by Walsh et al. (2015) (an update of Zwi et al., 2008) included school-based sexual abuse programmes, and reported on disclosure of sexual abuse by child or adolescent participants during or after undertaking a programme. Pitts (2015) included studies that reported on the disclosure of child sexual abuse. Radford et al. (2017) also included studies that reported on measures of safe disclosure (e.g. rates of disclosure) to peers, adults, institutions and services, including disclosure of nonrecent abuse.

Child safety – maltreatment occurrence or reoccurrence

Thirteen completed and ongoing primary studies reported/will report outcomes related to child maltreatment occurrence/reoccurrence (GST; Nkuba et al., 2018; Taylor et al., 2010; Baker-Henningham et al., 2016; McElearney et al., 2018; Ssenyonga et al., 2018). Eleven studies evaluated interventions focused on preventing maltreatment in educational settings (e.g. schools and day-care), with most addressing physical violence. Outcome measures included: student self-reported violence perpetrated by staff (Good School Kit); teacher and student reports of emotional and physical violence (Nkuba et al., 2018); and student-reported exposure to violence (Ssenyonga et al., 2018); and teacher-reported use of violent disciplinary methods (Ssenyonga et al., 2018). A further two QED studies used a child-report questionnaire to determine childrens’ experiences of inappropriate touching involving an uncomfortable or potentially abusive interaction (Kolko et al., 1987, 1989).

Three systematic reviews included interventions delivered in residential care settings that reported on child maltreatment occurrence/reoccurrence (Hermenau et al., 2017; Sherr et al., 2017; South et al., 2015). Outcomes examined included: self-reports or observations of maltreatment from staff/adults (physical/emotional), as well as peer to peer violence in institutional care (Sherr et al., 2017), sexual abuse in out-of-home care (South et al., 2015), exposure to violence of children living in a child care institution (Hermenau et al., 2017), and documented abuse in official records (Sherr et al., 2017).

Child wellbeing

Child wellbeing outcomes were coded into five subcategories: knowledge and awareness, mental health, cognitive functioning, social functioning, and health and development.

Across the child wellbeing outcome subcategories, more primary studies reported outcomes relating to knowledge and awareness (n  =  51) than primary studies reporting mental health outcomes (e.g. internalising and externalising behaviours, self-esteem and emotional intelligence; n  =  23), outcomes relating to child cognitive functioning (e.g. education scores, memory and executive functioning; n  =  5), social functioning (e.g. communication, self-control and social connections and relationships; n  =  6) or physical health and development (e.g. brain development; n  =  2). All 51 studies reporting child knowledge and awareness outcomes evaluated curriculum-based prevention interventions delivered in educational settings, with most focussing on child sexual abuse. Fewer studies assessed changes in participant knowledge and awareness about other child maltreatment types, such as physical or emotional abuse (n  =  7) (Barron & Topping, 2013; Dake et al., 2003; Dhooper & Schneider, 1995; Dryden et al., 2014; Edwards et al., 2019; Kraizer, 1991; Wolfe, MacPherson, Blount, & Wolfe, 1986).

Nine systematic reviews included studies that assessed interventions’ impact on child knowledge and awareness (e.g. knowledge of child sexual abuse and protective behaviours, attitudes towards violence and knowledge of safe sexual relationships; Walsh et al., 2015; Heidotting, 1996; Pitts, 2015; Quadara et al., 2015; Radford et al., 2017; Topping & Barron, 2009; Sherr et al., 2017; McKibbin, 2017; Ricardo et al., 2011). Six systematic reviews included studies that assessed an interventions’ impact on child mental health outcomes (e.g. externalising and internalising symptoms, post-traumatic stress symptoms, self-esteem and aggression; Walsh et al., 2015; Pitts, 2015; Topping & Barron, 2009; Sherr et al., 2017; Hermenau et al., 2017). One systematic review that evaluated interventions delivered in institutionalised care, included studies that reported child cognitive functioning outcomes, including child mental development, language development and intelligence (Hermenau et al., 2017). Hermenau et al. (2017) was the only systematic review that included studies evaluating interventions' impact on child social functioning, including outcomes relating to children’s social-emotional competencies and skills, as well as attachment and caregiver relationships. This was also the only review that reported on child physical development and health outcomes, including psychomotor development specifically, as well as general development (including cognitive, language, social-emotional development).

Outcomes related to adult perpetrators or child/youth offenders

Two studies reporting outcomes relating to adult perpetrators and child/youth offenders. Baker-Henningham et al. (2016) reported on an ongoing RCT for a prevention focused study that plans to include observations of teachers' use of violence against children in day-care settings in Jamaica. Edwards et al. (2019) evaluated a bystander-focused interpersonal violence prevention programme with high school students in the United States, reporting self-reported youth offender outcomes including sexual harassment, sexual assault and stalking victimisation and perpetration among high school students.

No systematic review reported outcomes for adult perpetrators or child/youth offenders that specifically related to child maltreatment that occurred in an institutional setting.

Parent or caregiver behaviour, knowledge or attitudes

Five studies reported parent or caregiver behaviour, knowledge or attitudes (Merrill et al., 2018; Wurtele, Gillispie, et al., 1992; McElearney et al., 2018; Kolko et al., 1987). Wurtele, Gillispie, et al. (1992) compared teachers and parents as instructors of a personal safety programme delivered to preschool children and assessed parents' perceptions of their child’s understanding of protective behaviour concepts, and their application of those behaviours. Merrill et al. (2018) assessed changes in parental normative beliefs relating to school-based physical discipline when assessing the GST programme (Merrill et al., 2018). In their evaluation of a multicomponent ‘whole-school’ programme designed to teach 4–11 year olds how to keep safe from all forms of maltreatment, McElearney et al. (2018) will assess parents' confidence in talking to their children about keeping safe. Kolko et al. (1987) reported changes to parental knowledge about sexual abuse when evaluating a school-based sexual abuse prevention intervention.

No systematic review reported outcomes related to parent or caregiver behaviour, knowledge or attitudes.

Intervention implementation

Of the primary studies, 23 reported outcomes relating to the implementation of the intervention, including one ongoing study (Ssenyonga et al., 2018). Outcomes representing feasibility (i.e. the utility, fit or practicality of the implemented programme), adoption (i.e. uptake or utilisation of the intervention), fidelity (i.e. the degree to which an intervention was implemented as it was intended), acceptability (i.e. perception among implementation stakeholders that an intervention is satisfactory in relation to content, complexity, comfort, delivery and credibility) and penetration (i.e. reach, spread and institutionalisation) (Proctor et al., 2011), were reported across these studies. Aspects of fidelity were assessed in 15 studies, acceptability was reported in 11, five studies reported aspects of penetration (Devries et al., 2017; Knight et al., 2018; Nkuba et al., 2018; Ssenyonga et al., 2018; White et al., 2018), and feasibility (Nkuba et al., 2018; Ssenyonga et al., 2018) and adoption (Devries et al., 2017; Knight et al., 2018) were each reported by two studies.

Adverse outcomes

An EGM is not designed to report on the direction of findings in relation to the reported outcomes. Therefore, we cannot report adverse effects on outcomes where the intervention had a negative effect but was hoped to have a positive effect (e.g. knowledge of sexual abuse). However, some studies included specific outcomes that aimed to capture adverse effects. For example, measures of anxiety, and fear and touch aversion, were commonly used to assess whether education-based prevention programmes targeting the sexual abuse of children had a negative effect on their wellbeing. For the most part, these programmes did not appear to adversely impact children. A single study (Taylor et al., 2010) reported that an intervention addressing gender violence and sexual harassment, delivered to sixth and seventh graders, reduced peer violence victimisation and perpetration, but may have increased dating violence perpetration, or at least the reporting of it.