Summary



Institutional Responses to Child MaltreatmentEvidence Gap Map Report December 2020Authors (alphabetical order):Bianca Albers1 | Ludvig Bj?rndal1 | Rebecca Featherston6 | Caroline Fiennes2 | Meghan Finch4 | | Joachim Krapels5 | Robyn Mildon4 | Aron Shlonsky3 1Centre for Evidence and Implementation, London, UK 2Giving Evidence, London, UK 3School of Primary and Allied Health Care, Monash University Peninsula Campus, Frankston, Victoria, Australia 4Centre for Evidence and Implementation, Carlton, Victoria, Australia5Porticus, Amsterdam, The Netherlands 6Department of Social Work School of Primary and Allied Health Care, Faculty of Medicine Nursing & Health Sciences, Monash University Peninsula Campus, Frankston, Victoria, AustraliaCorresponding author:Caroline Fiennes, Director, Giving Evidence+44 7803 954512, caroline.fiennes@giving-This document is accompanied by a shorter summary report, and other related products. They are all available at csaList of AbbreviationsAMSTARA Measurement Tool to Assess Systematic ReviewsBEIPBucharest Early Intervention ProjectEGMEvidence Gap MapFGMFemale Genital MutilationFGCFemale Genital CuttingGPGeneral PractitionerGSTGood School ToolkitOOHCOut-of-home care PICOPopulation, Intervention, Comparator, OutcomePRISMAPreferred Reporting Items for Systematic Reviews and Meta-AnalysesPTSDPost-traumatic Stress DisorderQEDs Quasi-Experimental DesignsRCTs Randomised Controlled TrialsRoBRisk of BiasSR Systematic ReviewContents TOC \o "2-2" \h \z \t "Heading 1,1,Appendix Heading 1,1,Appendix Heading 2,1,Heading 1 (non-numbered),1" 1.Summary PAGEREF _Toc38367329 \h 12.Introduction PAGEREF _Toc38367330 \h 72.1.Background PAGEREF _Toc38367331 \h 72.2.Objectives PAGEREF _Toc38367332 \h 72.3.Structure of the report PAGEREF _Toc38367333 \h 83.Summary of the findings PAGEREF _Toc38367334 \h 93.1.Summary results of the search PAGEREF _Toc38367335 \h 93.2.Visual map of the included studies PAGEREF _Toc38367336 \h 114.Discussion of the findings PAGEREF _Toc38367337 \h 144.1.Quality of the evidence PAGEREF _Toc38367338 \h 144.2.Gaps and strengths in the evidence PAGEREF _Toc38367339 \h 144.3.Implications for future research, policy and practice PAGEREF _Toc38367340 \h 164.4.Limitations of the EGM PAGEREF _Toc38367341 \h 175.Findings in detail PAGEREF _Toc38367342 \h 195.1.Study characteristics PAGEREF _Toc38367343 \h 195.2.Types of institution / organisations PAGEREF _Toc38367344 \h 195.3.Geographical distribution PAGEREF _Toc38367345 \h 215.4.Population PAGEREF _Toc38367346 \h 215.5.Interventions PAGEREF _Toc38367347 \h 315.6.Outcomes PAGEREF _Toc38367348 \h 385.7.Other outcomes: implementation and adverse outcomes PAGEREF _Toc38367349 \h 436.Conclusion and next steps PAGEREF _Toc38367350 \h 45Appendix AMethod PAGEREF _Toc38367351 \h 46A.1Evidence gap maps: definition and purpose PAGEREF _Toc38367352 \h 46A.2Conceptual framework and scope PAGEREF _Toc38367353 \h 46A.3Stakeholder engagement PAGEREF _Toc38367354 \h 47A.4Dimensions PAGEREF _Toc38367355 \h 48A.5Eligibility criteria PAGEREF _Toc38367356 \h 50A.6Search methods and sources PAGEREF _Toc38367357 \h 52A.7Screening and study selection PAGEREF _Toc38367358 \h 53A.8Data extraction and management PAGEREF _Toc38367359 \h 53A.9Study quality / risk of bias PAGEREF _Toc38367360 \h 53A.10Methods for mapping PAGEREF _Toc38367361 \h 54A.11Changes to protocol PAGEREF _Toc38367362 \h 54Appendix BStakeholders PAGEREF _Toc38367363 \h 55Appendix CSource of included studies PAGEREF _Toc38367364 \h 56Appendix DSearch strategy PAGEREF _Toc38367365 \h 60Appendix EAMSTAR 2 tool PAGEREF _Toc38367366 \h 62Appendix FCochrane risk of bias 2 tool PAGEREF _Toc38367367 \h 66Appendix GList of countries included in each WHO region PAGEREF _Toc38367368 \h 71Appendix HRisk of bias summary PAGEREF _Toc38367369 \h 72H.1Completed randomised controlled trials PAGEREF _Toc38367370 \h 72H.2Quasi-experimental designs PAGEREF _Toc38367371 \h 74Appendix ICharacteristics of included systematic reviews PAGEREF _Toc38367372 \h 75Appendix JIntervention characteristics (Primary studies) PAGEREF _Toc38367373 \h 79Appendix K Defn. of the categories of intervention: prevention, disclosure, response, treatment PAGEREF _Toc38367374 \h 104References PAGEREF _Toc38367376 \h 108____________This research went through peer-review with the Campbell Collaboration after production of this current version. At the time of writing, the peer review process is nearing completion but is not finished. The main story does not change though there are some minor differences, e.g., two studies are included?in the peer reviewed version which do not appear here because they published after the search was done.This document is accompanied by various other products: a 'Guidebook' which summarises what the evidence says, a summary report about both the EGM and the Guidebook, an interactive version of the EGM, and paper about activity of practitioner organisations in this area.?They are all available at?csaSummaryIntroductionBackgroundChild maltreatment has serious short and long-term negative impacts for people who experience and survive it. It is imperative that work to address it, and funding, be as effective as possible. That means ensuring that it is informed as much as possible by the evidence: evidence about where the problem is (in what geographies, and which types of institutions), why it happens, who is affected (who are the victims, who are the perpetrators, who can intervene to prevent it and who to respond), and what is effective in prevention, disclosure, response and treatment.Child maltreatment occurs in institutional or organisational settings, including organisations such as churches, schools, youth clubs, etc., and this has recently received substantial attention. However, evidence about interventions that identify, prevent or respond to maltreatment that has occurred in these environments is fragmented and often difficult to access. An evidence gap map aiming to support practitioners, organisational leaders, policy developers and research organisations will provide direction at multiple levels of the service system to address child maltreatment occurring in institutions, and will also strategically inform the commissioning of future research.ObjectivesThe objective of this evidence gap map is to provide a resource for stakeholders operating in the child health, welfare and protection sectors wanting to access high quality evidence on interventions addressing child maltreatment within institutions / organisations. It specifically aims to: (1) provide a structured and accessible collection of the existing evidence, from finalised and ongoing systematic reviews and effectiveness studies assessing institutional responses to child maltreatment, for those who work to fund, develop, implement, and evaluate interventions aimed at ensuring children’s safety in institutional settings, and; (2) identify gaps in the available evidence on institutional responses to child maltreatment, thereby helping to inform the research agendas of funders, researchers and others.What is an Evidence Gap Map?An evidence gap map (EGM) offers a visual presentation of the available evidence for a particular sector. The map shows what studies are available but does not summarise their findings. This EGM is typical, in that it is a matrix of intervention categories (rows) and outcome domains (columns). The map is shown graphically on pages 11-13.This study related to effectiveness. In order to answer the question of ‘what is effective’ in this area, we first need to see the issues where effectiveness has been studied. Giving Evidence, the Centre for Evidence and Implementation (CEI), and Monash University did a systematic search for effectiveness studies: that is, studies which look at the effect / effectiveness of some intervention(s) on some outcome(s). For example, on the effect that raising children in Romanian orphanages vs. in foster care had on their brain development; or the effect of using the Good School Toolkit had on physical violence against primary school children in Uganda. We then mapped them on a grid of interventions (as rows) and outcomes (as columns): this shows where the evidence is, where there are concentrations, and where there are gaps. The interventions were put into four groups: prevention, disclosure, treatment, response. These are defined in Appendix K. We also coded the studies for quality. This comprises an ‘evidence and gap map’ (EGM). The map is shown on pages 11 – 13 here. The EGM was produced during 2019-20. We aim to publish it with The Campbell Collaboration, which has already accepted the scope and protocol.To be clear, an evidence and gap map (EGM) shows where the research is; it does not show what the research says. That is a next step. ScopeWe looked for studies relating to child abuse within institutional contexts: so in schools, care homes, youth clubs, sports clubs, young offender institutes, churches, etc. We did not look at abuse within families. We included effectiveness studies of the following types:Primary studies which have a defensible counterfactual (i.e., some way of seeing ‘what would have happened otherwise’, which isolates and hence shows the effect of the intervention). Those are:Randomised controlled trials Non-randomised before-and-after studies??Quasi-experimental designs: several designs, all of which have credible counter-factuals.?Systematic reviews of effectiveness studies. The logic for the choice of studies to include was this. While we recognise that RCTs are considered the best design for a single study to assess?an intervention’s effectiveness, there are many institutional interventions where random assignment may not be appropriate or possible. Hence we were open to including highly controlled, quasi-experimental designs (QEDs). Non-controlled pre-post evaluations (i.e., without a credible counterfactual) were excluded from this EGM, as were qualitative studies, process evaluations, and non-impact evaluations (e.g., cross-sectional surveys, observational studies, case studies or opinion pieces).?We sought studies published anywhere globally, and we looked in various languages. The studies could have been published at any time: though in practice, the earliest study we found was published in 1985.We sought by searching databases of academic journal articles, by soliciting suggestions from relevant experts (both academics and practitioners), by searching the websites of some relevant organisations (e.g., statutory inquiries into institutional abuse including child sexual abuse, and some charities). The search strategy is described in detail in the longer document mentioned: it is also in the protocol (scope / plan / recipe) for the research which is published.The scope and methods are described in more detail in the appendices.FindingsThere is much work to do. Our map comprises 82 papers. There are some updates and papers written about the same underlying experiment. Excluding those, the map has 72 studies: 58 completed primary studies, protocols (i.e., plans) for three further primary studies which we assume are underway, and 11 systematic reviews. These are very small numbers given the scale of the problem. (To be clear, we had a broad search, so the small number of studies is unlikely to be the result of our search strategy being too narrowly focused, or too niche.) Much remains unknown: many more issues in this terrain need to be researched. But: “Where to start isn’t the issue, that we start at all is what matters most.” - Margaret Heffernan's book Willful BlindnessTo be clear, the absence of evidence about a type of intervention is no slight on that intervention. It is not (apart from in extraordinary circumstances) a comment on that intervention nor on any organisation that runs it: rather, it is a comment about the available research (which fits the scope and criteria of this EGM). What we foundOf those 72 studies: 58 were completed primary studies, 49 of them RCTs; three were protocols for new primary studies, all RCTs; and 11 were systematic reviews. Most of the included studies came from academic journals (by searching the databases of them); only a handful came from non-academic literature such as practitioner organisations. Geographically, the studies don’t seem to match where the world’s population is. Though there are studies from quite a few countries, the studies are markedly concentrated geographically. The US dominates, with 32 of the 58 completed studies; and Western Europe, the US and Canada account for 81% (47) of the completed primary studies between them. Those regions are nothing like 81% of the world’s population. Only five of the 61 primary studies are from countries which have Muslim majorities.By way of demonstrating the mismatch between where studies are vs. where the problem is, we found no studies from South Africa, where child sexual abuse alone is thought to affect over one child in three. We found no studies from India and only two from China, which obviously have ~2 billion of the world’s ~7 billion people between them. We found only three studies from Africa which has over a billion people (two studies from Uganda and one from Tanzania).The UK and Germany each have three studies, the Netherlands and Spain have two, and we found only one study from South America (Ecuador). There were none from Austria or Switzerland, nor any from Portugal or Zimbabwe. The major concentration of studies is in education-based prevention programmes, including both early education and school settings. Fully 53 of the 61 primary studies included examine these programmes (including the three protocols for planned RCTs). Most of the programmes were curriculum-based and aimed to teach children awareness and understanding of sexual abuse and teaching safety skills, e.g., the difference between good touches vs. bad touches, how/when to handle ‘secrets’ and who to tell (n = 42) These usually involved workshops or lessons, combined with relevant written, audiovisual or other resources (parent materials, activity books), and were delivered directly to children in small groups via an external agency or existing trained institutional staff. The good news is that a systematic review in 2015 of those programmes found that they all seem to work, and none produces harms. Most of the studies report intermediate outcomes, such as children's acquisition and retention of knowledge, but not actual disclosure of incidence: this may be because actual disclosure can take years, making it expensive and difficult to track.Most of the studies are about sexual abuse. Sexual abuse was considered by 56 of the primary studies: in 47 primary studies, sexual abuse was the singular focus, and in a further nine studies, sexual abuse was examined alongside other maltreatment types. By contrast, only 12 studies?reported on physical abuse, four on neglect, and three on emotional abuse.?None had emotional abuse as a main focus. Of the 11 systematic reviews, eight included studies that reported solely on interventions relating to sexual abuse. The three remaining reviews included studies that reported on one or more types of child maltreatment: two included studies assessing physical and emotional abuse, as well as neglect, and one included studies reporting on sexual, physical and emotional abuse. Most of the studies are about prevention. Prevention was examined in 59 primary studies (completed and on-going studies), and 10 systematic reviews. Some studies looked at prevention alongside other issues. By comparison, treatment was studied in only two primary studies and two systematic reviews; and response was studied in three primary studies and five systematic reviews. On disclosure, we found no primary studies of interventions aiming to facilitate disclosure(!), and only one systematic review?including interventions around disclosure. However, nine prevention studies included disclosure as an outcome. No completed study has assessed interventions with adults to stop them offending within organisations (either at all, or re-offending). This seems an amazing gap. We found only one on-going study working with adults to reduce violence against children: it was with teachers in Jamaica in day-care. There is one completed study of youth-on-youth violence. Only few studies focus on children particularly at-risk. Most (n= 56) of the programmes studied in the primary studies were universal, i.e., were of ‘general populations’ of children at school (i.e.,?not focusing on children at risk). These were all prevention focused and delivered in educational settings, e.g., schools or early childhood settings. Four primary studies focused on at-risk populations: one about special education high school students with cognitive and/or physical disabilities; one about boys in residential youth care; one about children in Romanian orphanages; and one about children sexually abused at a residential school for the deaf.We found no causal studies conducted in religious organisations. That is remarkable given the scale and media interest in clerical sexual abuse and the number of countries in which it has been reported. Almost all the studies have appreciable risk of bias. We assessed the possibility that the studies might be biased: this uses the material in the study report, e.g., if the report doesn’t describe a method of randomization, then we cannot be confident that randomization was done well (i.e., was unbiased), so there is a risk that it was biased. (To be clear, this is about confidence and risk: perhaps the study was conducted brilliantly, but we do not know that. See box.) We found no RCTs with low risk of bias (i.e., in whose results we can be highly confident). Of the 49 completed RCTs, 18 raised ‘some concerns’ of risk of bias, and the other had high risk of bias (i.e., we can have only low confidence that the reported results are accurate). The systematic reviews that we found were similar: we have only a low level of confidence in the results of ten of the systematic reviews, and high confidence in only one systematic review (which also includes a recent update).Few studies look at actual incidence of abuse. This is hardly surprising, particularly for sexual abuse (which, as discussed, was the focus of most of the studies) because not all survivors ever report it at all, and some may take decades to do so. Only 10 completed primary studies looked at measures of actual child maltreatment occurrence or reoccurrence. These were usually self-reports from children/young people, which seemed to be used as proxies for incidence. All other studies look at intermediate outcomes, e.g., neural development, or education programmes assessed on whether children acquire and retain knowledge.Only one study looks at educational attainment as an outcome (the Good Schools Toolkit study in Uganda). Clearly preventing abuse and dealing with abuse is important in its own right. But given the focus on education – in the SDGs and the amount of funding tied to education – this was striking.Relatively few studies disaggregated results by sex. Of the 58 completed primary studies, fewer than half (only 24) reported results disaggregated by sex (i.e., they analysed and reported any differences between males and females). 43 studies either did not conduct, or did not report, an analysis that would detect whether an intervention’s effectiveness differed by gender. There are no primary studies about treatment from the last nearly 30 years. The primary studies of treatment interventions are all either from Romanian orphanages in the aftermath of the fall of the Ceau?escu regime in 1989, or one non-randomised trial published in 1992. There are no more recent primary studies of treatment interventions.Institutional safeguarding practice was studied in seven primary studies. This again is remarkably thin given the amount of activity in organisations on creating and running safeguarding policies. Four of these studies are about operational practice, and three about institutional culture. The outcomes studied in relation to institutional safeguarding practice were: number of cases registered with CPS, teacher attitudes and their confidence in their ability to manage sensitive issues, and understanding of boundary-violating behaviours.On the positive side, research interest in this topic has risen dramatically: before 2014, there were only 15 relevant studies; during and since then, 25 have been published, and (at least) three more primary studies (all RCTs) are underway. A good range of age groups was studied: early childhood (0- 5 years) got 16 primary studies; middle childhood (6-11 years) saw most studies (38); early?adolescence (12-14 years) had 12, and late adolescence 15-17 years had nine. Two studies were across childhood ages (0-18 years).?Very few studies came from practitioners and non-profits. This is not a great surprise, because (sadly) so few ‘impact’ studies produced by charities, etc., are robust, and hence did not make the threshold for the types of study design that our EGM included. Nonetheless, it is striking that so few studies from non-profits met our criteria in terms of rigour.We only found studies relevant to three of the seven INSPIRE strategies (pictured), promoted by the World 3804920-3365500Health Organisation. Those are: norms and values; response and support services; and education and life skills. In other words, most of those strategies, as they apply to institutions, do not seem to be underpinned by rigorous evidence (that we found). (Much violence is outside institutions, e.g., within families, and perhaps there is robust evidence behind the INSPIRE strategies for that.)Implications for research and recommendationThis evidence gap map shows a need for more high-quality studies that assess interventions across many institutional contexts and maltreatment types. The evidence gaps are particularly evident for countries with large populations and most child maltreatment. Few studies focussed on perpetrators or the organisational environment. We found gaps in the evidence around interventions relating to disclosure, organisational responses and treatment, and few studies that assessed an intervention’s impact on perpetrators’ maltreatment behaviours, recidivism and desistence. There is also need for more studies to measure and report on programme cost, implementation and economic outcomes. IntroductionBackground Child maltreatment, including sexual abuse, physical abuse, neglect, and emotional abuse is a major social issue that has a negative impact on the physical, mental, spiritual, educational and interpersonal wellbeing of those experiencing and surviving it (Maniglio, 2009; Lueger-Schuster et al., 2018, Fang et al., 2007, Fang et al., 2012 & Felitti et al., 1998). The overall prevalence of child maltreatment is difficult to establish due to inconsistencies in measurement and suspected under-reporting (Finkelhor et al., 2014), resulting in considerable variability among estimates. That said, the overall prevalence of maltreatment, as estimated from a synthesis of existing meta-analyses from across the globe is alarmingly high at 127/1000 for child sexual abuse; 226/1000 for physical abuse; 363/1000 for emotional abuse; 163/1000 for child neglect; and 184/1000 for emotional neglect (Stoltenborgh et al., 2015). There is variability by country as well. For example, the Global Status report published by the World Health Organisation reported the prevalence of child physical abuse in Swaziland to be 22%, whereas in countries including Kenya, Tanzania and Zimbabwe prevalence ranged between 53-76% with higher rates of abuse experienced by boys than girls (WHO 2014). The overall economic cost of child maltreatment is also high, with average lifetime costs in the US upwards of $200,000 per child, resulting in hundreds of billions in cost burden from new cases each year (Fang et al, 2012). In short, child maltreatment is harmful, highly prevalent, and costly.In recent years, child maltreatment in institutional settings has received high public and policy recognition through a range of official inquiries particularly in high-income countries (e.g., the Royal Commission into Institutional Responses to Child Sexual Abuse in Australia, 2017; the Scottish Child Abuse Inquiry). These inquiries have led to a prioritisation of child maltreatment within institutional settings, as both a specific and serious issue among policy-makers, practitioners and service agencies working with children (Proeve et al., 2016; Blakemore et al., 2017). In addition, the inquiries themselves have produced many key reports examining the impact of institutional child maltreatment (Blakemore et al., 2017), how it can be prevented (e.g., South, Shlonsky & Mildon, 2014; Pitts, 2015), victims supported (Shlonsky et al., 2017), and appropriate responses implemented (Parenting Research Centre, 2015; Albers & Mildon, 2016). Institutional settings include schools, out-of-home care, sport clubs, religious institutions and comparable settings in which children live or spend time. In these settings, child maltreatment can be adults abusing children or children abusing other children. Children may be more or less vulnerable for reasons ranging from a lack of proper safeguarding in institutions (e.g., failing to respond to disclosures) (Royal Commission into Institutional Responses to Child Sexual Abuse, 2017; Lemaigre et al., 2017), to the characteristics of children (e.g., age, developmental or other disabilities) (Sullivan et al., 1992 & Devries et al., 2018). Institutional child maltreatment as a field of empirical research is at an early stage (Timmerman & Schreuder, 2014 Proeve et al., 2016; Blakemore et al., 2017). Whilst recent prevalence studies in residential care facilities suggest that children are at higher risk of sexual abuse compared to the general population (Allroggen et al., 2018, Greger et al., 2015), there has been virtually no comparison of other types of maltreatment in other settings (Proeve et al., 2016). Specific evidence about the effectiveness of interventions aimed at identifying, preventing or responding to institutional child maltreatment is fragmented, and dispersed across academic and non-academic (‘grey’) literature. This makes it difficult to access and interpret by sector stakeholders wishing to improve their practices and services in this area. The objective of this EGM is to provide a resource for a broad range of stakeholders operating in child health, welfare and protection sectors wanting to access high-quality evidence on interventions addressing institutional child maltreatment. Objectives The objectives of this EGM are to: Provide a structured and accessible collection of existing evidence from finalised and ongoing systematic reviews and effectiveness studies of institutional responses to child maltreatment for those who work to fund, develop, implement, and evaluate interventions aimed at ensuring children’s safety in institutional settings. 2. Identify gaps in the available evidence on institutional responses to child maltreatment thereby helping to inform the research agendas of funders and other organisations.Structure of the reportThis report has the following main sections:outline of the findings, including the visual map which presents the findings graphicallydiscussion of the findingsthe findings in more detailthe methods are described in detail in the appendices. Summary of the findingsSummary results of the search The EGM includes 72 studies (reported across 82 articles): 61 primary studies and 11 systematic reviews. The academic electronic search yielded 8691 citations, and an additional 2643 records from additional sources were identified. After removing duplicates and screening titles and abstracts, 305 studies remained for full-text review. A total of 82 eligible studies were identified after full-text review (including systematic reviews, papers describing primary studies and protocols for primary studies). See REF _Ref31569833 \r \h Appendix C for where we found each study that we included. Of these 82, 12 are completed systematic reviews. Two are related: a review by Walsh and colleagues (2015) was an update of an earlier Cochrane review published in 2007 (Zwi, 2007). While both are included in the EGM, where the reported characteristics are identical for each (e.g., maltreatment, setting, target), they have been represented collectively (i.e., counted as a single study). Where the reported characteristics differ (e.g., study quality, included age groups), they have been represented separately (i.e., counted as two separate studies). Seventy primary studies (effectiveness studies) were identified: 67 were completed studies, and three were ongoing (described in a published protocol where results had not yet been generated). Among these, five studies related to the Good School Toolkit (GST) (see Box 1 later), and reported different outcomes from the same sample, or a subset of the sample (Devries 2015, Devries 2017, Devries 2018, Knight 2018 and Merrill 2018). Six studies reported results of the Bucharest Early Intervention Project (BEIP) (see Box 2 later) (Bick 2015, Humphries 2015, Johnson 2010, Smyke 2010, Troller-Renfree, 2015, Wade 2018). These studies report the same or different outcomes at various follow-up points from a single sample of children. Therefore, though the search identified 70 primary studies (i.e., publications), for the purposes of most of the counting in this document, the five GST studies are counted as a single study, as are the six BEIP studies. Hence, we report on 61 unique studies, reported in 70 separate publications. A table outlining the number of studies identified and included by search source is in REF _Ref31569852 \r \h \* MERGEFORMAT Appendix C.Figure 1 Diagram of the search process and its results at the various stagesleft24257000Visual map of the included studies 30480024828500Figure 2 below shows the spread of the included studies, across the intervention and outcome categories used. The colours show the quality ratings (explained below) (N = 82).-268605224790005440Discussion of the findingsThis EGM had two primary objectives. First, to provide a signpost to existing evidence from finalised and ongoing systematic reviews and effectiveness studies of institutional responses to child maltreatment for those who fund, develop, implement, and evaluate interventions to ensure children’s safety in institutions. And second, to show gaps in the available evidence, to inform the research agendas of funders, researchers and others.Quality of the evidenceMost of the studies included in the EGM are low to moderate quality. Ten of 12 systematic reviews received a low quality rating, and 18 of the 49 included RCTs were assessed as having a high risk of bias (low quality). We only found one high quality systematic review, and no RCTs which we assessed as having a low risk of bias (high quality). Therefore, any assessment of effectiveness of the interventions on the reported outcomes should be cautiously interpreted. Gaps and strengths in the evidenceOverall, there were more gaps across the EGM than areas with high quality evidence. This, combined with the fact that most studies were published in the last five years, suggests that empirical research on the effectiveness of interventions addressing child maltreatment in institutions is very much at an early stage and highlights a need for considerable future research.Most studies focused on children, on prevention, and on sexual abuse specifically. This is not proportionate to the prevalence of different maltreatment types. For example, current estimates suggest that physical abuse is more, or at least equally, prevalent as sexual abuse (WHO 2014). Most studies targeted universal populations, with far fewer targeting children who are high-risk or who had already been exposed to maltreatment. This raises concerns because potentially it places the burden of responsibility of prevention and disclosure of child maltreatment on children, rather than on perpetrators of abuse or on the organisations that serve them. Of further concern is that focusing on children in this way may place the blame on the child if maltreatment occurs.Institutional settings: Education and early childhood settings were by far the most well-studied. This is perhaps not surprising, given that most children have more contact with schools than any other institution and studying children in schools is relatively easy. In contrast, evidence assessing the effectiveness of interventions across other institutions, such as OOHC (e.g., foster care, residential care, orphanages), was very limited. For many types of institution within our scope, there were no specific studies at all, e.g., religious organisations, sports clubs.There are several potential explanations for this. While it is certainly the case that many institutional settings have not adequately addressed child maltreatment, there are interventions which are run to address maltreatment but which have not yet been evaluated or have not been evaluated in an explicitly institutional context. The EGM’s selection criteria excluded studies that did not explicitly define an institutional setting. However, there are also evaluations that either focus on maltreatment in the home, or do not specify where the maltreatment occurred. Taking this into account, it is possible that existing evidence-based interventions targeting general populations, or specific populations outside of an institutional setting, may also be effective, or may be adapted and be effectively used within an institutional context. For instance, interventions targeting sexual abuse perpetrators could possibly be adapted to specifically target people who perpetrated sexual abuse in an institutional setting. Or, interventions targeting staff in schools may be adapted to target staff in other organisational contexts. However, this approach has limitations: institutional environments are diverse, and one-size-fits-all interventions are unlikely to be effective without some modifications. There are also differences in risk factors for perpetrators and victims, as well as differences in the experience, perpetration and response to maltreatment both across different institutional settings and also when compared to other settings where maltreatment occurs (Quadara 2015, Radford 2017). These factors would need to be considered, and likely a strong implementation plan developed and executed well, when adapting existing interventions to (other) institutional environments. Geographically; though the studies look at many countries, the evidence is dominated by studies about programmes in the US and Europe. It is clear therefore, that the available research does not currently represent countries with the largest populations (and therefore, potentially the greatest incidence of child maltreatment), nor does it represent countries with the highest estimated prevalence of child maltreatment (WHO 2014). Target populations: Most of the included studies assessed education or skills-based interventions delivered to children. Fewer were delivered to institutional staff, teachers, and/or adult care providers. There was a lack of evidence targeting adult perpetrators and only one study of youth perpetrators and where evidence was identified, the focus was primarily on children who display sexually aggressive behaviour towards other children. Gender: Only a third of studies analysed differences in outcomes between girls and boys. For those that did, several found different outcomes by gender for at least one reported outcome. There are multiple reasons why boys and girls may respond differently to an intervention, and future research should consider gender-specific interventions or include analyses that allow an evaluation to determine any differential impact an intervention may have on boys and girls. Maltreatment type: most interventions focussed on sexual abuse – and specifically on preventing sexual abuse. Though we did identify a cluster of studies focused on addressing physical violence in schools (including harsh discipline), far fewer studies targeted other maltreatment types. Intervention type: a major gap was identified in relation to studies evaluating interventions that aimed to improve disclosure. Interventions to encourage disclosure were studied in none of the primary studies that we found, and included in only one systematic review (which was of low reliability). Evidence supporting the effectiveness of organisational response-based approaches was lacking in both breadth and quality. Of the small number of studies, only one was an RCT, which evaluated a very brief staff training intervention. Studies that assessed treatment interventions that addressed child maltreatment experienced or perpetrated in institutional settings were also extremely limited and solely focused on OOHC settings. Prevention-based interventions were by far the most highly represented group of interventions. Of these, most reported on school-based interventions that primarily aimed to provide children with knowledge and skills to better protect themselves from maltreatment. This was also reflected in the findings for alignment of interventions with the WHO INSIPRE framework, with the vast majority aligning with the ‘education and life skills’ domain. Outcomes: The predominance of curriculum-based interventions in education settings targeted towards children is also reflected in the outcomes presented in the EGM. Across all the included studies, outcomes relating to child knowledge and awareness were reported more than any other type of outcome. Child mental health and maltreatment occurrence outcomes were also reported in a substantial number of studies. It is perhaps not surprising, given the nature of child maltreatment and its measurement in institutional contexts, that these studies mostly focused on short-term, self-report risk indicators for maltreatment rather than measurement of whether maltreatment actually occurred. Overall, reported outcomes tended to focus on children, and not perpetrators. Direct measures of perpetrator maltreatment behaviours, recidivism and desistence were included in only one completed primary study and one protocol for a planned study (with adult child-care workers). Institutional safeguards: Despite lowering our inclusion criteria for primary studies well-below the RCT threshold, there was scarce evidence reporting outcomes relating to institutional safeguarding practices that may better support the prevention, disclosure and organisational responses to child maltreatment. Unfortunately, these gaps may be due to a lack of concerted, rigorous efforts at evaluation in institutional settings. Though the reasons for this are unknown, it may be related to a reluctance to look closely at institutional failures and to evaluate them in a way that builds the knowledge base for prevention work in this area. The past has seen a larger research focus on maltreatment in the home / families than in institutions. This is only now being challenged as victims of child sexual abuse recount their experiences, seeking justice and restitution, sparking numerous inquiries across the world. Hopefully, this level of scrutiny and a demand for a meaningful response will translate into a growing number of safeguarding approaches that are rigorously evaluated.Implementation: Finally, only a third of the studies reported one or more outcomes that related to implementation. This seems few, given the importance of implementation quality for producing outcomes. These included measures of feasibility, adoption, fidelity, acceptability and reach/ consistency of delivery. Implementation outcomes are “the effects of deliberate and purposive actions to implement new treatments, practices, and services” and describe the result of intentional actions to deliver a policy or an intervention (see Proctor 2011). Measuring implementation is important in determining how or whether an intervention was delivered as intended, information that is essential to ascertaining its effectiveness. Moreover, the effectiveness of an intervention may be compromised by insufficient attention to implementation. Measures of implementation also provide information about whether an intervention is acceptable to participants, and/or whether it is likely to be successfully adopted in real life contexts. The fact that most studies in the EGM did not report on measures of implementation is concerning, given that many studies reported on interventions which were delivered by multiple individuals (e.g., practitioners, trained staff) and across multiple study sites. This creates ample scope for variation in what gets delivered, which may impact the reliability of a study’s findings. Implications for future research, policy and practiceOverall, the evidence included in the EGM is sparse and of low to moderate reliability. There is much need for further high quality research undertaken. Specifically, for research:evaluating interventions in a broader range of institutions in countries with the largest populations and the greatest incidence of child maltreatment in institutions is likely to occurassessing interventions that focus on perpetrators and the organisational environment (as well as children) studies of gender-specific interventions or studies that include disaggregate the results by gender, particularly those evaluating group-based delivery approaches.assessing interventions addressing a broader range of maltreatment types, in particular those relating to neglect and emotional abuse (i.e., not just sexual abuse)assessing interventions focussed on disclosure, organisational responses, and treatmentassessing interventions targeting perpetrators, maltreatment behaviours, recidivism and desistence assessment and reporting of implementation outcomes. The current evidence base for interventions specifically addressing institutional child maltreatment is sparse. It is therefore difficult to assess whether an intervention which achieved some result in one location or setting will achieve that same result elsewhere. For instance:Could school-based education and skills training interventions be appropriately translated to other institutions and/or other populations? (e.g., Could the kind of child trainings which have been studied schools be delivered at Scouts? training for teachers be delivered to clergy, etc. Or, existing treatment for perpetrators be tested with a population of perpetrators who abused within an institutional setting.)Can safeguarding practices be adapted to other organisational contexts and/or personnel? Are treatment principles for children who experienced maltreatment in other settings appropriate and effective for children who experienced maltreatment in an institutional environment?Given the potential for boys to respond differently to programmes than girls, should non-gendered approaches be adapted into gender-specific interventions? (This might be especially important in group-based delivery approaches.) Clearly, interventions that are moved from one type of setting to another may not work as well there. So, for example, if an intervention which has been effective when delivered in schools is now tested at Scouts, it should be evaluated there.Limitations of the EGMProducing the EGM involved an extensive and rigorous search for peer reviewed and grey literature, and examining over 6000 citations. We also sought relevant studies from contact with experts in the ?eld. Despite this, it is possible that some studies relating to institutional responses to child maltreatment were missed. When screening at the title or abstract level, we may have incorrectly excluded some studies, where information provided did not clearly reveal relevance to the setting or topic. Similarly, some relevant studies with relevant to settings outside the scope of our EGM, including health or clinical settings, may have been excluded on the basis of setting criteria. Snowballing techniques were not used for screening primary studies, and though we screened for inclusion the primary studies included in the included systematic reviews, we do not screen all the studies in their reference lists.Though the search terms were carefully designed and piloted, relevant studies could still have been missed because of on our included terms. There may have been studies in other languages that were not picked up by our search strategy, or studies that used different language/terms to describe institutional settings or child maltreatment. We will further assess the appropriateness of search terms in future updates to ensure that the search terms include relevant terminology. It is not possible for an EGM to comment on whether the interventions studied produced adverse outcomes.Box 1 – The Good School Toolkit The Good School Toolkit was developed by the Ugandan not-for-profit organisation Raising Voices. The primary aim of the Good School Toolkit is to decrease violence within schools. {“Physical violence in schools” does not ‘just’ mean corporal punishment for purposes of discipline, but rather can be much more severe. For example, a study in Luwero region of Uganda (reported in Devries 2015) found that 8% of school pupils had experienced “extreme physical violence such as being choked, burned, stabbed, or severely beaten up”.} The Good School Toolkit uses school-wide approach, targeting staff, students, and administration. It uses behaviour-change techniques, including: setting school-wide goals, developing action plans, encouraging empathy by facilitating reflection on experiences of violence, providing knowledge on alternative non-violent forms of discipline, and providing opportunities to practise new behavioural skills. Schools are encouraged to self-monitor their progress according to their action plans. Reinforcement of new information and ideas, feedback on progress, and modelling of new techniques and behaviours is support by the Raising Voices team, and also by within school “protagonists”. Children participate actively and form committees and groups related to different activities. Schools celebrate successful achievement of their goals and action plan deliverables, and social support for behavioural change is created through engagement of multiple groups within a school (teachers, administration, students, and also parents).Activities, implemented over six steps, relate to creating a better learning environment, respecting each other, creating opportunities for students to participate in decision-making processes, understanding power relationships, using nonviolent discipline, improving classroom management techniques, and promoting responsive school governance. The schools also received one-on-one support visits and phone calls to support implementation.Devries, K. M., Knight, L., Child, J. C., Mirembe, A., Nakuti, J., Jones, R.,. & Walakira, E. (2015). The Good School Toolkit for reducing physical violence from school staff to primary school students: a cluster-randomised controlled trial in Uganda.?The Lancet Global Health,?3(7), e378-e386.Box 2 – Bucharest Early Intervention Project The Bucharest Early Intervention Project was initiated after the fall of the Romanian communist dictator Nicolae Ceau?escu in 1989. The world became aware of many children being raised in impoverished orphanages. As the children's plight was brought to light, researchers realised they had a unique opportunity to study the effects of early institutionalization. A research project began in 2000 by assessing 136 children who had been living in Bucharest's institutions from birth (all the children there under 31 months of age). In the orphanages, the children’s lives were characterised by impoverished stimulation in all areas including social, emotional, linguistic, and cognitive, and experienced severe neglect and deprivation as well as physical, emotional and potentially other forms of maltreatment. Researchers randomly assigned half of the 136 children to move into Romanian foster families (taking advantage of a natural shortage of foster homes). The other half remained in care as usual. Over the subsequent months and years, the researchers returned to assess the development of the children and have published a series of academic papers reporting on the findings. Weir, K: American Psychological Association. (June, 2014). The lasting impact of neglect. Retrieved from Findings in detailStudy characteristicsStudy designOf the 61 completed and ongoing primary studies, 43 were RCTs and 18 used a quasi-experimental design. They are described in REF _Ref25934989 \r \h \* MERGEFORMAT Appendix EE. StatusOf the 61 unique primary studies, the vast majority (n = 58) were completed. Three were described in published protocols and coded as ongoing (Baker-Henningham 2016, McElearney 2018, Ssenyonga 2018). No ongoing systematic reviews were identified. LanguageOf the 61 included primary studies, one was written in German (Feldmann 2018) and one in Spanish (del Campo Sanchez 2006). The remaining studies were published in English. Publication yearThe earliest primary study included in our EGM was published in 1985. No more than four studies (Range: 1 – 4 studies) were published per year before or during 2011. There is then a marked increase in the amount of activity. Of the total studies, 54% were published between 2012 and 2019, with the peak number of completed primary studies published in 2018 (n = 10). The first systematic review was published in 1994, nine years after the first primary study was published, with the four most recent reviews published in 2017. Figure 3 details the type and number of studies by publication year.Figure 3 Studies by publication year (N = 82) Note: This graph reports multiple reports of the same study and review updates separately.Types of institution / organisations The systematic reviews. Most of the 11 unique systematic reviews reported on studies conducted exclusively in school and/or early childhood settings (i.e., kindergartens, preschool, day-care) (n = 5). Of these, one systematic review (plus, one update) included studies reporting both primary/elementary and secondary/high school settings (Walsh 2015, Zwi 2007), one systematic review included early childhood and primary/elementary settings (Heidotting 1994), one included middle and secondary/high school settings (Ricardo 2011), one systematic review included several settings (across early childhood, primary/elementary and secondary/high school) (Topping 2009), and one included only early childhood settings (Pitts, 2015). Of the remaining five systematic reviews, four focused on residential care (e.g., orphanages, out-of-home care) (Hermenau 2017, McKibbin 2017, Sherr 2017, South 2015). Two systematic reviews included a generalised narrative summary of studies conducted in various settings (Radford 2017, Quadara 2015), including school and early childhood settings, voluntary and faith-based organisations, and sports clubs. (However, these are descriptions, rather than results of high-quality evidence about work in churches). is While both systematic reviews cite studies that describe risk factors associated with institutional child maltreatment, and also discuss the potential of interventions that address child maltreatment within institutions, they both highlight the lack of effectiveness evidence available to support these. The institutional setting for each review is listed in REF _Ref25935076 \r \h \* MERGEFORMAT Appendix II. Figure 4 details the breakdown of systematic reviews by institutional setting. The primary studies. Most primary studies (n = 47) were conducted in school settings, including: primary/elementary school (n = 39); 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 2013, Ssenyonga 2018). Eleven primary studies were conducted in early childhood settings (e.g., kindergarten, preschool, day-care), and three of these also included primary/elementary school settings (Fryer 1987, Krazier 1981, Wurtele 1986). Two primary studies were conducted across multiple settings, which included: health, school and social services agencies who respond to child maltreatment (Cerezo, 2004); and organisations delivering services that children access or attend (e.g., schools, day-care, church organisations) (Rheingold 2014). Three were conducted in out-of-home care, including foster care, orphanages (BEIP studies), a residential school for the deaf (Sullivan, 1992), and group homes (van Lieshout 2019). REF _Ref25935108 \r \h \* MERGEFORMAT Appendix EE lists the institutional settings for each primary study. No studies were identified where the primary setting was sports clubs, religious organisations, summer camps, detention centres, rescue centres or primary and secondary health care facilities. Figure 4 shows the number of completed and ongoing primary studies by institutional setting.Figure 4 Primary studies and systematic reviews by type of organisation (N = 61) Geographical distribution CountriesHalf of the primary studies were from the United States (US) (32). Canada produced four studies; three came each from Germany and the UK (one from Northern Ireland, two from Scotland); six countries produced two studies each (Turkey, China, Spain, The Netherlands, Uganda); and, a further 9 countries contributed one study each (Australia, Ecuador, Indonesia, Ireland, Jamaica, Malaysia, Romania (inclusive of the six studies), Taiwan, Tanzania). Figure 5 below shows the distribution of completed and ongoing primary studies by country. Notably, the geographic distribution of studies does not match that of the world’s population, e.g. there are only two studies from China, and none from India.Figure 5 Completed and ongoing primary studies by country (N = 61).Note: Colours represent the number of studies produced by a country, e.g., all countries that produced one study have been shaded in purple. The six reports conducted in Romania are represented as one study, as are the five studies reporting on the one study sample of the Good School Toolkit in Uganda. World Health Organisation (WHO) regions Regionally, the overwhelming proportion of primary studies were conducted in the Americas (62%) and Europe (23%). The rest of the studies were conducted in South East Asia (8%), Africa (5%), and the Western Pacific (2%). No studies were conducted in the Eastern Mediterranean region. These figures account for multiple reports relating to the same study. A list of studies from each region is at REF _Ref25935157 \r \h \* MERGEFORMAT Appendix EE. PopulationAge groupsSystematic reviews: Most systematic reviews included studies reporting on participants in early (0-5 years) and/or middle (6-11 years) childhood (n = 6). Fewer systematic reviews included studies reporting on participants in early adolescence (12-14 years) and/or late adolescence (15-17 years) (n = 4). Most of the reviews included studies from more than one age group (n = 8), four additional reviews included or reported on children of all ages (Hermenau 2017, McKibbin 2017, Quadara 2015, Radford 2017), and South (2015) did not specify age. Figure 6 shows the number of systematic reviews by their target age groups. Primary studies: Most (n = 38) primary studies focused on middle childhood (6-11 years). Fewer focused on early childhood (0- 5 years) (n = 16), early adolescence (12-14 years) (n = 12), or late adolescence (15-17 years) (n = 9). A list of studies with included age groups is in Appendix I. Fifteen of the primary studies included children from more than one age group (e.g., both early childhood and middle childhood aged participants), including two studies reporting on participants aged 0 – 18 years (Cerezo 2004 and Rheingold 2014). Figure 6 below shows the number of completed and ongoing primary studies by the age of the children studied. Figure 6 Primary studies and systematic reviews by target age group (N = 73).Note: Several studies included more than one age group. The systematic review by Zwi 2007 and update by Walsh 2015 reported different age groups, and have therefore been counted separately. This is why there are 73 studies, and not the 72 reported elsewhere in this document.Target populationSystematic reviews: Most reviews (n = 7) examined interventions targeted solely at children, one included interventions targeting only institutional staff and/or adult care providers (e.g., teachers) (Hermenau 2017), and four reviews included studies assessing interventions that targeted either or both of these populations (Quadara 2015, Radford 2017, Sherr 2017, South 2015). More detail is in REF _Ref31570008 \r \h Appendix EE.Primary studies: Among the completed and ongoing primary studies, most evaluated interventions targeted children in organisations (n = 46). Six studies assessed interventions solely for institutional staff and/or adult care providers (e.g., teachers, afterschool care staff, day-care staff, youth service organisation staff, and health and social services agency staff) (Baker-Henningham 2016, Cerezo 2004, Gushwa 2018, Nkuba 2018, Rhiengold 2014, Ssenyonga, 2018). Nine studies assessed interventions targeted at both children and institutional care staff and/or adult care providers (GST studies, Baker 2012, del Campo Sanchez 2006, Edwards 2019, Kolko 1987, Kolko 1989, Krazier 1991, MacIntyre 1999, Taal 1997). Child risk status Systematic reviews: Most systematic reviews included primary studies focused on child populations that were not at a higher risk of maltreatment than the general population (i.e., universal child populations) (n = 7) (see REF _Ref25935255 \r \h Appendix EE). Four systematic reviews included studies assessing exposed populations, three of which included child participants in out-of-home care (e.g., residential care, orphanage, foster care) (Hermenau 2017, Sherr 2017, South 2015) and one included interventions providing support for victims and survivors of child sexual abuse (Radford 2017). One review included studies that focused on children at a higher risk of maltreatment living in out-of-home care (McKibbin 2017). Primary studies: Most primary studies focused on children not at particular risk of maltreatment (n = 56). That is, the approach was universal rather than targeted to specific groups known to be at greater risk. All interventions targeted at universal populations were prevention-focused and delivered in educational settings. The Good School Toolkit is also a school-based prevention intervention targeted universally, though because the children in it reported violence in the past week, these studies were coded as studying children at-risk and/or exposed to violence. Two further primary studies included children at increased risk, including special education high school students with cognitive and/or physical disabilities (Dryden 2014) and boys in residential youth care (van Lieshout 2019). Two focused on children exposed to maltreatment, including children raised in terrible orphanages (BEIP study) and children sexually abused at a residential school for the deaf (Sullivan 1992). Note that all studies ultimately had a focus on children, even where the intervention was delivered solely to institutional staff. Gender analysis Of the completed primary studies, 24 reported results disaggregated by sex (i.e., they analysed and reported any differences between males and females). 43 studies either did not conduct, or did not report, an analysis that would detect whether an intervention’s effectiveness differed by gender. One of these primary studies included male participants only (van Lieshout 2019). Two protocols (McElearney 2018 and Baker-Henningham 2016) reported that a gender analysis will be done; the other protocol did not include a planned gender analysis (Ssenyonga 2018). Of the 24 studies which disaggregated results by sex, 20 assessed curriculum-based preventive interventions delivered in educational settings, and eight of these reported differences between males and females for at least one outcome (Czerwinski 2018, Jin 2017, Bustamante 2019, Hazzard 1991, Hillenbrand-Gunn 2012, Oldfield 1996, Snyder 1986, Weatherley 2012). Three Good School Toolkit related studies assessing the implementation and/or effectiveness of a prevention programme addressing physical violence in Ugandan schools, reported that the intervention produced more positive results for male students than for female students (Devries 2015, Devries 2017, Knight 2018). Across three reports of the BEIP study, two reported differences between boys and girls in relation to child mental health outcomes for internalising and externalising symptoms and caregiver attachment (Humphreys 2015 and Smyke 1992), and one additional report showed no effect of gender (Johnson 2010). Sullivan (1992) examined differences in behavioural symptoms (including internalising symptoms, somatic, schizoid, uncommunicative and obsessive behaviours) between sexually abused boys and girls attending a residential school for the deaf, after receiving a psychotherapeutic treatment (Sullivan 1992). Type of maltreatment Systematic reviews: 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 (2017) and Sherr (2017) included studies assessing physical and emotional abuse, as well as neglect, and Ricardo (2011) included studies reporting on sexual, physical and emotional abuse. Primary studies: Most completed and ongoing primary studies included interventions that had a singular focus on sexual abuse (n = 47), with nine additional studies focussing on sexual abuse alongside other maltreatment types (total sexual abuse: n = 56). Four primary studies assessed interventions specifically addressing physical abuse, and a further eight incorporated physical abuse alongside other maltreatment types (total physical abuse: n = 12). Child neglect was the primary focus of the BEIP studies, 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 Good School Toolkit studies and four others (total emotional abuse: n = 5). Figure 7 Studies by maltreatment type (N = 72).Note that some studies included more than one maltreatment type. Quality / risk of biasSystematic reviews Overall, most systematic reviews (n = 10) were assessed as low quality (i.e., low confidence in the reported results) using the AMSTAR 2 checklist (see Box 3) (Heidotting 1994, Hermenau 2017, McKibbin 2017, Pitts 2015, Radford 2017, Quadara 2015, Ricardo 2011, South 2015, Sherr 2017, Topping 2009). Two received a high quality rating (i.e., high confidence in the reported results) (Zwi 2007, and updated Walsh 2015). There were slight variations in the methods reported in the original Zwi review and the Walsh updated review, and so a separate quality assessment was undertaken for each. Box 3 –AMSTAR (A Measurement Tool to Assess Systematic Reviews) Though systematic reviews are the gold standard for synthesising the results of multiple studies of the effectiveness of interventions on outcomes, they are subject to a range of biases. When reviewing evidence it is important, therefore, to distinguish high quality reviews (i.e., we can have a high confidence in the reported results) from those of lower quality (i.e., lower confidence in reported results). AMSTAR 2 is a comprehensive critical appraisal instrument for systematic reviews (Shea et al., 2017)AMSTAR 2 is a set of questions about features of the systematic review. The confidence we can have in the reported results is determined by the answers to the questions. An overall assessment is determined responses to question relating to critical domains outlined by the tool: High: The systematic review report provides an accurate and comprehensive summary of the results of the available studies that address the question of interestModerate - The systematic review has more than one weakness, but no critical flaws. It may provide an accurate summary of the results of the available studies that were included in the review.Low/Critically Low - The review has one or more critical flaw and may not provide an accurate and comprehensive summary of the available studies that address the question of interest.Questions assessing the features of reviews include: Did the research questions and inclusion criteria for the review include the components of population, intervention, control group and outcome (PICO)? Did the review contain an explicit statement that the review methods were established prior to conduct of the review? Did the review authors explain their selection of the study designs for inclusion? Did the review authors use a comprehensive literature search strategy?Did the review authors perform study selection in duplicate? Did the review authors perform data extraction in duplicate? Did the review authors provide a list of excluded studies and justify the exclusions? Did the review authors describe the included studies in adequate detail? Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) for studies included in the review?Did the review authors report on the sources of funding for the studies included?If meta-analysis was justified did the review authors use appropriate methods for statistical combination of results?If meta-analysis was performed did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?Did the review authors account for RoB in individual studies when interpreting/discussing the results of the review?Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results? If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?Reference: Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., Henry, D. A. (2017). AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non‐randomised studies of healthcare interventions, or both. BMJ, 21(358), pleted randomised controlled trialsOf the 49 reports of completed RCTs (counting all the BEIP and GST ones separately), all were assessed to have either a ‘high risk’ of bias (n = 18) or ‘some concerns’ (n = 31) using the Cochrane Risk of Bias 2 tool (see Box 4). No study received an overall assessment of low risk. Most studies raised concerns in relation to the randomisation process (n = 30), often because insufficient information about the randomisation method was provided to allow for high confidence in it. Of the studies assessed, 33 received an assessment of ‘some concerns’ for items concerning deviations from the intended intervention. Thirty-one of the 49 RCTs were assessed as low risk for potential biases associated with missing outcome data: the concerns about them were usually due to (few) participants leaving the study. (Participants leaving a study may be nothing to worry about, or may be a sign of some serious problem, e.g., the intervention being fatal.) On how the outcomes were measured, 22 RCTs were at a low risk of bias, with the remainder raising ‘some concerns’ or ‘high risk’ of bias. Almost all studies received an assessment of ‘some concerns’ in relation to the selection of reported results, with one study being at a high risk of bias for this domain. Box 4 –Cochrane Risk of Bias 2 Randomised trials provide the most reliable evidence about the effects of interventions. However, flaws in their design, conduct, analysis, and reporting can cause the effect of an intervention to be biased towards under or overestimation of treatment effects. Version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2) is the recommended tool to assess the risk of bias in randomised trials in Campbell Collaboration reviews. RoB 2 is structured into a fixed set of domains of bias, focussing on different aspects of trial design, conduct, and reporting. Within each domain, a series of questions ask for information about features of the trial that are relevant to risk of bias. A proposed judgement about the risk of bias arising from each domain is generated by an algorithm, based on answers to the questions. Judgement can be 'Low' or 'High' risk of bias, or can express 'Some concerns'. Domains include: Domain 1 – Risk of bias arising from the randomisation process: Was the allocation sequence random? Was the allocation sequence concealed until participants were enrolled and assigned to interventions? Did baseline differences between intervention groups suggest a problem with the randomisation process?Domain 2 – Risk of bias due to deviations from the intended interventions (effect of assignment to intervention): Were participants aware of their assigned intervention? Were people delivering the interventions aware of participants' assigned intervention? Were there deviations from the intended intervention? Were these deviations likely to have affected the outcomes? Were deviations balanced between groups? Was an appropriate analysis used to estimate the effect of assignment? Was there potential for a substantial impact (on the result) of the failure to analyse participants in the group to which they were randomised?Domain 3 – Risk of bias due to missing outcome data: Were data for this outcome available for all, or nearly all, participants randomised? Is there evidence that the result was not biased by missing outcome data? Could missingness in the outcome depend on its true value? Is it likely that missingness in the outcome depended on its true value? Domain 4 – Risk of bias in measurement of the outcome: Was the method of measuring the outcome inappropriate? Could measurement or ascertainment of the outcome have differed between intervention groups? Were outcome assessors aware of the intervention received by study participants? Could assessment of the outcome have been influenced by knowledge of intervention received?Domain 5 – Risk of bias in the selection of the reported result: Were the data that produced this result analysed in accordance with a pre-specified analysis plan that was finalized before unblinded outcome data were available for analysis? Is the numerical result being assessed likely to have been selected, on the basis of the results, from... (a) multiple eligible outcome measurements (e.g., scales, definitions, time points) within the outcome domain? (b) multiple eligible analyses of the data?Reference: Cochrane Methods Bias. (2019). RoB 2: A revised Cochrane risk-of-bias tool for randomized trials, from: 5 – Risk of Bias example Chen 2012: Pilot Evaluation of a Sexual Abuse Prevention Programme for Taiwanese Children The purpose of this study was to develop and evaluate the efficacy of a school-based child sexual abuse prevention program for Taiwanese children. Domain 1: The study received an overall rating of ‘some concerns’ indicating a moderate risk of bias after receiving a low risk of bias in one domain and ‘some concerns’ in the remainder. Regards the randomisation process, the baseline groups were similar among the intervention and control groups, but the study did not specify the randomisation method and whether randomised allocation was concealed for participants. For these reasons, this domain was assessed as ‘some concerns’. Domain 2: In relation to deviations from the intended intervention, the study did not explicitly state whether the children were aware of the status of the group to which they were assigned. As the study also didn’t specify if randomisation was concealed, it is possible that participants were aware that they were assigned to the intervention. This can be important because knowledge of the intervention may alter outcomes (e.g., a participant may report outcomes differently if they know they are getting an intervention vs getting a placebo or nothing). This study showed no strong evidence suggesting that there were deviations from the intended intervention, yielding a rating of ‘some concerns’ of bias for this domain. Domain 3: Regards missing outcome data, outcomes for all participants were reported clearly resulting in a low risk of bias for this domain. Domain 4: All methods to measure outcomes were appropriate and consistent between the intervention and control group. However, it is possible that some participants knew that they were getting the intervention and that this may influence the way they respond to the self-report measures. This raises ‘some concerns’ of bias in this domain. Domain 5: When assessing selection of reported results, we determined that no information was provided about whether the trial was analysed in accordance with a pre-specified plan. This resulted in an overall rating of ‘some concerns’ for this domain. Across all domains, a combination of the algorithm and the authors’ judgement produced an overall rating of ‘some concerns’. REF _Ref25935541 \r \h \* MERGEFORMAT Appendix HH shows the domain assessments for each study. Figure 8 shows the number of completed RCTs in each risk category for each domain and overall (all the BEIP and GST studies are counted separately). Figure 8 Risk of bias assessment overall for RCTs, and by domains of the biases (N = 49).Note: The various reports of the BEIP and GST studies were assessed for their risk of bias separately because they differ in their reporting and in their outcome data. Completed trials with quasi-experimental designsOf the 18 QEDs, four were assessed as having serious risk of bias, eight moderate, and six were low risk of bias. The assessment used the ROBINS-I tool, which includes assessments on risk of bias in seven areas: confounding selection of participants into the study classification of interventions deviations from intended interventions missing data measurement of outcomes and selection of the reported result. Most studies were universal programs which were delivered to everyone in a given classroom or school irrespective of history of victimization. Almost all studies chose one or more schools for the intervention and similar schools to serve as controls. Some common issues across studies were (i) lack of addressing confounding from parental education, family/home environment and history of victimization (ii) inability to mask outcome assessors on awareness of the intervention being implemented (iii) the possibility that answers provided by children were affected by knowledge of the intervention received – especially if the abuser (such as a parent, guardian or peer) was privy to a child’s reported answers to post-intervention questions. The other domains assessed were generally robust across studies. We were concerned that consent procedures could be an issue given the topic but in almost all studies individual consent from parents/guardians and children was received before the intervention or administration of any study questionnaires. The only study with a major issue had consent of parents/guardians bypassed by having staff at a residential school record behavioral outcomes of children (Sullivan 1992).Consent biasBefore moving to report the results by domain, we discuss the pervasive issue of consent bias, also called recruitment bias.Most of the studies require either student or parental consent for participation. This will also be the case for RCTs, in which case they should get consent and then randomize amongst consenters. This approach gives internal validity. However, even an RCT suffers from low external validity in the likely event that the non-consenters are not similar to the consenters.Quasi-experimental studies can take the following approaches:1.Get consent and then assign to treatment and control. This is analogous to what an RCT should do but may suffer from bias if treatment and control are dissimilar which can arise because of the small number of units of assignment which is discussed below.2.Assign to treatment and control and then seek consent. This approach is more likely to yield bias, especially if there is differential consent between treatment and control, which is a common problem across social science intervention studies.3.Get consent and make the comparison group from those who consent but fail to participate. The two groups appear not to be comparable in such cases, though regression-based methods can remove any selection based on observables.4.Get consent and then ask non consenters to consent to be in the control not the programme. The two groups appear not to be comparable in such cases. Whilst regression methods can remove selection based on observables the risk of remaining bias for unobserved, and possibly unobservable, factors is high. Note that the problem is absent or negligible if consent is at or near 100% but that is hardly ever the case. The grading of consent bias depends on treatment of confounders, which are discussed below after discussion of number of units of assignment.Number of units of assignmentIn a clustered design the power of the study mainly depends on the number of units over which the treatment is assigned not the total sample size. Most of the 18 studies assign across schools, usually a small number (as low as one treatment and one control). The small number of units of assignment is likely to mean weak balance on potential confounders as school catchment areas and school environments are unlikely to be identical. This also means that many of the studies are likely under-powered.Analysis by RoB domainDomain 1. Bias due to confoundingConfounding of intervention effects occurs when one or more prognostic factors (factors that predict the outcome of interest) also predict whether an individual receives one or the other intervention of interest.Confounding is a potentially important issue in these studies as both consent bias and small sample size make it very likely that the treatment and comparison groups are dissimilar. Moreover, since many interventions are in schools, they may lack data on parents’ education level or background or socioeconomic status in general which are amongst the major confounders. For example, Kenny (2012) has data on the age, race and gender of participants and shows baseline balance on those; but we know nothing about parental characteristics or prior history of abuse which are potential confounders. A second example, Cerezo (2004) was a large-scale study that aimed to increase child maltreatment detection in a geographical region by training of frontline workers (e.g., social workers, police) and teachers in schools. Very little information was provided on characteristics of those trained or the schools involved or on how confounding might be addressed in the analysis.Nonetheless, 11 studies are rated as low risk of bias on this domain. This is partly as we took authors at their word on their matching approach. So, for example, Warden (1997) had three treatment schools and three comparison schools which they said were matched in terms of school size, social background, catchment area, religious denomination and not having had a formal safety training. Other studies randomized amongst consenters, which ensures internal validity. Domain 2. Bias in selection of participants into the studyIn ROBINS-I, selection bias is distinguished from confounding, specifically referring to ‘selection of participants into the study (or into the analysis) based on participant characteristics observed after the start of intervention’ or variations in timing based on these factors. This description does not encompass consent bias which we have discussed under confounding.Fifteen of the 18 studies rank as low risk of bias on this criterion. The exceptions are Cerezo (2004), Krazier (1991) and Neherta (2017). Cerezo (2004) implemented a training intervention sequentially in different territories and had different follow-up times for different territories. However, the overall effect estimate for all territories was reported together. In Krazier (1991) the intervention was delivered to the control group after the intervention group and the outcome compared the treatment group who had received the intervention the previous year. This is a source of a risk of bias as per item 2.4 ‘Do start of follow-up and start of intervention coincide for most participants?’. Neherta (2017) does not report how participants were selected but does say they use a non-equivalent comparison group. Domain 3. Bias in classification of interventionsThis domain concerns the intervention groups being clearly defined, recorded and allocation to the treatment group not being affected by knowledge of the outcome or likelihood of the outcome.Fifteen of the eighteen studies rank as low risk of bias on this criterion. The exceptions are Dryden (2014) in which those expected to be most likely to benefit from the intervention were recruited to the treatment group, Neherta (2017) provides insufficient information that the groups are clearly defined and Cerezo (2004) where the reason provided for the initial territory choice for intervention implementation was because it had many “troubled” areas and authors expected a higher detection rate of child maltreatment (than other territories). Domain 4. Bias due to deviations from intended interventionsThis domain is concerned with fidelity of implementation, and if such variations were consistent across groups. Thirteen studies were classified as low risk of bias and four as moderate risk of bias. Cerezo (2004) was the only study to be assessed as serious risk of bias on this domain. In this study, the intervention was sequentially implemented across different territories. Authors noted a high degree of contamination reflected in the higher baseline rate for child maltreatment detection for the last territory to receive the intervention. They surmised that this was due to media attention and movement of professionals (who had received the training intervention) across territories.Domain 5. Bias due to missing dataThis domain concerns whether data are available for all participants for all variables.The consent issue would arise here if all those invited are seen as potential participants. But we decided to deal with consent under confounding. So, this outcome captures attrition and in particular differential attrition between treatment and control. Attrition is a common problem, with half of the studies (9 out of 18) being rated as low risk of bias. The remaining nine studies are rated as moderate risk of bias. For example, in Hillenbrand-Gunn (2010) more than 20% of participants dropped out after initial assignment, and only participants with complete data were included in the analyses. It is unclear if the proportion of dropouts was comparable across groups.Domain 6. Bias in measurement of outcomes (blinding)Domain 6 refers to blinding those in the programme and the outcome assessors. It also includes possible errors in outcome measurement.We do think it likely that outcome measurement may be affected if participants know that they are in the intervention group. It is not possible to blind participants to the interventions, and the intervention may include their parents. Even if parents are not included, children are likely to mention it to their parents, and indeed are sometimes encouraged to do so. From the children’s perspective, if they are being told they should have a certain attitude or belief by the intervention, then they may well answer ‘correctly’ even if they don’t actually believe it. From the parental perspective then (i) a conservative family may tell the child ‘we don’t talk about such things’ which may discourage the correct response, or (ii) if a parent is abuser (or is condoning the abuse), they may tell the child not to reveal this and so not discuss the issue either. If the child is being abused they may also mention it to the abuser, which may also have effects. All studies but one are moderate on this domain (Warden 1997).It is generally not possible to blind the assessors to social interventions, especially if assignment is at the level of the school. Blinding was only done when assignment was within the school. We made the decisions to (1) rate as moderate not serious for failure to blind, and (2) not take account of this moderate rating in the overall risk of bias rating.Domain 7. Bias in selection of the reported resultThis domain asks whether there may be outcome reporting bias because of multiple outcomes in a domain, multiple analyses of the intervention-outcome relationship or multiple sub-groups.All studies but one are rated as low risk of bias on this criterion. Cerezo (2004) was rated as serious risk of bias on this domain. They used a post-hoc analysis to report overall results due to a high degree of contamination that was observed during implementation of the intervention.Appendix H shows the risk of bias assessment for each study, both overall and in each domain.Interventions As mentioned, we categorised interventions into: prevention, disclosure, response, and treatment. These are discussed in further detail in the sections below.Prevention: The overwhelming majority of studies assessed the efficacy of prevention interventions (n = 56 primary studies; n = 5 systematic reviews), and a smaller number included prevention approaches alongside other intervention types (n = 3 primary studies; n = 5 systematic reviews). Disclosure: No primary studies were coded as evaluations of interventions aiming to facilitate disclosure of child maltreatment. However several primary studies did report disclosure rates (see Section REF _Ref37184818 \r \h 5.6 about outcomes). Two systematic reviews searched for primary studies assessing interventions targeting disclosure (Quadara 2015, Radford 2017). Note that these reviews either did not identify primary studies, or did not identify primary studies that met our inclusion criteria for disclosure interventions.Response intervention were studied in fewer studies (n = 3 primary studies; n = 5 systematic reviews), and for all bar one systematic review (Hermenau 2017), these were reported alongside, or combined with, prevention-focused interventions. Treatment interventions fewer studies still (n = 2 primary studies; n = 2 systematic review). Figure 9 Studies by intervention type (N = 72).Note: Some systematic reviews included more than one intervention type. Several of the systematic reviews included studies that did not meet our study design criteria (e.g., they are just pre-post studies with no control group). Therefore, some intervention types were discussed in the systematic reviews, but we have not included the primary studies. Prevention 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 both interventions for any child / adult (‘universal populations’), as well as interventions targeted at specific populations. Examples of types of prevention interventions that could be included were school-based safety programmes, organisational guidelines or practices, or perpetrator targeted interventions to reduce reoffending. Systematic reviews: Ten systematic reviews (plus one update) included studies reporting on prevention interventions. These are described in REF _Ref25935600 \r \h \* MERGEFORMAT Appendix II. Two reviews were assessed as being of high quality (Zwi 2017, and update Walsh 2015), and the remaining systematic reviews assessed as low quality (Heidotting 1994, McKibbin 2017, Pitts 2015, Radford 2017, Quadara 2015, Sherr 2017, Ricardo 2011, South 2015, Topping 2009). Most systematic reviews included studies that evaluated programmes in educational settings (e.g. schools, early childhood settings) to prevent sexual abuse, either as sole focus or reported alongside studies assessing other intervention types (n = 7) (Heidotting 1994, Pitts 2015, Quadara 2015, Ricardo 2011, Radford 2017, Walsh 2015, Zwi 2007, Topping 2007). The remaining three reviews (South 2015, McKibbin 2017, Sherr 2017), included prevention interventions delivered in out-of-home care.Walsh 2015 (an update of Zwi 2007) identified 24 RCTs and QEDs evaluating school-based education interventions for preventing child sexual abuse. Interventions were delivered to children, who were provided with age-appropriate information relating to sexual abuse, sexual abuse prevention concepts, and/or taught self-protective skills. The duration of these interventions ranged from a single 45-minute session to eight 20-minute sessions on consecutive days. Most interventions were brief (less than 90 minutes total duration) with some of longer duration (lasting from 90 to 180 minutes). All programmes were delivered on school premises and during school hours, apart from one study in which the programme was delivered in the morning before school (Walsh 2015). Three reviews also synthesised the available evidence on school-based education interventions for the prevention of child sexual abuse (Heidotting 1994, Pitts 2015, Topping 2009), assessing their impact on child knowledge and protective skills. Ricardo (2011) had a slightly different focus, examining interventions for preventing boys’ and youths’ use of sexual violence in community and school settings. This review included studies with randomised or quasi-experimental designs, and reported that the vast majority (n = 55) used group education methods to deliver the intervention, often using existing curricula (Ricardo 2011). One third of included interventions were one session, 14 interventions were conducted in 2-9 sessions, and 12 were conducted in 10-15 sessions. Session durations ranged from around one hour to 4.5 hours, with most lasting approximately one hour. Interventions conducted as media or education campaigns lasting from a few weeks to several years were also identified. Most of the interventions were delivered by teachers (n = 17) (Ricardo 2011). Radford (2017) and Quadara (2015) also included studies evaluating school-based sexual abuse prevention interventions, but within the broader policy context of child sexual abuse prevention. Radford (2017) included systematic reviews, quantitative studies, and qualitative studies, and examined effective policy and interventions delivered by sectors and institutions to prevent and respond to child sexual abuse operating in jurisdictions outside, but comparable to, England and Wales (Radford 2017). Quadara (2015) included a similar range of studies. Notably, Radford (2017) highlighted that universal or primary prevention responses to child sexual abuse have focused predominantly on teaching children to protect themselves, that limited evidence exists to support the effectiveness of interventions targeting those with a sexual interest in children (which was corroborated by our search findings), and that evidence for social marketing or the use of media to promote public awareness and/or behaviour change was limited (Radford 2017). Both Quadara (2015) and Radford (2017) also noted the lack of robust evidence supporting the effectiveness of preventive interventions implemented within organisations (such as using situational crime prevention or safeguarding practices/policies). Radford (2017) noted the particular need to expand safeguarding practices to faith-based organisations and churches. Three systematic reviews (South 2015, McKibbin 2017, Sherr 2017) included prevention interventions in out-of-home care settings. Reviews by South (2015) and McKibbin (2017) were both systematic scoping reviews (i.e., reviews that use systematic review methods, but are broader in scope) and both had a focus on sexual abuse prevention. The scoping review by South (2015) included seven evaluations of training, support and/or treatment for sexually abusive and/or sexually ‘acting-out’ children in out-of-home care and their caregivers. Of the total included studies, three were effectiveness studies, only one of which included a comparison group. This systematic review reported that the most common programme aim was to promote caregivers’ understanding of sexual abuse and its consequences, including the effect of sexual abuse on children’s behaviour and needs. Another common aim was to provide caregivers with strategies for coping with, and responding to, children’s sexually abusive and/or sexual ‘acting-out’ behaviours (South 2015). Programmes provided training, treatment or support for the children themselves, involving training/treatment sessions utilising one-to-one behavioural management, socialisation, crisis intervention and supportive counselling by psychiatric aids. McKibbin (2017) identified 20 studies, including one systematic scoping review and two RCTs. The authors highlighted that the current evidence base supporting prevention responses to harmful sexual behaviour and sexual exploitation of children and young people living in residential care, is under-developed (McKibbin 2017). The review by Sherr (2017) focused on interventions to reduce violence in institutionalised care and included two studies describing caregiver training interventions that consisted of workshops and an instructional system which included training for caregivers. Primary studies: We identified 59 primary studies reporting evaluations of interventions aimed to prevent child maltreatment, including three ongoing studies. These are summarized in REF _Ref31569973 \r \h Appendix DD. Most of these studies were undertaken in the United States (n = 31), four were from Canada, three from Germany and the UK (two from Scotland and one from Northern Ireland), two each from China, The Netherlands, Spain, Turkey and Uganda, and one each from Australia, Ecuador, Indonesia, Jamaica, Malaysia, Taiwan, Tanzania, and Ireland. Most were RCTs, including: n = 3 ongoing studies; n = 39 completed studies; and n = 43 reports of completed studies, including the GST studies. Eighteen primary studies were assessed as having a high risk of bias, with the remaining 25 assessed as raising ‘some concerns’ of risk of bias. Most interventions were delivered in schools (n = 47), with fewer solely or also delivered in kindergarten/preschool/day-care settings (n = 13), two included after-school programmes, two interventions were delivered across youth service organisations (Cerezo 2004, Rheingold 2014), and one was delivered in residential care (a group home) (van Lieshout 2019). The most frequently targeted age group was middle childhood (6-11 years) (n = 38), followed by early childhood (n = 15) and early adolescence (n = 15). Fewer prevention interventions targeted children in late adolescence (15-17 years) (n = 8). Some interventions targeted more than one age group, including one study which targeted children across the range of age groups, from 0-18 years. In relation to maltreatment type, most interventions aimed to prevent sexual abuse (n = 55), either as a primary focus (n = 46), or in combination with other forms of maltreatment (n = 9) (Barron 2013, Cerezo 2004, Dake 2003, Dhooper 1995, Good School Toolkit, Edwards 2019, Krazier 1991, McElearney 2018, Wolfe 1986). Fewer focused solely on physical abuse, either in isolation (n = 4) (Baker-Henningham 2016, Dryden 2014, Nkuba 2018, Ssenyonga 2018) or in combination with other forms of maltreatment (n = 8) (Barron 2013, Cerezo 2004, Dake 2003, Dhooper 1995, Good School Toolkit, Edwards 2019, Krazier 1991, Wolfe 1986 ). No prevention interventions focused solely on neglect or emotional abuse, however these maltreatment types were the focus of six interventions which also addressed other maltreatment types (neglect – Cerezo 2004, Dake 2013, McElearney 2018; emotional – Barron 2013, Cerezo 2004, Dake 2013, Good School Toolkit, Krazier 1991). Most 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 = 53). For most (n = 42), the main intervention involved workshops or lessons, alongside written, audio-visual or other resources (e.g., films or plays, images, activity books, 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 (Daigenaught 2012, Pulido 2015); delivery of between two to eight lessons over the course of 1-2 weeks (Dake 2003, Fryer 1987, Jin 2017, Conte 1985, Cercen Erogul 2013, White 2018, Wurtele 1992); and more intense delivery with multiple lessons delivered over longer periods ranging from five to ten weeks (Taylor 2010, van Lieshout 2019, Citak Tunc 2018, Drydan 2014, Weatherley 2012). One additional study assessed a school-based rape prevention intervention consisting of three 45-minute sessions addressing social norms relating to rape (Hillenbrand-Gunn 2010). Five interventions aimed to improve the knowledge, attitudes and practices of the organisation’s staff via training – some with and some without follow-up support (Baker-Henningham 2016, Gushwa 2018, Nkuba 2018, Rheingold 2014, Ssenyonga 2018) in educational settings (n = 4) and multiple youth service organisations (n = 1). All were RCTs, two at high risk of bias (Gushwa 2018, Nkuba 2018) and one raising some concerns (Rheingold 2014). Two studies were ongoing (Baker-Henningham 2016, Ssenyonga 2018). Among these interventions, training for staff ranged from a brief one-hour session (Gushwa 2018), up to five days (Ssenyonga 2018), with inclusion of follow-up support strategies such as in-school coaching (Dryden, Baker-Henningham 2016), performance feedback and text messaging (Baker-Henningham 2016), and supervision and peer networks (Ssenyonga 2018). All staff training interventions with follow-up support were focused on reducing violent discipline and improving teacher student relationships in educational settings (including school and daycare). Some studies do not specify the type of interventions evaluated, but there appear to be no studies of the impact of recruitment practices, structures for reporting disclosures, whistle-blowing procedures.Four school-based prevention interventions were more comprehensive, 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) (McElearney 2018, Good School Toolkit studies, Ratto 1990, Baker-Henningham 2016). All were RCTs, two assessed at high risk of bias (Ratto 1990, Devries 2015, 2017, 2018, Knight 2018, Merril 2018) and two were ongoing (Baker-Henningham 2016, McElearney 2018). For example, the Good School Toolkit targets multiple levels within the schools including head teachers, administration, class-room teachers, and students with multilayered training, processes, and school-led activities for each level (see Box 1).Two prevention interventions involved online or web-based delivery. Both interventions targeted staff in institutional settings and were RCTs. One raised some concerns of risk of bias (Rheingold 2014) and one was rated as having a high risk of bias (Gushwa 2018). Gushwa and colleagues described a one-hour interactive online course targeting teachers in schools inclusive of kindergarten to year 12 (where learners could choose to take the course in one session or in separate 20-minute segments). The course addressed signs and symptoms of child sexual assault, grooming, sexual misconduct behaviours, and reporting responsibilities and requirements (Gushwa 2018). The second study conducted by Rheingold and colleagues (2014) included delivery of a 2.5 hour interactive web-based training session (with in-person training as a comparison) to staff from youth service organisations (including day care centres, church organisations, schools) focused on preventing, recognising, and responding to child sexual assault (Rheingold 2014). 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, organisational guidelines). Systematic reviews: One low quality largescale rapid review included both primary studies and systematic reviews relating to child sexual abuse, and included 21 studies reporting on interventions implemented at the agency, organisation or community level that may support the disclosure, identification and reporting of child sexual abuse (Radford 2017). The studies reported on a range of interventions, including: proactive outreach and engagement with minority communities; training those who work with children to be alert to the signs of sexual abuse and exploitation; co-located multi-disciplinary investigation and response models; protocols and best practice approaches for investigative interviewing; and, improved assessment methods and training for professionals. Radford (2017) noted that research on improving disclosure had been largely focused on children and young people who are victims, and that research on improving the disclosure of those who abuse is a relatively recent development. A second systematic review (Quadara 2015), also broad in scope, included a narrative synthesis of both primary and systematic review studies. The review mentions both mandatory reporting and 'Working With Children Checks’, however the authors note that there have been few tests of the effectiveness of these schemes. Primary studies: We did not identify any primary studies that assessed interventions specifically aimed at facilitating disclosure. However, several prevention interventions included components that aimed to provide children with knowledge and/or skills to disclose maltreatment to a trusted adult, and nine of these studies included participant rates of disclosure (see Outcomes). Response Response interventions were defined as any intervention that aimed to improve institutional responses to child maltreatment in relation to each of the target populations. Response interventions included enhancing safeguarding practices, legal and policy interventions, supporting the victim and/or family, working with child protection agencies, and providing training and crisis support to staff within organisations. Systematic reviews: We found five low quality systematic reviews that included studies examining institutional response interventions (Hermenau 2017, Radford 2017, Quadara 2015, Sherr 2017, South 2015). Only one of these reviews focussed solely on interventions relating to institutional responses to child maltreatment (Hermenau 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, 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 review included 24 studies; 15 with experimental and control groups, three of which were RCTs. (However, those RCTs did not meet the criteria for inclusion in this EGM, e.g., the maltreatment did not occur in an institution.) Fifteen of its studies focused on interventions involving staff training and capacity building, nine studies assessed structural changes implemented within the institution, and one study assessed both (Hermenau 2017). The authors concluded that caregiver trainings, structural changes, and enriched caregiving environments in institutional care environments can have beneficial effects on the child’s emotional, social, and cognitive development. The four remaining reviews included studies assessing response interventions alongside other intervention types (Radford 2017, Quadara 2015, Sherr 2017, South 2015). The review by Sherr (2017) identified three studies that reported on interventions aiming to reduce violence within institutionalised care. Two had a primary focus on staff training, and one compared institutional care with foster care. A scoping review by South (2015) identified 16 studies in order to identify practice elements that aim to prevent child sexual abuse in out-of-home care. Seven studies evaluated training, support and/or treatment for sexually abusive and/or ‘acting-out’ children in out-of-home care, and nine retrospective case studies and surveys attempted to identify practices that contributed to, or prevented, child sexual abuse in out-of-home care. Two broad reviews (Radford 2017, Quadara 2015) focused on child sexual abuse, and included studies on interventions aimed at improving institutional responses to child sexual abuse. Radford (2017) highlighted the lack of evidence assessing the effectiveness of response interventions within institutions, including religious organisations and institutional care (Radford 2017). While Quadara (2015) included some discussion on response interventions, including institutional policies for identifying and reporting maltreatment, no studies are included that assess the effectiveness of response interventions.Primary studies: Three primary studies evaluated the effectiveness of response interventions. Cerezo (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 in the territory, and professionals from all schools in the territory. An RCT reported by Rheingold (2014) compared a web-based and in-person training versions of an intervention with a dual focus on preventing and responding to child sexual assault among children (ranging from 0-18 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 program included education about child sexual assault, ways to minimise child sexual assault, how to recognise the signs and how to respond appropriately when a child discloses (Rheingold 2014). Czerwinski (2018) report on a quasi-experimental evaluation from Germany which included eight intervention and four control schools. The intervention involved training teachers in two workshops to deliver educational child sexual abuse prevention sessions to Grade 3 children at primary school (aged 8 years). In addition to increasing the knowledge and protective skills of children, the intervention also aimed to raise awareness among school personnel about sexual abuse to enable them to identify inappropriate situations and react adequately (Czerwinski 2018). Treatment 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 institutional perpetrators of child abuse. The Romania studies are included here, because foster care was provided as treatment for young children who spent their early lives in institutionalised care.Systematic reviews: The systematic 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 United Kingdom. The review by Quadara (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. Primary studies: Two primary studies assessed the effectiveness of treatment interventions, including the six reports describing the Bucharest Early Intervention Project (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). Each of the six reports was assessed as raising some concerns relating to risk of bias. A range of outcomes was reported for children aged between 6-32 months, with follow-up assessments reported across the ages of 42 months (Smyke 2010) and 54 months (Johnson 2010), and again between age 8 and 16 years (Troller-Renfree 2015, Humphreys 2015, Bick 2015, Wade 2018). Sullivan (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 two hours 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 1992). Alignment with INSPIRE strategies363645752424600We coded the interventions described in the included primary studies for their alignment with the WHO INSPIRE framework. This framework identifies seven evidence‐based strategies to prevent violence against children and adolescents across the health, social welfare, education, finance, and justice. The strategies are intended to reinforce each other and work best in combination. They include (spelling INSPIRE): implementation and enforcement of laws; norms and values; safe environments; parent and caregiver support; income and economic strengthening; response and support services; and education and life skills (WHO‐INSPIRE, 2016). The interventions described in the included in primary studies aligned with three of these seven INSPIRE strategies (shown in REF _Ref31569945 \r \h Appendix JJ), which are: Education and life skills: This strategy aims to increase children’s access to more effective, gender-equitable education, social-emotional learning and life-skills training, and ensure that school environments are safe. Interventions relevant to this category can include establishing a safe and enabling school environment, improving children’s knowledge about sexual abuse and how to protect themselves against it, adolescent intimate partner violence prevention programmes, and life and social skills training programmes. We found primary studies (n = 57) of interventions focused on education and life skills either as a primary focus (n = 54) or in combination with other strategies (n = 3).Norms and values: This strategy aims to strengthen norms and values that support non-violent, respectful, nurturing, positive and gender equitable relationships for all children and adolescents. Interventions relevant to this category include community mobilisation programmes, bystander interventions, and small group programmes that challenge harmful gender and social norms. We found four studies evaluating interventions relating to norms and values. This was the primary approach of one intervention (n = 1), and was used in combination with other strategies for the remaining interventions (n = 3). Response and support services: This strategy aims to improve access to good quality health, social welfare and criminal justice support services for all children who need them – including for reporting violence – to reduce the long-term impact of violence. Interventions in this category can include counselling and therapeutic approaches, screening combined with interventions, treatment programmes for juvenile offenders in the criminal justice system, and foster care interventions involving social welfare services.We found three studies assessing interventions focused on response and support services (n = 3).Outcomes This section describes outcomes reported across the included studies. Figure 10 shows the number of primary studies and systematic reviews reporting outcome sub-categories. Figure 10 Number of primary studies and systematic reviews reporting each of the outcome sub-categories (n = 70 primary studies; n = 12 systematic reviews: all the BEIP and GST studies are counted here separately, as are the two SRs of which one is an update of the other).Note: In this graph, each report of the BEIP and Good School Toolkit studies have been presented separately because they reported on different outcomes. Studies report more than a single outcome – these counts combined should add to substantially more than 72.Institutional safeguarding practice Systematic reviews: We found two recently-published (2017) systematic reviews of interventions delivered in out-of-home care settings. They examined outcomes relating to: institutional safeguarding practice (Hermaneau 2017, McKibbin 2017); quality of caregiving and quality of the institutionalised environment (Hermaneau 2017); and staff recognition of children’s problematic sexual behaviour (McKibbin 2017). Primary studies: We found seven studies reporting outcomes related to institutional safeguarding practice: four focused on operational practice (Cerezo 2004, Gushwa 2018, del Campo Sanchez 2006, Rhiengold 2014) and three on institutional culture (McElearney 2018, Merril 2018, Nkuba 2018). Operational practice included both prevention and response interventions targeting staff in schools (del Campo Sanchez 2006, Gushwa 2018) and youth service agencies and organisations (Cerezo 2004, Rheingold 2014). An RCT undertaken by Gushwa (2018), with a high risk of bias, assessed a one-hour online training programme focused on debunking misconceptions and fears/biases associated with responding to, and reporting, suspected abuse. This study reported K-12 teachers’ identification of boundary-violating behaviours, as well as teacher suspected or child disclosed cases of child sexual assault (Gushwa 2018). A second RCT, with some concerns relating to risk of bias, offered a pre-training session to both teachers and parents that aimed to provide them with knowledge about sexual abuse and prepare them for interacting with students undergoing a school-based sexual abuse prevention intervention (del Campo Sanchez 2006). They reported an increase in the conversations between teachers and students relating to sexual abuse (del Campo Sanchez 2006). Rheingold (2014) reported on a RCT, assessed as having some concerns for risk of bias, that included a self-report measure of child sexual assault prevention behaviours by staff in youth services organisations (i.e., teachers, childcare personnel, clergy) after receiving web-based or in-person training on preventing and responding to child sexual assault. Cerezo (2004) used a quasi-experimental design to assess whether professional training and support offered to frontline health and social services agencies and school professionals increased the detection of cases of child maltreatment across a single territory in Spain. Three primary studies reported outcomes related to institutional culture: one ongoing study (McElearney 2018), and two completed RCTs (Merril 2018, Nkuba 2018), both assessed as having a high risk of bias. The ongoing study (protocol) will report outcomes related to teachers’: willingness and perceived confidence in their own skills and ability to manage sensitive issues; attitudes toward teaching and learning about sensitive issues and sexual health education safe messages; and teacher perceptions of their school culture indicating how frequently various practices occur (McElearney 2018). The whole school prevention intervention aims to teach children how to keep safe from all forms of maltreatment carried out online or using digital technology, abuse perpetrated by other children, and bullying. It involves training and support for teachers and whole school staff and parent directed homework activities (McElearney 2018).In an assessment of the Good School Kit, Merril (2018) reported outcomes relating to school operational culture, including relational (e.g. student emotional support from teachers), psychological (e.g. student/staff identification with school) and structural (e.g. Student/staff perceived involvement with school operations) measures, as well as student and staff normative beliefs. Nkuba (2018) reported on attitudes to physical and emotional violence towards children in a study evaluating training delivered to teachers in secondary schools in Tanzania aimed at preventing violent discipline and at improving teacher-student relationships (Nkuba 2018). Adult institutional care provider Adult institutional care providers included any person within an organisation who could reasonably have a duty of care to children. This included, but was not limited to, teachers, sports coaches, people responsible for pastoral care, and residential/institutional care workers.Primary studies: We found two ongoing RCTs (McElearney 2018, Ssenyonga 2018), two completed RCTs (Nkuba 2018, high risk of bias; Rheingold 2014, some concerns), and three quasi-experimental studies (Kolko 1987, Kolko 1989, MacIntyre 1999) that reported, or intend to report, outcomes relating to adult institutional care providers’ knowledge, attitudes and practices. All seven studies were focused on prevention and/or a combination of prevention and response interventions delivered in schools or youth serving organisations. Knowledge and attitude outcomes included confidence teaching the programmes, attitudes towards maltreatment (e.g. child sexual abuse, emotional violence, physical violence, violent discipline) and knowledge related to child sexual abuse, as well as perceived change in the teacher-student relations. (These studies mostly used self-reports from children to assess violence towards them, e.g. perceived relationship with students, perceived relationship with parents, perceived relationship with the organisation, normative beliefs relating to violence against students, etc.).Teacher practice outcomes related to institutional self-reported child sexual abuse preventative behaviours, teachers’ self-reported use of violence (emotional and physical violence) and violent discipline strategies in school (Nkhuba 2018 & Ssenyonga 2018).Child maltreatment disclosureSystematic reviews: We found three systematic reviews examining interventions’ impact on disclosure-related outcomes. A high quality review by Walsh (2015; an update of Zwi 2007) included school-based sexual abuse programmes, and reported on disclosure of sexual abuse by child or adolescent participants during or after undertaking a program. Pitts (2015) included pre-school child sexual abuse prevention programme, and included reports of abuse. Radford (2017) also included school-based sexual abuse prevention interventions, and reported on disclosure to peers, adults, institutions and services, as well as disclosure of non-recent abuse (Radford 2017). Primary studies: Six RCTs, four with some concerns relating to risk of bias (Barron 2013, del Campo Sanchez 2006, Hazzard 1991, Oldfield 1996), and two with a high risk of bias (Daigneault 2015, Devries 2015), and three QEDs (Czerwinski 2018, Kolko 1987, Kolko 1989) reported outcomes relating to the disclosure of child maltreatment. 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 evaluation (Barron 2013, del Campo Sanchez 2006, Hazzard 1991, Kolko 1987, Kolko 1989, Oldfield 1996; child reported courses of action to hypothetical scenarios, including possible disclosure options (Czerwinski 2018); youth recognition of sexual assault and hypothetical disclosure and response to a disclosure of sexual assault (Daigneault 2015); students’ self-reports of physical violence from school sta? (assessed in a follow-up survey) (Devries 2015).Child maltreatment occurrence / reoccurrence Systematic reviews: We found three recent low quality systematic reviews including interventions delivered in residential care settings that reported on child maltreatment occurrence / reoccurrence (Hermenau 2017, South 2015, Sherr 2017). Outcomes examined included: exposure to maltreatment (physical, emotional) (Sherr), sexual abuse (South), physical violence (Sherr 2017, Hermenau 2017), reported levels of abuse (Sherr 2017), and documented abuse in official records (Sherr 2017). Primary studies: We found 13 primary studies. Eight completed studies, all with high risk of bias (Good School Toolkit studies, Nkuba 2018, Taylor 2010) and three of the protocols in the EGM (Baker-Henningham 2016, McElearney 2018, Ssenyonga 2018) reported/will report outcomes related to the incidence of child maltreatment. Eleven studies evaluated interventions focused on preventing maltreatment in educational settings (e.g. schools, day-care), with most addressing physical violence. Outcome measures included: student self-reported violence perpetrated by staff (Good School Kit studies); teacher and student reports of emotional and physical violence (Nkuba 2018); and, student-reported exposure to violence, as well as teacher-reported use of violent disciplinary methods (Ssenyonga 2018). A further two QED studies used a student questionnaire to determine the frequency of abusive experiences reported (Kolko 1987, Kolko 1989).Child wellbeing We coded child wellbeing outcomes into five sub- categories: cognitive functioning; health and development; mental health; social functioning; and knowledge and awareness. Systematic reviews: One low quality systematic review that assessed interventions delivered in residential care, reported outcomes relating to child cognitive functioning. The reported outcomes included child mental development, language development, and intelligence (Hermenau 2017). Six systematic reviews included studies that assessed an interventions’ impact on outcomes relating to the child mental health. One high quality systematic review (Walsh 2015) evaluated whether participation in school-based sexual abuse programmes adversely affected child anxiety or fear. Likewise, two low quality reviews evaluated whether children displayed increased levels of fear or anxiety (Pitts 2015, Topping 2009), self-esteem or aggression (Topping 2009) after participation in sexual abuse prevention interventions in educational settings. Another low quality review by Sherr (2017) included evaluations of interventions to ameliorate abuse in institutions and reported child outcomes relating to depression, externalising and internalising symptoms and suicidality. A further low quality review that included studies evaluating interventions aimed at addressing physical and emotional abuse and neglect within institutional care, reported child outcomes relating to depression, internalising and externalising symptoms, anxiety and post-traumatic stress symptom (Hermenau 2017). Hermenau (2017) was the only systematic review that reported on outcomes related to child physical development and health, including psychomotor development specifically, as well as general development (including cognitive, language, social-emotional development) (Hermenau 2017).Again, Hermenau 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 (Hermenau 2017). Nine systematic reviews reported whether studies assessed an interventions’ impact on child knowledge and awareness. Walsh (2015) evaluated whether school-based sexual abuse programmes increased knowledge of sexual abuse or sexual abuse prevention concepts, protective behaviours, retention of protective behaviours over time, and retention of knowledge over time. Six low quality reviews also examined sexual abuse prevention interventions in educational settings and also reported outcomes relating to knowledge of child sexual abuse, as well as protective behaviours (Pitts 2015, Radford 2017, Heidotting 1994, Quadara 2015, Topping 2009). The review by Sherr (2017) reported outcomes relating to risk awareness and behaviour of children in institutional care. One low quality systematic review examined sexual abuse prevention interventions delivered in residential care, and reported outcomes on child knowledge of normal sexual development and safe sexual relationships (McKibbin 2017). A low quality review by Ricardo (2011) included studies assessing interventions aimed at preventing boys’ and youths’ use of sexual violence in community and school settings, and reported outcomes relating to attitudes toward violence, acceptance of rape myths and bystander attitudes (Ricardo 2011).Primary studies: Across the child wellbeing outcome sub-categories, more primary studies reported outcomes relating to knowledge and awareness (n = 51) than the number of primary studies reporting mental health outcomes (n = 23), outcomes relating to child cognitive functioning (n = 5), social functioning (n = 6) or physical health and development (n = 2). All 51 studies reporting outcomes relating to child knowledge and awareness evaluated curriculum-based prevention interventions delivered in educational settings, with most focussing on child sexual abuse. Thirty-three were completed RCTs, approximately a third of which were at a high risk of bias, with the remainder assessed as raising some concerns about risk of bias. The most highly represented outcomes across these studies were:Knowledge about child sexual maltreatment, prevention and protective strategies. Multiple outcome measures were used to assess varying components of knowledge (e.g., knowledge about child sexual maltreatment, ability to differentiate between ok and not okay touches, ability to identify inappropriate scenarios, knowledge about how to act when confronted with inappropriate scenarios, knowledge about how and who to disclose to) Protective skills. Multiple outcomes measures were used to assess whether children acquired protective skills as a result of the intervention. These were commonly assessed using hypothetical scenarios, where participants responded to a written (e.g. what-if-situations-test) or other (e.g. roleplay) scenario. Fewer studies assessed changes in participant knowledge and awareness about other child maltreatment types, such as physical or emotional abuse (n = 7) (Dake 2003, Dryden 2014, Edward 2019, Barron 2013, Dhooper 1995, Krazier 1991, Wolfe 1986).Twenty-three studies reported outcomes relating to child mental health. Mental health outcomes were measured in three studies evaluating treatment interventions (2 RCTs at high risk of bias; 1 QED) (Humphreys 2015, Troller-Renfree 2010, Sullivan 1992), and 20 studies evaluating preventive interventions (including, two about the Good School Kit). Of the 20 prevention interventions, three were on-going RCTs (Baker-Henningham 2016, Ssenyonga 2018 & McElearney 2018), twelve were completed RCTs (four with a high risk of bias: Devries 2015, Knight 2018, Ratto 1990, Van Lieshout 2019), and five were quasi-experimental studies. Collectively, the studies that evaluated prevention interventions reported outcomes relating to internalising and externalising behaviours, including anxiety, subjective wellbeing, self-esteem and emotional intelligence. These studies focused primarily on sexual and physical maltreatment and all but one was delivered in educational settings (van Lieshout 2019; delivered in a group home for adolescent boys). The three studies evaluating treatment interventions reported outcomes relating to internalising and externalising behaviours among abused children attending residential school for the deaf after receiving psychotherapy (Sullivan 1992), and prosocial behaviour, internalising and externalising behaviours in two studies describing outcomes of the BEIP (Humphreys 2015, Troller-Renfree 2010). Five primary studies reported outcomes related to cognitive functioning, including two RCTs assessing prevention interventions and three publications from the BEIP RCT. The Devries (2015) RCT, assessed as having a high risk of bias, evaluated the Good School Toolkit intervention in Ugandan primary schools, and reported scores of educational performance including word recognition, word reading and reading comprehension in both English and Luganda, silly sentences tests, spelling tests in English and written numeracy tests. This was the sole primary study to report on educational outcomes. Three studies reported cognitive functioning outcomes of participants in the BEIP study, and all three have some concerns relating to risk of bias. These studies reported on intellectual levels over time using the baseline developmental quotient, developmental status using the Bayley Scale, as well as children's ability to regulate behaviour and emotion by measuring memory and executive functioning (Johnson 2010, Smyke 2010, Wade 2018). The ongoing Baker-Henningham (2016) RCT plans to assess outcomes for school attendance obtained from school records. Four RCTs (Daigneault 2013, del Campo Sanchez 2006, Smyke 2010, van Lieshout 2019; all some concerns relating to risk of bias) and 2 QEDs (Hebert 2001, Taal 1997) reported outcomes relating to social functioning. Two RCTs assessed outcomes relating to social competencies and skills, including participants’ confidence in others, respect towards one another, empathy and social norms (Daighneault 2013, van Lieshout 2019). Van Lieshout (2019) evaluated an education programme to promote respectful (sexual) relationships and to prevent sexual harassment which was delivered to boys aged 12 to 18 residing in residential care, reporting outcomes relating specifically to determinants of sexual harassment such as communication, self-control, boundaries, dating violence, adverse sexual beliefs, and rape attitude. The two remaining RCTs assessed changes in outcomes related to attachment and caregiver relationships (del Campo Sanchez 2006, Smyke 2010). Taal (1997) reported on social connections and relationships (e.g., relationships with classmates, teachers), and Hebert (2001) reported adaptive behaviours, including positive and negative behavioural responses to participation in a sexual abuse prevention program. Two BEIP RCT studies, with some concerns for risk of bias, reported on physical health and development (Bick 2015, Johnson 2010). Specific outcomes reported included measures of brain white matter integrity (Bick 2015) and measures of auxology (i.e., human physical growth incorporating length and height, occipital frontal circumference, weight) (Johnson 2010).Adult perpetrator and child / youth offender Systematic reviews: No systematic review reported outcomes for adult perpetrators or child/youth offenders that specifically related to child maltreatment that occurred in an institutional setting.Primary studies: We found two studies reporting outcomes relating to perpetrators. Only one targeted adults: Baker-Henningham (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 in Jamaica. (To be clear, there were studies targeting adult perpetrators, but where the type of perpetrator and maltreatment was not specified, meaning that we couldn’t tell if there were participants who perpetrated the abuse in an institutional setting. These studies were excluded, but could be important sources for developing programmes targeted at institutional abuse.)The other targeted youth offenders: Edwards (2019) evaluated a bystander-focused interpersonal violence prevention programme with high school students in the United States. The study was an RCT with high risk of bias, and reported youth offender outcomes including sexual harassment, sexual assault and stalking perpetration among high school students as reported in a study evaluating (Edwards 2019). Parent or caregiver knowledge or attitudesPrimary studies: We identified four studies reporting outcomes relating to parent or caregiver knowledge or attitudes; two RCTs (high risk of bias: Merril 2018, Wurtele 1992), one ongoing RCT (McElearney 2018), and one QED study (Kolko 1987). Wurtele (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. Merril (2018) assessed changes in parental normative beliefs relating to school based physical discipline when assessing the Good School Toolkit programme (Merril 2018). In their evaluation of a multi-component ‘whole-school’ programme designed to teach 4-11 year old how to keep safe from all forms of maltreatment, McElearney (2018) will assess parents' confidence in talking to their children about keeping safe. Kolko (1987) reported changes to parental knowledge about sexual abuse when evaluating a school-based sexual abuse prevention intervention. Other outcomes: implementation and adverse outcomesImplementation Of the primary studies, 23 reported outcomes relating to the implementation of the intervention, including one ongoing study (Ssenyonga 2018). Outcomes representing feasibility (i.e., the utility, fit or practicality of the implemented program), 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 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 2017, Knight 2018, Nkuba 2018, Ssenyonga 2018, White 2018), feasibility (Nkuba 2018, Ssenyonga 2018) and adoption (Devries 2017, Knight 2018) were each reported by two studies. Almost all of the studies reporting on fidelity used either checklists or questionnaires to assess how closely the implemented program adhered to the intended intervention, and almost all were evaluations of an intervention delivered to children, teachers or parents in educational settings (excepting Rhiengold 2014, delivered across youth service organisations). These assessments varied in their comprehensiveness, but generally included how much core content was covered and/or which activities had been completed in the session/s or workshop/s. For some, additional information was captured, such as the timeframe or mode of delivery, or whether any other modifications were made to the intervention’s delivery. Of the 13 studies reporting on intervention fidelity; all or a proportion of the fidelity checklists/questionnaires were completed by independent assessors (e.g. research assistant/s, volunteer/s) in eight studies (Baker 2012, Daigenault 2012, Daigenault 2015, Hebert 2001, Jin 2017, Kolko 1989, Pulido 2015, Rhiengold 2014), and all or a proportion of the fidelity checklists/questionnaires were completed by intervention facilitators (e.g. teachers, counsellors) in seven of the studies (Barron 2013, Daigenault 2012, Kenny 2012, Pulido 2015, Warden 1997, White 2018, Zhang 2014). Most studies assessing the acceptability of an intervention used a questionnaire, and were evaluations of an intervention delivered to children, teachers or parents in educational settings. Questionnaires were completed in writing or face-to-face interviews, and generally assessed satisfaction and/or requested feedback on content of an intervention. These were completed by children (Barron 2013, del Campo 2006, Grendel 1991, Hebert 2001, Jin 2017, Krazier 1991, MacIntyre 1999, Wurtele 1992), teachers/program facilitators (Barron 2013, Jin 2017, Krazier 1991, MacIntyre 1999, Nkuba 2018, Ssenyonga 2018, Wurtele 1992), and/or parents (Grendel 1991, Kolko 1987, MacIntyre 1999, White 2018, Wurtele 1992). Five studies reported several components of implementation. An RCT by Nkuba (2019), evaluating the Interaction Competencies with Children for Teachers (ICC-T) programme to prevent violent discipline in schools in Tanzania, used multiple measures to report an overall assessment of feasibility. Feasibility was assessed using teacher responses to survey items, and related to the demand for the programme (i.e. attitudes towards the use of violence to discipline students), the applicability of the program to teachers (e.g. relevance of the workshop content to the daily work), and acceptability (e.g., satisfaction, the topics of the workshop related to the daily work). Aspects of intervention penetration were also reported, including self-reports of teachers’ integration of the core intervention strategies at follow-up (Nkuba 2019). The ongoing study by Ssenyonga 2018), evaluating the same intervention in Uganda, will use similar methods to assess implementation as those reported by Nkuba (2018). A process evaluation of the Good School Kit included measures relating to the adoption of the programme, fidelity and penetration (reported in Devries 2017, Knight 2018). Adoption of the school kit elements by schools was assessed independently by a set of questions, answered once a term by a teacher representative, designed to determine the presence of the intervention structures and elements implemented at the school (Knight 2018). Other process measures captured aspects of the intervention’s fidelity and penetration, including: routine data collection relating to program delivery in schools; school-led monitoring of the activities planned and completed across a school term; and, completed surveys to determine the exposure of both teachers and students to components of the intervention. Outcomes related to adoption, fidelity and acceptability were reported by White (2018), in a study conducted in Australia evaluating a child sexual assault prevention programme delivered in primary schools. Implementation measures included a record of child attendance at each session, a facilitator checklist recording whether core content and activities were undertaken, and a parent/caregiver questionnaire assessing satisfaction with their child’s involvement in programme (White 2018). Adverse outcomesThe aim of an EGM is not 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). Some studies included outcomes to capture adverse effects. These included anxiety, fear and touch aversion, which were commonly used to assess whether education-based prevention programmes targeting the sexual abuse of children had a negative effect on their well-being. For the most part, these programmes did not appear to adversely impact children. A single study (Taylor 2010) reported that an intervention addressing gender violence and sexual harassment, delivered to sixth and seventh graders, reduced peer violence victimization and perpetration, but may have increased dating violence perpetration, or the reporting of it. Conclusion and next stepsThe project to produce this EGM was born of a desire to enable work on child protection to be more effective by making it based on sound evidence about what works. A first step was to find out what such evidence exists. This EGM shows that. It finds that the rigorous, causal evidence is scarce, much of it may be biased, and it is very concentrated: one cell on our map has 51 studies, whereas many have three or fewer, and many have none at all. Our next steps are that this EGM and report will go through peer-review with The Campbell Collaboration, and be published (as will a summary) in order to be findable and usable by other funders, policy-makers and practitioners. We will proactively share them with others. We will produce other outputs, such as a ‘guidebook’ which explains what the evidence says. All of this will inform the work of the foundation which commissioned it – and we hope that of others too. We strongly recommend that it informs future research in this area, by ensuring that those scarce resources break new ground and do not duplicate what is already adequately understood. There is much to do. MethodEvidence gap maps: definition and purposeAn EGM provides a systematic visual presentation of the available relevant evidence for a particular sector or issue (Snilstveit et al., 2013). They have a broad thematic scope (broader than a typical systematic review) and cover a wide range of interventions and outcomes (Saran & White 2018). Therefore, unlike effectiveness systematic reviews, EGMs do not synthesise what the evidence says, but rather locate and categorise the existing evidence in a wide area. That is, they aim to describe the nature, characteristics and volume of research (Saran & White 2018) by consolidating the studies in a single location. The studies included in an EGM are identified through a comprehensive and systematic, pre‐specified (often published) search protocol, similar to a rigorous systematic review search strategy. A typical map (of which ours is an example) is a matrix of intervention categories (rows) and outcome domain (columns). The map is also often accompanied by a descriptive report to summarise, at a high level, the amount, substance, and quality of evidence for later use by stakeholders, such as researchers, research commissioners, policy makers, and practitioners (Saran & White 2018). EGMs have proven a helpful tool to: strategically inform research agendas (including those related to policy and practice); plan systematic reviews; facilitate the adoption of evidence‐based policy and practice decision-making by identifying areas with strong, weak or non-existent evidence; apprise funders of the alignment between grant applications and areas of need, and to inform a strategic approach for commissioning and conducting research (Saran & White 2018; Littell, 2018).Conceptual framework and scopeThe scope of the EGM was guided by the overarching research question that asks: “What is the prevalence of evidence on the effectiveness of interventions that, within institutional settings, aim to: prevent the occurrence of maltreatment of children (including preventing peer-to-peer abuse);prevent the recurrence of maltreatment of children (preventing offenders from re-offending); reduce harm to the health and wellbeing of children exposed to child maltreatment;enhance the disclosure of child maltreatment; andimprove organisational practice and standards for addressing issues related to child maltreatment”.The scope of the EGM relates specifically to interventions aiming to prevent, facilitate disclosure of, respond to, or treat the consequences of, maltreatment occurring in an institutional setting. The EGM is represented on a grid: rows show categories relating to the main focus of an intervention, including prevention, disclosure, response and treatment; and, columns show the outcome categories of interest to this EGM, including child, perpetrator and institutional outcomes. This framework was developed in collaboration with subject matter experts representing 16 relevant organisations concerned with safeguarding practice and research who provided input into how relevant aspects of child maltreatment within institutional settings should best be captured in the EGM. The dimensions of the EGM are outlined in greater detail below.Child maltreatment in institutional settings is a complex problem consisting of four potential factors influencing the occurrence of child maltreatment (Royal Commission into Institutional Responses to Child Sexual Abuse, 2017):?Perpetrator:Adults abusing childrenChildren abusing other children?Institutions enabling child maltreatment?Child characteristics enhancing their vulnerability to maltreatment.In targeting child maltreatment, interventions’ goals may relate to:?Preventing occurrence and reoccurrence of child maltreatment. This may be based on either: Universal services available to an entire target population and aimed at promoting positive behaviours and functioning and/or at decreasing risk factors and the likelihood of problems and challenges in a person’s life.Targeted services available to selected members of a target population who are at risk of developing or experiencing particular problems – with the intervention aimed at reducing these risks.Disclosing child maltreatment. A key factor in stopping, responding to and treating the consequences of child maltreatment is its disclosure – especially in cases of child sexual abuse (Paine & Hansen, 2002; Lemaigre, Taylor & Gittoes, 2017). Recent inquiries have documented the substantial barriers existing in institutional settings to facilitate such disclosure (Australian Royal Commission into Institutional Responses to Child Sexual Abuse, 2017; Lemaigre, Taylor & Gittoes, 2017), pointing to the importance of including disclosure interventions in this EGM.Responding to the occurrence of child maltreatment. Institutions have strong legal and ethical obligations to respond appropriately when child maltreatment has been detected or disclosed. This includes reporting the maltreatment, supporting the victim and/or family, working with child protection agencies, and providing training and crisis support to staff. Treating the consequences of child maltreatment. Providing services or referring children and families to agencies that provide therapeutic care for one or more of the many known problems associated with experiencing child abuse and neglect (e.g., post-traumatic stress, difficulties forming and maintaining positive relationships).Based on this understanding, the EGM includes studies examining interventions in the above four categories. These interventions could range from those focused on an individual (e.g. therapy) to system-wide interventions (e.g. mandatory reporting). They could target actual/potential perpetrators (adult or child), children (potential victims), or the institutional itself. Stakeholder engagementThe development of this EGM has been led by a team inclusive of representatives from the funder Porticus (Jane Leek, Regional Director, and Dr Joachim Krapels, Senior Analyst), Giving Evidence (Caroline Fiennes, Director), The Centre for Evidence and Implementation (Dr Robyn Mildon, Bianca Albers and Dr Meghan Finch), and Monash University (Professor Aron Shlonsky and Dr Rebecca Featherston). All stakeholder representatives are included as co-authors on the published EGM Campbell Collaboration Protocol (Albers et al., 2018). In addition, subject matter experts representing 16 relevant organisations concerned with safeguarding practice and research were invited to an information and engagement teleconference to seek input into how relevant aspects of child maltreatment within institutional settings should best be captured in the EGM. This group were also invited to share studies, both peer-reviewed and grey, to be considered for inclusion in the EGM and will be invited to disseminate this final EGM through relevant organisations, institutions and networks around the world. The members of this group are listed in REF _Ref25922746 \r \h A.11.DimensionsA.4.1 InterventionsThis EGM focuses on the four intervention categories (prevention, disclosure, response and treatment) and the three primary targets (the child (victim), the perpetrator and the institution/organisation). The following table shows each intervention category with example interventions for each related primary target. Intervention categoryTargetExamplesPreventionVictimUniversal/primary interventions (e.g., educational interventions used in school settings, maternal-child health screening)Tertiary interventions (e.g., advocacy, social supports)PerpetratorUniversal/primary interventions (e.g., traditional or social media campaigns)Targeted therapeutic interventions (e.g., CBT group therapy, education interventions)Tertiary interventions (e.g., criminal justice, pre-employment screening/criminal background checks)Organisational contextStaff training/professional development (e.g., education programs)Organisational guidelines and/or practicesLegal/policy interventions aimed at introducing new procedures for institutions to follow (e.g., response framework) Particular institutions aimed at enhancing safeguarding practice and outcomes in institutional settings (e.g., Child Advocacy Centres)DisclosureVictimUniversal/primary interventions (e.g., Traditional or social media campaigns, abuse helplines)Targeted therapeutic interventions (e.g., play therapy)PerpetratorLegal interventions (e.g., mandatory reporting)Organisational contextStaff training/professional developmentOrganisational guidelines and/or practices (e.g., guidelines for reporting abuse)Legal/policy interventions aimed at introducing new procedures for institutions to follow (e.g., response framework)Particular institutions aimed at enhancing safeguarding practice and outcomes in institutional settings (e.g., Child Advocacy Centres)ResponseVictimTertiary interventions (e.g., Legal avenues for criminal redress, advocacy, social supports)PerpetratorTertiary interventions (e.g., criminal justice, arrest, removal of credentials)Organisational contextStaff training/professional developmentOrganisational guidelines and/or practices (e.g., response framework, perpetrator accountability)Legal/policy interventions aimed at introducing new procedures for institutions to followParticular institutions aimed at enhancing safeguarding practice and outcomes in institutional settings (e.g., Child Advocacy Centres)TreatmentVictimTargeted therapeutic interventions (e.g., trauma-focussed interventions)PerpetratorTargeted therapeutic interventions (e.g., CBT group therapy, behaviour change programs, narrative therapy)Organisational contextStaff support (e.g., staff counselling)A.4.2 OutcomesThis EGM focuses on six broad outcome domains with 18 sub-categories described in the table below.Outcome categorySubcategoryExamplesInstitutional safeguarding practiceCultureLeadership behaviour (e.g., role modelling of safeguarding behaviour)Staff perceptions of the importance of safeguarding/risk-aware/risk-targeting behaviour.OperationsStaff recruitment procedures to enhance safeguarding practicesStaff training to increase knowledge and awareness.Implementation of child safeguarding policiesEnvironmentChanges in the institution’s physical environmentChild maltreatment disclosureDisclosure ratesThe disclosure of different types of maltreatment through the victim, caregivers, institutional staff or others involved in the child’s life.Adult institutional caregiver competenciesBehaviours/knowledge/ attitudes Knowledge and attitudes about institutional policies and practices required to safeguard childrenKnowledge and attitudes about child maltreatment and its impact on childrenKnowledge about risk factors for child maltreatment, observation and interview skills related to identifying child maltreatmentAbility to handle child maltreatment disclosure including listening, supporting, documenting and actioning a responseSensitivity and skills needed to support and work with children who have been maltreatedDisclosureDisclosure ratesReports of maltreatment Child knowledge/attitude/awareness of disclosureChild maltreatment occurrence or reoccurrence (child safety)Maltreatment behaviourThe occurrence or re-occurrence of these different types of child maltreatment within the institutional setting, for study participants – measured, e.g., through self- or informant-reportsFeelings of personal safety and securityPresence of relationships that facilitate disclosure and/or harmChild health and wellbeingKnowledge/awarenessKnowledge about child maltreatment and potential responses to offending behaviourRisk-aware/risk-targeting behaviourPhysical healthNormative standards for growth and developmentGross motor and fine motor skillsOverall healthBMI (body-mass index)Risk‐avoidance behaviour related to healthMental healthSelf‐control, emotional management and expressionInternalising and externalising behavioursTrauma symptomsSelf-esteemEmotional intelligenceSelf‐efficacyMotivationProsocial behaviourPositive outlookCopingSocial-emotional functioningSocial competencies and skillsAttachment and caregiver relationshipsAdaptive behaviourSocial connections and relationshipsCognitive functioningLanguage developmentPre‐academic skills (e.g., literacy/numeracy)Approaches to learningProblem‐solving skillsAcademic achievementSchool engagement/school attachmentPerpetrator/ Offender outcomes (adult or child)DesistanceThe degree of cessation of the maltreating behaviourRecidivismThe occurrence of relapse into maltreating behaviourMaltreatment behavioursHarmful coercive behavioursProblem sexual behaviour (children under 10)Harmful sexual behaviour (children aged from 10 up to 18-)Sexually offending behaviour (children aged from 10- up to 18 receiving treatment through a juvenile justice intervention)Parent/caregiverKnowledge/awareness/attitudesParental normative beliefs relating to institutional maltreatment related policies and practices Parent perceptions about their child’s understanding of protective behaviour conceptsEligibility criteriaA.5.1 Study designsStudy designs eligible for inclusion in this EGM were, finalised and ongoing:overviews of systematic reviews systematic reviews effectiveness studies (primary studies) that report on the effectiveness of child maltreatment interventions used within institutional settings. These were:randomised trials non-randomised trials controlled before-and-after studies the following quasi-experimental designs: interrupted time series, regression discontinuity designs, difference in differences, and propensity score matching (and other matching designs).Though we recognise that RCTs are considered the most stringent type of assessment of effectiveness, there are many institutional interventions where, for various reasons, random assignment may not be realistic. Therefore, we included several highly-controlled, quasi-experimental designs (QEDs). Non-controlled pre-post evaluations were excluded from this EGM as were qualitative studies, process evaluations, and non-effectiveness studies (e.g., cross-sectional surveys, observational studies, case studies or opinion pieces).A full list of included studies is included in REF _Ref31569732 \r \h Appendix C at the end of this report.A.5.2 Institutional settings includedOnly studies testing interventions’ effectiveness in “institutional settings” were eligible for inclusion. These were defined as an establishment or organisation used to promote child-related activities and/or care. Based on this definition, studies conducted in the following settings were eligible:?kindergarten/preschool/centre-based early childhood education and care settings?schools/before and after-school care settings ?sports clubs, sport and recreation settings?dance, drama and music studios/schools?churches / religious institutions?Summer/vacation camps ?out-of-home care settings (OOHC)/foster care?orphanages?detention centres/juvenile justice settings?rescue centres?hospitals/health clinics/emergency departments* ?any other type of organisation/institutional setting in which children may spend their time.Studies testing interventions’ effectiveness in home-based settings/in family/in non-institutional settings were excluded as were studies assessing parent training (intervention) conducted in clinics/primary care (or other institutional settings, i.e., hospital) as they target child maltreatment in families not in institutions. *A note on ‘hospitals/health clinics/emergency departments’. Medical interventions (see under interventions below) were excluded. However, of interest were interventions that aim to support health staff (e.g., GPs, nurses and doctors) to better identify or prevent maltreatment when the study specified that it included maltreatment which may occur in an institutional setting. This is because health professionals can and do work in institutional settings outside traditional health organisations, e.g., sport clubs can have doctors appointed to work with young people, nurses may work with children in residential care. (To be clear, we excluded studies which were clearly about medical professionals identifying abuse in the home.) A.5.3 GeographyThe EGM had a global focus and included studies conducted in low, middle and high-income countries with no exclusions on where studies were conducted. A.5.4 LanguageStudies written in the following languages were eligible for inclusion:EnglishGermanFrenchSpanishItalianPortugueseDutchDanishSwedishNorwegianA.5.5 Time limitsNo limitations were placed on the years in which studies were published. With regards to the electronic database searches, all searches included all years that were available within each of the databases. A.5.6 Status of studiesThis EGM includes both finalised and on-going studies. We included studies regardless of publication status, including unpublished manuscripts (where they were accessible), working papers, journal articles and policy and evaluation reports. We excluded conference proceedings, conference papers, dissertations, books, book reviews and news and magazine articles.Search methods and sourcesA.6.1 Electronic database searchesThe following academic databases were searched for eligible studies: Medline, PsycInfo, CINAHL, ERIC, Informit Families and Society Collection (Australian), Sociological Abstracts Sociology Source Ultimate and Scopus. The detailed search strategy for PsycInfo can be found at REF _Ref25934042 \r \h Appendix DD. An experienced librarian from the University of Newcastle, NSW Australia (Debbie Booth) adapted the search strategy and executed the searches in the electronic databases on 16th July 2019. A.6.2 Other sourcesWe also conducted searches of: The Campbell Collaboration Library; ProQuest (grey literature database); trial registries (PROSPERO, ClinicalTrials, ISRCTN registry, EU Clinical Trials Register, Australia and New Zealand Clinical Trial Registry), as well as the following organisational websites: ?US Child Welfare Services ?World Health Organization?World Bank?UNICEF?Australian Institute for Family Studies?London School of Hygiene and Tropical Medicine?National Institute for Health and Care Excellence?National Society for the Prevention of Cruelty to Children?Better Care Network.We also searched websites and reference lists of related publications for each of the following statutory inquiries into child abuse in institutions:?Royal Commission into Institutional Responses to Child Sexual Abuse (Australia, 2014-2017)?Pennsylvania Attorney General (2018). Pennsylvania Diocese Victims Report.?MHG Studie – Sexueller Missbrauch an Minderj?hrigen durch Kleriker?Law Commission of Canada (2012). Restoring Dignity – Responding to Child Abuse in Canadian Institutions?The Scottish Government (2012). Review of Child Neglect in Scotland?New Zealand House of Representatives (2014). Inquiry into Improving Child Health Outcomes and preventing child abuse with a focus from preconception until three years of age?Northern Ireland Historical Institutional Abuse Inquiry 1922-1995 (2017)?Unabh?ngige Kommission zur Aufarbeitung sexuellen Kindesmissbrauchs (Germany, 2016-2023).Given the relevance of the registered Pundir et al. (2019) EGM focused on violence against children in low- and middle-income countries, we also collaborated with their research team to secure and review their list of included studies in order to identify additional potentially relevant grey literature that could be included here.We also assessed the full text of all primary studies within the systematic reviews that we included.A.6.3 Asking expertsThe Subject Matter Experts group (see REF _Ref25934131 \r \h A.11endix B) were invited to forward relevant ongoing or unpublished studies or grey literature publications of potential relevance, make their networks aware of the project and seek further assistance in identifying potentially relevant studies.Screening and study selectionSeven reviewers in total took part in screening the literature. At least two reviewers separately screened each title and abstract that was identified by the search strategy. Articles included in the full text screening were then screened again by two reviewers (working separately). Any discrepancies in their decisions were resolved by consensus or by a third reviewer. Reviewers were not blind to the author or journal information. At the full text level, the primary reason for exclusion was recorded. Data extraction and managementFive reviewers were involved in data extraction. All data extraction and coding for each study was done by at least two reviewers, working separately. Discrepancies were resolved by consensus, or by a third reviewer. No reviewers who were involved with any of the primary studies undertook data extraction/coding/critical appraisal. We extracted the following information: name of the first author, year of publication, study design, study aimchild population of interest gender, age group(s), child risk status, maltreatment type, institutional setting, country/city, geography (by World Health Organisation regions) information about the intervention(s) of interest and the comparison condition(s), including intervention category, and alignment with INSPIRE strategies (see Section REF _Ref37184736 \r \h 5.5.5)outcomes of interest, a brief description of study results, and any reporting of implementation outcomes. Following the data extraction, the data was coded by relevant characteristics, and intervention and outcome categories. Due to unclear reporting, it was at times difficult to categorise the intervention type, define age groups and identify the exact institutional setting where the intervention was delivered or where the abuse took place. For instance, we didn’t code school-based prevention interventions as disclosure interventions even though almost all had a disclosure component (i.e. tell someone). As a result, we categorised the information based on what was available and, at times, some assumptions were necessary.Study quality / risk of biasAssessments of quality (i.e., the confidence we can have in the study findings) were conducted using the following: ?AMSTAR 2 tool for Systematic Reviews (Shea et al 2017) ( REF _Ref25934363 \r \h Appendix EE). ?Cochrane Risk of Bias 2 (CRoB2) tool for completed RCTs (Higgins et al 2016) ( REF _Ref25934390 \r \h Appendix FF). Five reviewers assessed the quality/risk of bias of the included studies. Two reviewers assessed each study independently, and discrepancies were cleared via consensus or by a further independent reviewer. Only RCTs were assessed for their risk of bias; neither QEDs nor protocols primary studies which were assessed. The scores for RCT assessments were coded as either ‘low risk’, ‘some concerns’, or ‘high risk’ as outlined by the RoB2 tool. AMSTAR 2 scores were coded as ‘critically low’, ‘low’, ‘moderate’ or ‘high’ quality (i.e., confidence in study finding) as outlined with the tool’s guidelines (Shea et al 2017). In order to present the AMSTAR 2 categorisations alongside the primary study assessments, studies that received a ‘critically low’ or ‘low’ assessment, were combined into a single ‘low’ category. For the Cochrane Risk of Bias (RoB) 2.0 tool, risk of bias was explored for each domain and for overall risk. The RoB 2.0 tool includes an algorithm for the set of responses within each domain resulting in a proposed risk of bias judgement for each domain including ‘low risk of bias’, ‘some concerns’ and ‘high risk of bias’. While the algorithm provides a proposed judgment, the investigators still need to verify this and change the judgement if it does not reflect the study appropriately. A study is deemed to have ‘low risk’ of bias if it is judged to be at a low risk of bias for all domains; ‘some concerns’ is when there are some concerns regarding at least one domain, and there are no high risk of bias assessments for any single domain; and ‘high risk’ of bias is when the study is judged to be at high risk of bias in at least one domain OR there some concerns for multiple domains in a way that substantially lowers confidence in the study’s findings.Methods for mapping The map was developed using the R Project for Statistical Computing (R Core Team, 2019). Bespoke code was developed by the Centre for Evidence and Implementation that utilised the ggplot2 package for visualisation (Wickham, 2016). As described above, the included studies are mapped in tables in which the rows are the intervention categories and settings, and the columns the outcomes (with sub-categories). A single study can appear in several cells on the map if it evaluated more than one intervention and/or more than one outcome. The cells of the table in the Visual Map (Figure 2) show the number of studies for each study type (RCT, QED, systematic review). Author names are shown for each study. Study quality is also highlighted by colour, using the traffic light system (i.e., Low risk of bias/high quality = green; Some concerns of bias/moderate quality = yellow; High risk of bias/low quality = red).Changes to protocolOur affiliated university libraries were unable to access the Family and Society Studies Worldwide and SocIndex academic databases. On the recommendation of our librarian and with approval of the author team, the following databases were searched as suitable replacements: Informit Families and Society Collection (Australian) – Covers subjects related to family and community, social services and public welfare, family law, and culture and institutions. Contains journals, books, and reports.Sociological Abstracts - Proquest index to international literature in sociology and related disciplines in the social and behavioural sciences.Sociology Source Ultimate - Subjects include gender identity, marriage and family, demographics, political sociology, religion and socio-cultural anthropology. Interventions were further coded using the INSPIRE categories outlined by the World Health Organisation. The included studies lists of all included systematic reviews underwent title and abstract screening in order to find further primary and/or systematic review studies. StakeholdersNameOrganisational affiliationCountry1Professor Leah BromfieldAustralian Centre for Child Protection, University of South AustraliaAustralia2Professor Daryl HigginsInstitute of Child Protection Studies, Australian Catholic UniversityAustralia3Professor Ben MathewsDirector, Childhood Adversity Research Program, Faculty of Health, Queensland University of TechnologyAustralia4Emeritus Professor Stephen SmallboneGriffith UniversityAustralia5Mathieu Lacambre & Wayne BodkinDepartment of Forensic Psychiatry, University Hospital MontpellierFrance6Dr Karen Devries & Louise KnightLondon School of Hygiene and Tropical MedicineUK7Donald Findlater & Stuart Allardyce‘Stop It Now’/Lucy Faithfull FoundationUK8Honorary Professor Derek E. PerkinsSchool of Law, Royal Holloway University of LondonUK9Professor Richard Wortley & Professor Lorraine SherrUniversity College LondonUK10Dr Franziska MeinckEdinburgh UniversityUK11Professor Elizabeth J. LetourneauJohns Hopkins Bloomberg School of Public HealthUS12Professor Jennie NollPenn State College of Health and Human DevelopmentUS13Dr Bruce TaylorNORC, University of ChicagoUS14Nicole WilliamsMaestral InternationalInternational15Kerry AlbrightUNICEFInternational16Claire FeinsteinSave the ChildrenInternationalList of studies and the Source of Each(‘Pundir’ refers to another EGM: The effectiveness of interventions for reducing violence against children: An evidence and gap map in low‐ and middle‐income countries, Pundir et al, 2019)AuthorYearTitleSourceBaker2012Increasing Knowledge of Sexual Abuse: A study with Elementary School Children in HawaiiReference listBaker-Henningham2016Irie Classroom Toolbox: a study protocol for a cluster-randomised trial of a universal violence prevention programme in Jamaican preschoolsDatabaseBarron2013Prevention programs and legal considerations for child sexual abuse casesReference listBick 2015Effect of early institutionalization and foster care on long-term white matter development: a randomised clinical trialDatabaseBlumberg 1991The touch discrimination component of sexual abuse prevention training: Unanticipated positive consequencesDatabaseBustamante 2019"I have the right to feel safe": Evaluation of a school-based child sexual abuse prevention programme in EcuadorDatabaseCecen-Erogul 2013The Effectiveness of Psycho-educational School-based Child Sexual Abuse Prevention Training Program on Turkish Elementary StudentsDatabaseCerezo 2004Improving child maltreatment detection systems: a large-scale case study involving health, social services, and school professionalsDatabaseChen 2012Pilot evaluation of a sexual abuse prevention programme for Taiwanese childrenDatabaseCitak2017Preventing Child Sexual Abuse: body Safety Training for Young Children in TurkeyPundirConte 1985An evaluation of a programme to prevent the sexual victimization of young childrenDatabaseCrowley1989Evaluation of Good Touches/Bad Touches: A program to prevent child sexual abuse in school-age childrenReference listCzerwinski 2018Effectiveness of a school-based intervention to prevent child sexual abuse-Evaluation of the German IGEL programDatabaseDaigneault2012Evaluation of a sexual abuse prevention workshop in a multicultural, impoverished urban areaReference listDaigneault 2015Effectiveness of a sexual assault awareness and prevention workshop for youth: A 3-month follow-up pragmatic cluster randomization studyDatabaseDake 2003Evaluation of child abuse prevention curriculum for third-grade students: assessment of knowledge and efficacy expectationsDatabasedel Campo Sanchez2006Evaluación de un programa de prevención de abusos sexuales a menores en Educación PrimariaReference listDevries2015The Good School Toolkit for reducing physical violence from school staff to primary school students: a cluster-randomised controlled trial in UgandaWebsitesDevries 2017Does the good schools toolkit reduce physical, sexual and emotional violence, and injuries, in girls and boys equally? A cluster-randomised controlled trialDatabaseDevries 2018Reducing physical violence toward primary school students with disabilitiesDatabaseDhooper1995Evaluation of a school-based child abuse prevention programReference listDryden 2014Effectiveness of the IMPACT:Ability programme to improve safety and self-advocacy skills in high school students with disabilitiesDatabaseEdwards 2019Evaluation of a Bystander-Focused Interpersonal Violence Prevention Program with High School StudentsDatabaseFeldmann 2018ReSi: Evaluation of a programme for competency training and prevention of sexual abuse in KindergartenDatabaseFryer1987Measuring actual reduction of risk to child abuse: A new approachReference listGrendel1991Cognitive and emotion al effects of a brief child sexual abuse prevention program for first-gradersReference listGushwa 2019Advancing Child Sexual Abuse Prevention in Schools: An exploration of the effectiveness of the enough! Online training program for K-12 teachersDatabaseHarvey1988The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age childrenReference listHazzard1991Child sexual abuse prevention: Evaluation and one-year follow-upReference listHeidotting 1994A Quantitative Synthesis of Child Sexual Abuse Prevention ProgramsDatabaseHerbert2001Proximate effects of a child sexual abuse prevention program in elementary school childrenReference listHermenau 2017Fostering child development by improving care quality: A systematic review of the effectiveness of structural interventions and caregiver trainings in institutional careDatabaseHillenbrand-Gunn2012Men as allies: The efficacy of a high school rape prevention interventionReference listHumphreys 2015Effects of institutional rearing and foster care on psychopathology at age 12 years in Romania: Follow-up of an open, randomised controlled trialDatabaseJin 2017Evaluation of a sexual abuse prevention education programme for school-age children in China: a comparison of teachers and parents as instructorsDatabaseJohnson 2010Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children randomised to foster vs ongoing institutional careDatabaseKenny2012Evaluation of a personal safety program with Latino preschoolersReference listKolko1987Promoting awareness and prevention of child sexual victimization using the Red Flag/Green Flag program: An evaluation with follow-upReference listKolko1989Classroom training in sexual victimization awareness and prevention skills: An extension of the Red Flag/Green Flag people programReference listKrahe2009A group-randomized evaluation of a theatre-based sexual abuse prevention programme for primary school children in GermanyReference listKnight 2018Implementation of the Good School Toolkit in Uganda: a quantitative process evaluation of a successful violence prevention programDatabaseKraizer 1988Programming for preventing sexual abuse and abduction: What does it mean when it works?DatabaseKraizer1991"The Safe Child Program for the prevention of child abuse: Development and evaluation of a school-based curriculum"Reference listMcElearney 2018Cluster randomised controlled trial of 'whole school' child maltreatment prevention programme in primary schools in Northern Ireland: study protocol for Keeping SafeDatabaseMacintyre1999Evaluation of the effectiveness of the Stay Safe primary prevention programme for child abuseReference listMcKibbin 2017Preventing Harmful Sexual Behaviour and Child Sexual Exploitation for children & young people living in residential care: A scoping review in the Australian contextDatabaseMerrill 2018Effects of a violence prevention intervention in schools and surrounding communities: Secondary analysis of a cluster randomised-controlled trial in UgandaPundirNeherta 2017The difference in intervention of sexual abuse prevention by two variance professions on primary school children in PadangDatabaseNkuba 2018Reducing violence by teachers using the preventative intervention Interaction Competencies with Children for Teachers (ICC-T): A cluster randomized controlled trial at public secondary schools in TanzaniaDatabaseOldfield1996Evaluation of the effectiveness of Project Trust: An elementary school-based Victimization Prevention StrategyReference listPitts 2015Child sexual abuse prevention programmes for pre-schoolers: A synthesis of current evidenceInquiries - AusPulido 2015Knowledge gains following a child sexual abuse prevention programme among urban students: A cluster-randomized evaluationDatabaseQuadara2015Conceptualising the prevention of child sexual abuse. Final ReportExpert InputRadford 2017Rapid Evidence Assessment: What can be learnt from other jurisdictions about preventing and responding to child sexual abuseInquiries - Ind InqRatto 1990An Evaluation of a Preschool Curriculum to Educate Children in the Prevention of Sexual AbuseDatabaseRheingold 2014Child Sexual Abuse Prevention Training for Childcare Professionals: An Independent Multi-Site Randomized Controlled Trial of Stewards of ChildrenExpert InputRicardo2011Engaging Boys and Young Men in the Prevention of Sexual Violence: A systematic and global review of evaluated interventionsPundirSaslawsky1985Educating children about sexual abuse: Implications for pediatric intervention and possible preventionReference listSherr 2017Child violence experiences in institutionalised/orphanage careDatabaseSmyke 2010Placement in Foster Care Enhances Quality of Attachment Among Young Institutionalized ChildrenDatabaseSnyder1986An evaluation of the 'Good Secrets, Bad Secrets' Sexual Assault Prevention programReference listSouth 2015Scoping review: Evaluations of out-of-home care practice elements that aim to prevent child sexual abuseInquiries - AusSsenyonga2018Reducing violence against children by implementing the preventative intervention Interaction Competencies with Children for Teachers (ICC-T): study protocol for a cluster randomized controlled trial in Southwestern UgandaDatabaseSullivan 1992The effects of psychotherapy on behavior problems of sexually abused deaf childrenDatabaseTaal1997Positive and negative effects of a child sexual abuse prevention programReference listTaylor 2010The effects of gender violence/harassment prevention programming in middle schools: A randomized experimental evaluationDatabaseTelljohann1997Evaluation of a third Grade sexual abuse curriculumReference listTopping2009School-based child sexual abuse prevention programs: A review of effectivenessReference listTroller-Renfree 2015The effects of early foster care intervention on attention biases in previously institutionalized children in RomaniaDatabaseTutty 1997Child sexual abuse prevention programmes: evaluating Who Do You TellDatabasevanLieshout 2019Make a Move: A Comprehensive Effect Evaluation of a Sexual Harassment Prevention Program in Dutch Residential Youth CareDatabaseWade 2019Long-term effects of institutional rearing, foster care, and brain activity on memory and executive functioningDatabaseWalsh 2015School-based education programmed for the prevention of child sexual abuse (Review)CampbellWarden1997An evaluation of a children's safety training programReference listWeatherley2012Evaluation of a school-based sexual abuse prevention curriculum in MalaysiaPundirWhite 2018Promoting young children’s interpersonal safety knowledge, intentions, confidence, and protective behavior skills: Outcomes of a randomized controlled trial Expert InputWolfe1986Evaluation of a brief intervention for educating school children in awareness of physical and sexual abuseReference listWurtele1986Teaching personal safety skills for potential prevention of sexual abuse: A comparison of treatments.Reference listWurtele1992aA comparison of teachers vs parents as instructors of a personal safety program for preschoolersReference listWurtele 1992bSexual abuse prevention education for young children: A comparison of teachers and parents as instructors Inquiries - AusZhang 2014Evaluation of a sexual abuse prevention education for Chinese preschoolersDatabaseZwi 2007School‐Based Education Programmes for the Prevention of Child Sexual AbuseCampbellSearch strategyDatabase(s):?PsycINFO?1806 to July Week 2 2019?Search Strategy:#SearchesResults1(adolescence 13 17 yrs or childhood birth 12 yrs or infancy 2 23 mo or neonatal birth 1 mo or preschool age 2 5 yrs or school age 6 12 yrs).ag.7584122(Infant or infants or infancy or Child or childs or children or childrens or childhood or Minors or Minor person* or minor people or Toddler or toddlers or baby or babies or Adolescent or adolescents or adolescence or teen or teens or teenage or teenaged or teenager or teenagers or young person or young persons or young people or youth or youths or juvenile or juveniles or boy or boys or girl or girls).mp.112557531 or 212688444child neglect/ or child abuse/292995(neglect* or abandon* or maltreat* or mistreat* or ill treat* or illtreat* or harm or harmful or harmed or vulnerab* or abus* or assault or problem sexual behavi*).mp.31400364 or 53140037meta analysis/ or "systematic review"/45148(metaanal* or meta anal* or (systematic adj2 review*) or systematic synthesis).mp. or (meta analysis or metasynthesis or "systematic review").md.598219randomized controlled trials/7510(RCT or randomi* or (random* adj3 (assign* or allocat*)) or blinded or double blind* or doubleblind*).mp.13213811quasi experimental methods/15012time series/200313(Quasi experiment* or quasiexperiment* or step wedge or "difference in difference*" or synthetic control group or covariate matching or propensity score or doubly robust estimat* or regression adjustment estimate* or regression discontinuity or instrumental variable* estimate* or time series or timeseries or before after or before-after or pre post).mp.30397147 or 8 or 9 or 10 or 11 or 12 or 1320890415intervention/5950016(intervention or interventions or prevent* or treatment or treatments or programme or programs or programme or programmes or policy or policies).mp.135677217Health Education/ or Mass Media/ or Prevention/ or Social Media/ or Communications Media/6122418professional development/ or continuing education/ or inservice teacher education/ or inservice training/ or training/ or professional training/ or mental health inservice training/ or professional certification/ or professional competence/ or professional standards/5089519(Human Resource Management or Job Applicant Screening or Personnel Recruitment or employ* screening or pre employ* screening).mp.149832015 or 16 or 17 or 18 or 19141293721((residential and (care or institution)) or (oohc or (out of home adj3 care*)) or (foster* adj2 (youth or child* or infant*)) or (child* adj2 "looked after") or orphanage or (child* adj2 home) or (child* adj2 institution) or pre school or preschool or "pre k" or kindergarten or day care or day-care or nursery or nurseries or play group* or playgroup* or ((after school or afterschool or out of school) and program*) or camp or camps or club or clubs or (child* and (center* or centre* or institution*)) or (institution* adj2 (faith based religious or care or setting)) or church* or temple* or mosque*).mp.17717722exp correctional institutions/949723junior high schools/ or technical schools/ or middle schools/ or nursery schools/ or elementary schools/ or nongraded schools/ or military schools/ or high schools/ or charter schools/ or boarding schools/ or schools/ or institutional schools/482752421 or 22 or 23229295253 and 6 and 14 and 20 and 24768 AMSTAR 2 tool Did the research questions and inclusion criteria for the review include the components of PICO?For Yes: Optional (recommended) ? Population? Timeframe for follow-up ? Yes ? Intervention ? No ? Comparator group ? Outcome46177201106170 Yes Partial Yes No00 Yes Partial Yes NoDid the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol? 225234564770For Yes: As for partial yes, plus the protocol should be registered and should also have specified: a meta-analysis/synthesis plan, if appropriate, and a plan for investigating causes of heterogeneity justification for any deviations from the protocol00For Yes: As for partial yes, plus the protocol should be registered and should also have specified: a meta-analysis/synthesis plan, if appropriate, and a plan for investigating causes of heterogeneity justification for any deviations from the protocol-6413564770For Partial Yes: The authors state that they had a written protocol or guide that included ALL the following:? review question(s) ? a search strategy? inclusion/exclusion criteria ? a risk of bias assessment 00For Partial Yes: The authors state that they had a written protocol or guide that included ALL the following:? review question(s) ? a search strategy? inclusion/exclusion criteria ? a risk of bias assessment 4445184150For Yes, the review should satisfy ONE of the following: Explanation for including only RCTs OR Explanation for including only NRSI OR Explanation for including both RCTs and NRSI00For Yes, the review should satisfy ONE of the following: Explanation for including only RCTs OR Explanation for including only NRSI OR Explanation for including both RCTs and NRSIDid the review authors explain their selection of the study designs for inclusion in the review? 34499556985 Yes No00 Yes NoDid the review authors use a comprehensive literature search strategy? -64135184150For Partial Yes (all the following): searched at least 2 databases (relevant to research question)provided key word and/or search strategyjustified publication restrictions (e.g. language)00For Partial Yes (all the following): searched at least 2 databases (relevant to research question)provided key word and/or search strategyjustified publication restrictions (e.g. language)209994526670For Yes, should also have (all the following): searched the reference lists/bibliographies of included studiessearched trial/study registriesincluded/consulted content experts in the fieldwhere relevant, searched for grey literatureconducted search within 24 months of completion of the review00For Yes, should also have (all the following): searched the reference lists/bibliographies of included studiessearched trial/study registriesincluded/consulted content experts in the fieldwhere relevant, searched for grey literatureconducted search within 24 months of completion of the review4331970144145 Yes Partial Yes No00 Yes Partial Yes No27305157480For Yes, either ONE of the following: at least two reviewers independently agreed on selection of eligible studies and achieved consensus on which studies to include00For Yes, either ONE of the following: at least two reviewers independently agreed on selection of eligible studies and achieved consensus on which studies to includeDid the review authors perform study selection in duplicate? 458470098425 Yes No00 Yes No330200-4445OR two reviewers selected a sample of eligible studies and achieved good agreement (at least 80 per cent), with the remainder selected by one reviewer0OR two reviewers selected a sample of eligible studies and achieved good agreement (at least 80 per cent), with the remainder selected by one reviewerDid the review authors perform data extraction in duplicate?-889037465For Yes, either ONE of the following: at least two reviewers achieved consensus on which data to extract from included studies OR two reviewers extracted data from a sample of eligible studies and achieved good agreement (at least 80 per cent), with the remainder extracted by one reviewer00For Yes, either ONE of the following: at least two reviewers achieved consensus on which data to extract from included studies OR two reviewers extracted data from a sample of eligible studies and achieved good agreement (at least 80 per cent), with the remainder extracted by one reviewer431355594615 Yes No00 Yes No-7295213759For Partial Yes: provide a list of all potentially relevant studies that were read in full text form but excluded from the review00For Partial Yes: provide a list of all potentially relevant studies that were read in full text form but excluded from the reviewDid the review authors provide a list of excluded studies and justify the exclusions?4334510133985 Yes Partial Yes No00 Yes Partial Yes No223139031115For Yes, must also have: Justified the exclusion from the review of each potentially relevant study00For Yes, must also have: Justified the exclusion from the review of each potentially relevant studyDid the review authors describe the included studies in adequate detail?225744060930For Yes, should also have ALL the following:described population in detaildescribed intervention and comparator in detail (including doses where relevant)described study’s settingtimeframe for follow-up00For Yes, should also have ALL the following:described population in detaildescribed intervention and comparator in detail (including doses where relevant)described study’s settingtimeframe for follow-up-889058420For Partial Yes (ALL the following):described populationsdescribed interventionsdescribed comparatorsdescribed outcomesdescribed research designs00For Partial Yes (ALL the following):described populationsdescribed interventionsdescribed comparatorsdescribed outcomesdescribed research designs4543425125199 Yes Partial Yes No00 Yes Partial Yes No2372360297815For Yes, must also have assessed RoB from allocation sequence that was not truly random, and selection of the reported result from among multiple measurements or analyses of a specified outcome00For Yes, must also have assessed RoB from allocation sequence that was not truly random, and selection of the reported result from among multiple measurements or analyses of a specified outcomeDid the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?-107956985RCTsFor Partial Yes, must have assessed RoB from unconcealed allocation, and lack of blinding of patients and assessors when assessing outcomes (unnecessary for objective outcomes such as all cause mortality)00RCTsFor Partial Yes, must have assessed RoB from unconcealed allocation, and lack of blinding of patients and assessors when assessing outcomes (unnecessary for objective outcomes such as all cause mortality)4460240118110 Yes Partial Yes No Includes only NRSI00 Yes Partial Yes No Includes only NRSI2298065105410For Yes, must also have assessed RoB: methods used to ascertain exposures and outcomes, and selection of the reported result from among multiple measurements or analyses of a specified outcome00For Yes, must also have assessed RoB: methods used to ascertain exposures and outcomes, and selection of the reported result from among multiple measurements or analyses of a specified outcome-3746581280NRSIFor Partial Yes, must also have assessed RoB: from confounding, and from selection bias 00NRSIFor Partial Yes, must also have assessed RoB: from confounding, and from selection bias 447357589535 Yes Partial Yes No Includes only RCTs00 Yes Partial Yes No Includes only RCTsDid the review authors report on the sources of funding for the studies included in the review? 71120120015For Yes Must have reported on the sources of funding for individual studies included in the review. Note: Reporting that the reviewers looked for this information but it was not reported by study authors also qualifies00For Yes Must have reported on the sources of funding for individual studies included in the review. Note: Reporting that the reviewers looked for this information but it was not reported by study authors also qualifies455739583185 Yes No00 Yes NoIf meta-analysis was performed, did the review authors use appropriate methods for statistical combination of results?-3175102870RCTsFor Yes: The authors justified combining the data in a meta-analysis00RCTsFor Yes: The authors justified combining the data in a meta-analysis4037330156210 Yes No No meta-analysis conducted00 Yes No No meta-analysis conducted185420206375 AND they used an appropriate weighted technique to combine study result and adjust for heterogeneity if present AND investigated the causes of any heterogeneity 00 AND they used an appropriate weighted technique to combine study result and adjust for heterogeneity if present AND investigated the causes of any heterogeneity 5016545720For NRSIFor Yes: The authors justified combining the data in a meta-analysis00For NRSIFor Yes: The authors justified combining the data in a meta-analysis4043045106680 Yes No No meta-analysis conductedc00 Yes No No meta-analysis conductedc301625131445AND they used an appropriate weighted technique to combine study results, adjusting for heterogeneity if presentAND they statistically combined effect estimates from NRSI that were adjusted for confounding, rather than combining raw data, or justified combining raw data when adjusted effect estimates were not availableAND they reported separate summary estimates for RCTs and NRSI separately when both were included in the review00AND they used an appropriate weighted technique to combine study results, adjusting for heterogeneity if presentAND they statistically combined effect estimates from NRSI that were adjusted for confounding, rather than combining raw data, or justified combining raw data when adjusted effect estimates were not availableAND they reported separate summary estimates for RCTs and NRSI separately when both were included in the reviewIf meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis? -889071755For Yes: included only low risk of bias RCTs OR, if the pooled estimate was based on RCTs and/or NRSI at variable RoB, the authors performed analyses to investigate possible impact of RoB on summary estimates of effect00For Yes: included only low risk of bias RCTs OR, if the pooled estimate was based on RCTs and/or NRSI at variable RoB, the authors performed analyses to investigate possible impact of RoB on summary estimates of effect408305064770 Yes No No meta-analysis conductedc00 Yes No No meta-analysis conductedc12065273050For Yes: included only low risk of bias RCTs OR, if RCTs with moderate or high RoB, or NRSI were included in the review provided a discussion of the likely impact of RoB on the results00For Yes: included only low risk of bias RCTs OR, if RCTs with moderate or high RoB, or NRSI were included in the review provided a discussion of the likely impact of RoB on the resultsDid the review authors account for RoB in individual studies when interpreting/discussing the results of the review? 4277360172085 Yes No00 Yes No-3175312420For Yes: There was no significant heterogeneity in the results OR, if heterogeneity was present the authors performed an investigation of sources of any heterogeneity in the results and discussed the impact of this on the results of the review00For Yes: There was no significant heterogeneity in the results OR, if heterogeneity was present the authors performed an investigation of sources of any heterogeneity in the results and discussed the impact of this on the results of the reviewDid the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?4214495172720 Yes No00 Yes No4218305327660 Yes No No meta-analysis conducted00 Yes No No meta-analysis conductedIf they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? 4254525400For Yes: performed graphical or statistical tests for publication bias and discussed the likelihood and magnitude of impact of publication bias00For Yes: performed graphical or statistical tests for publication bias and discussed the likelihood and magnitude of impact of publication bias4445306070For Yes: The authors reported no competing interests OR The authors described their funding sources and how they managed potential conflicts of interest00For Yes: The authors reported no competing interests OR The authors described their funding sources and how they managed potential conflicts of interestDid the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?4031615140970 Yes No00 Yes No Cochrane risk of bias 2 tool Study detailsReferenceStudy design?Individually-randomized parallel-group trial?Cluster-randomized parallel-group trial?Individually randomized cross-over (or other matched) trialSpecify which outcome is being assessed for risk of biasSpecify the numerical result being assessed. In case of multiple alternative analyses being presented, specify the numeric result (e.g. RR = 1.52 (95% CI 0.83 to 2.77) and/or a reference (e.g. to a table, figure or paragraph) that uniquely defines the result being assessed.Is the review team’s aim for this result…??to assess the effect of assignment to intervention (the ‘intention-to-treat’ effect)?to assess the effect of adhering to intervention (the ‘per-protocol’ effect)Which of the following sources were obtained to help inform the risk-of-bias assessment? (tick as many as apply)?Journal article(s) with results of the trial?Trial protocol?Statistical analysis plan (SAP)?Non-commercial trial registry record (e.g. record)?Company-owned trial registry record (e.g. GSK Clinical Study Register record)? “Grey literature” (e.g. unpublished thesis)?Conference abstract(s) about the trial?Regulatory document (e.g. Clinical Study Report, Drug Approval Package)?Research ethics application?Grant database summary (e.g. NIH RePORTER or Research Councils UK Gateway to Research)?Personal communication with trialist?Personal communication with the sponsorDomain 1: Risk of bias arising from the randomisation processSignalling questionsDescriptionResponse options1.1 Was the allocation sequence random?Y / PY / PN / N / NI1.2 Was the allocation sequence concealed until participants were enrolled and assigned to interventions?Y / PY / PN / N / NI1.3 Did baseline differences between intervention groups suggest a problem with the randomised process? Y / PY / PN / N / NIRisk-of-bias judgementLow / High / Some concernsOptional: What is the predicted direction of bias arising from the randomised process?Favours experimental / Favours comparator / Towards null /Away from null / UnpredictableDomain 2: Risk of bias due to deviations from the intended interventions (effect of assignment to intervention)Signalling questionsDescriptionResponse options2.1. Were participants aware of their assigned intervention during the trial?Y / PY / PN / N / NI2.2. Were carers and people delivering the interventions aware of participants' assigned intervention during the trial?Y / PY / PN / N / NI2.3. If Y/PY/NI to 2.1 or 2.2: Were there deviations from the intended intervention that arose because of the experimental context?NA / Y / PY / PN / N / NI2.4. If Y/PY to 2.3: Were these deviations from intended intervention balanced between groups?NA / Y / PY / PN / N / NI2.5 If N/PN/NI to 2.4: Were these deviations likely to have affected the outcome?NA / Y / PY / PN / N / NI2.6 Was an appropriate analysis used to estimate the effect of assignment to intervention?Y / PY / PN / N / NI2.7 If N/PN/NI to 2.6: Was there potential for a substantial impact (on the result) of the failure to analyse participants in the group to which they were randomised?NA / Y / PY / PN / N / NIRisk-of-bias judgementLow / High / Some concerns Optional: What is the predicted direction of bias due to deviations from intended interventions?Favours experimental / Favours comparator / Towards null /Away from null / UnpredictableDomain 2: Risk of bias due to deviations from the intended interventions (effect of adhering to intervention)Signalling questionsDescriptionResponse options2.1. Were participants aware of their assigned intervention during the trial?Y / PY / PN / N / NI2.2. Were carers and people delivering the interventions aware of participants' assigned intervention during the trial?Y / PY / PN / N / NI2.3. If Y/PY/NI to 2.1 or 2.2: Were important co-interventions balanced across intervention groups?NA / Y / PY / PN / N / NI2.4. Could failures in implementing the intervention have affected the outcome?Y / PY / PN / N / NI2.5. Did study participants adhere to the assigned intervention regimen?Y / PY / PN / N / NI2.6. If N/PN/NI to 2.3 or 2.5 or Y/PY/NI to 2.4: Was an appropriate analysis used to estimate the effect of adhering to the intervention?NA / Y / PY / PN / N / NIRisk-of-bias judgementLow / High / Some concernsOptional: What is the predicted direction of bias due to deviations from intended interventions?Favours experimental / Favours comparator / Towards null /Away from null / UnpredictableDomain 3: Missing outcome dataSignalling questionsDescriptionResponse options3.1 Were data for this outcome available for all, or nearly all, participants randomised? Y / PY / PN / N / NI3.2 If N/PN/NI to 3.1: Is there evidence that result was not biased by missing outcome data?NA / Y / PY / PN / N3.3 If N/PN to 3.2: Could missingness in the outcome depend on its true value?NA / Y / PY / PN / N / NI3.4 If Y/PY/NI to 3.3: Do the proportions of missing outcome data differ between intervention groups? NA / Y / PY / PN / N / NI3.5 If Y/PY/NI to 3.3: Is it likely that missingness in the outcome depended on its true value?NA / Y / PY / PN / N / NIRisk-of-bias judgementLow / High / Some concernsOptional: What is the predicted direction of bias due to missing outcome data?Favours experimental / Favours comparator / Towards null /Away from null / UnpredictableDomain 4: Risk of bias in measurement of the outcomeSignalling questionsDescriptionResponse options4.1 Was the method of measuring the outcome inappropriate?Y / PY / PN / N / NI4.2 Could measurement or ascertainment of the outcome have differed between intervention groups ?Y / PY / PN / N / NI4.3 If N/PN/NI to 4.1 and 4.2: Were outcome assessors aware of the intervention received by study participants ?Y / PY / PN / N / NI4.4 If Y/PY/NI to 4.3: Could assessment of the outcome have been influenced by knowledge of intervention received?NA / Y / PY / PN / N / NI4.5 If Y/PY/NI to 4.4: Is it likely that assessment of the outcome was influenced by knowledge of intervention received?NA / Y / PY / PN / N / NIRisk-of-bias judgementLow / High / Some concernsOptional: What is the predicted direction of bias in measurement of the outcome?Favours experimental / Favours comparator / Towards null /Away from null / UnpredictableDomain 5: Risk of bias in selection of the reported resultSignalling questionsDescriptionResponse options5.1 Was the trial analysed in accordance with a pre-specified plan that was finalized before unblinded outcome data were available for analysis ?Y / PY / PN / N / NIIs the numerical result being assessed likely to have been selected, on the basis of the results, from...5.2. ... multiple outcome measurements (e.g. scales, definitions, time points) within the outcome domain?Y / PY / PN / N / NI5.3 ... multiple analyses of the data?Y / PY / PN / N / NIRisk-of-bias judgementLow / High / Some concernsOptional: What is the predicted direction of bias due to selection of the reported result?Favours experimental / Favours comparator / Towards null /Away from null / UnpredictableOverall risk of bias Risk-of-bias judgementLow / High / Some concernsOptional: What is the predicted direction of bias due to selection of the reported result?Favours experimental / Favours comparator / Towards null /Away from null / UnpredictableList of countries included in each WHO regionAfricaAmericasEuropeSouth eastWestern pacific TanzaniaUSAGermanyChinaAustraliaUgandaCanadaIrelandIndonesiaEcuadorNorthern IrelandMalaysiaJamaicaNetherlandsTaiwanRomaniaScotlandSpainTurkeyRisk of bias summary Completed randomised controlled trialsStudy (Author and year)Overall risk of biasDomain 1. Randomised processDomain 2. Deviations from intended interventionsDomain 3. Missing outcome dataDomain 4. Measurement of the outcomeDomain 5. Selection of the reported resultBarron2013Some concernsSome ConcernsLow riskLow riskLow riskSome concernsBick2015Some concernsSome concernsSome concernsLow riskLow riskSome concernsBlumberg1991High risk of biasSome concernsHigh riskHigh riskHigh riskSome concernsBustamante2019High risk of biasLow riskHigh riskHigh riskSome concernsSome concernsCecen Erogul2013Some concernsSome concernsSome concernsLow riskLow riskSome concernsChen2012Some concernsSome concernsSome concernsLow riskSome concernsSome concernsCitak2018Some concernsSome concernsLow riskLow riskLow riskSome concernsConte1985Some concernsLow riskHigh riskLow riskLow riskSome concernsCrowley 1989Some concernsSome concernsLow riskSome concernsSome concernsSome concernsDaigneault2012Some concernsLow riskSome concernsLow riskLow riskSome concernsDaigneault 2015High Risk of BiasSome concernsSome concernsHigh riskHigh riskSome concernsDake2003Some concernsSome concernsSome concernsSome concernsSome concernsSome concernsDel Campo Sanchez2006Some concernsSome concernsSome concernsLow riskLow riskSome concernsDevries2015High riskLow riskSome concernsLow riskHigh riskSome concernsDevries2017High riskLow riskSome concernsLow riskHigh riskSome concernsDevries2018High riskLow riskSome concernsHigh riskHigh riskSome concernsEdwards2019High riskSome concernsSome concernsHigh riskHigh riskSome concernsFeldmann2018High risk of biasSome concernsLow riskLow riskHigh riskSome concernsFryer 1987Some concernsLow risk Some concernsLow riskSome concernsSome concernsGrendel 1991Some concernsLow riskSome concernsLow riskLow riskSome concernsGushwa2018High risk of biasSome concernsLow riskHigh riskSome concernsSome concernsHarvey 1988Some concernsSome concernsSome concernsLow riskLow riskSome concernsHazzard 1991Some concernsSome concernsSome concernsLow riskSome concernsSome concernsHumphreys2015Some concernsLow risk of bias Some concernsLow riskSome concernsSome concernsJin2017Some concernsSome concernsSome concernsLow riskSome concernsSome concernsJohnson2010Some concernsLow riskSome concernsLow riskLow riskSome concernsKnight2018High riskLow riskSome concernsLow riskHigh riskSome concernsKrahe2009High riskLow riskSome concernsLow riskHigh riskSome concerns Kraizer1988High riskSome concernsHigh riskHigh riskHigh riskSome concernsMerril 2018High risk of biasLow riskSome concernsSome concernsHigh risk of biasSome concernsNkuba2018High riskSome concernsHigh riskHigh riskSome concernsSome concernsOldfield1996Some concernsSome concernsSome concernsLow riskLow riskSome concernsPulido2015Some concernsSome concernsLow riskLow riskLow riskSome concernsRatto1990High riskSome concernsHigh riskSome concernsHigh riskSome concernsRheingold2014Some concernsLow riskSome concernsLow risk Some concernsSome concernsSaslawsky1976Some concernsLow riskSome concernsLow riskLow riskSome concernsSmyke2010Some concernsSome concernsSome concernsSome concernsLow riskSome concernsTaylor2010High riskLow riskSome concernsHigh riskHigh riskSome concernsTelljohann1997Some concernsSome concernsSome concernsSome concernsLow riskSome concernsTroller-Renfree2015Some concernsSome concernsSome concernsSome concernsLow riskSome concernsTutty1997High riskSome concernsLow riskLow riskHigh riskSome concernsvan Lieshout2019High riskSome concernsHigh riskHigh riskSome concernsSome concernsWade2018Some concernsLow riskSome concernsSome concernsLow risk of biasSome concernsWhite2018Some concernsLow riskLow riskLow riskLow riskSome concernsWolfe1986Some concernsSome concernsSome ConcernsLow riskLow riskSome concernsWurtele1986Some concernsLow riskSome concernsLow riskLow riskSome concernsWurtele 1992aSome concernsLow riskSome concernsLow riskLow riskSome concernsWurtele1992bHigh risk of biasSome concernsHigh RiskHigh riskLow riskSome concernsZhang2014Some concernsSome concernsSome concernsLow riskSome ConcernsSome concernsQuasi-experimental designs LEGENDFrequency?Low6Moderate8Notes: * Given overall low on agreement of both codersSerious4?** Coders agreed moderate despite one serious ratingNo information0 Characteristics of included systematic reviewsAuthor, Publication yearReview aim AMSTAR 2 ScoreStudy designs Maltreatment type/sSettings Child population of interest and ageIntervention typeInterventions of interest included Heidotting, 1994The purpose of this study was to investigate the effectiveness of school-based sexual abuse and personal safety prevention programmes for children by objectively and empirically synthesizing primary research evidence using the techniques of metaanalysisLow 0-5Treatment and non-equivalent control group designs, as well as repeated measures.Sexual abuseKindergarten/preschool; primary/elementary schoolChildren attending pre-school and primary/elementary school (3-11 years)ResponseSchool-based sexual abuse and personal safety prevention programmes for childrenHermenau, 2017This systematic review investigated the effects of structural interventions and caregiver trainings on child development in institutional environments.Low 0-5Studies with controlled and uncontrolled researchdesigns. Physical abuse, emotional abuse and neglectResidential care/orphanages Children aged 0–17 years living full timein child care institutions in any part of the world PreventionInterventions implemented within institutions aiming to change the context of the institutions as well as the ways in which caregivers interacted with the children; and interventions that aimed to improve the children’s development and living conditions by employing one or more intervention components (i.e., caregiver training or supervision, structural changes, or additional stimulation). McKibbin, 2017To conduct a scoping exercise of the evidence about preventing harmful sexual behavior and child sexual Exploitation problems with the intent of summarising and disseminating knowledge to policy-makers, practitioners and researchers. Low 0-5Mixed (peer-reviewed journal articles; government reports; presentation transcripts; literature reviews; qualitative report; government inquiry report; submission to government inquiry; consultation paper for government inquiry; guideline; and educational resource)Sexual abuseResidential careChildren & young people living in residential carePrevention and treatmentPrevention programmes (education); Upskilling workers; Targets grooming and problematic sexual behaviour (perpetration and/or victimisation); Early intervention/recognition; Holistic response; Treatment, safety planning and placement managementPitts, 2015The aim of this evidence review is to determine what is known from the existing literature about the efficacy of pre-school child sexual abuse prevention programmes.Low 0-5Not reportedSexual abuseKindergarten /preschool/ centre based early childhood education and care settings/day-carePre-school children(age not specifically reported)Prevention, response, and disclosureChild sexual abuse prevention programmes for pre-schoolers.Radford, 2017The Rapid Evidence Assessment was to identify what is known in countries other than England and Wales about best practice and ‘what works’ to prevent, identify and respond to child sexual abuse with an institutional dimensionLow 0-5Systematic reviews, qualitative and qualitative studiesSexual abuseMultiple settingsNot specified other than "children"Prevention, response, treatment, and disclosureTypes of institutional response to child sexual abuse: Those aimed at primary prevention, stopping child sexual abuse and/or sexual exploitation happening in the first place. Those aimed at improving child protection through better identification, disclosure, reporting and responses, enabling children to disclose abuse, improving recognition among those in contact with children. Those aimed at better control and management of offenders, especially ensuring they do not reoffend. Those aimed at providing better support for victims and survivors, aiding recovery and undoing the harm and injustices caused to victims and survivors and their families.Quadara,2015Overall aims of this project were to consider the specific dynamics of child sexual abuse and their implications for prevention and early intervention. Specific aims: map current prevention, early intervention and therapeutic responses against this analysis; andassess key points of prevention and intervention in light of identified risk factors and facilitators of child sexual abuse and apparent gaps in prevention.Low 0-5Not clear/reportedSexual abuseMultiple settingsNot specified other than "children"Prevention, response, and disclosurePrevention programmes: Primary prevention, preventing recidivism, integrated treatment, current Australian programmes. Ricardo, 2011To investigate the effectiveness of interventions for preventing boys’ and young men’s use of sexual violence, including: increasing gender-equitable attitudes, bystander intentions, and other attitudes and behaviors. Moderate 6-11Randomised controlled trials and studies with quasi-experimental designsSexual abuse, physical abuse and emotional abuseMiddle school; secondary school; high schoolAdolescent boys and young men aged 12-19 yearsResponse andpreventionInterventions included are those designed to prevent boys and young men’s use of rape and other forms of sexual violence, or to change those attitudes about gender, violence, and/or intimate relationships with women that are correlated with boys’ and young men’s use of rape and other forms of sexual violence. Interventions designed to increase boys’ and young men’s positive bystander attitudes and behaviors are also included.Sherr, 2017Part of a systematic review series addressing violence and abuse experiences in institutionalised care, this review explores interventions to reduce such violence or abuse. Low 0-5Include a comparison group not exposed to institutional care, a comparison group of some other form, or use a repeated measures designPhysical violenceneglect, emotional abuseResidential care; institutional careChildren within institutional careResponse and preventionStudies that reported on the use of an intervention to reduce abuse/maltreatment within institutional care.South, 2015The aim of this scoping review was to map evaluations of out-of-home care (OOHC) practice elements that aim to prevent child sexual abuse in OOHC.Moderate 6-11No restriction on study typeSexual abuseOut-of-home care settings; foster careAny child in overnight care between the ages of 0-17 years, where the state or territory makes a financial payment, or where a financial payment has been offered but has been declined by the carer.PreventionAny type of program, service or practice element that contributes to decreasing the occurrence or preventing child sexual abuse in ping, 2009To systematically and critically review evidence from 1990 onward for the effectiveness of programs based in schools for primary prevention of child sexual abuse.Low (0-3)RCTs, pretest / posttest with and without a control group, and posttest with and without a control groupSexual abuseKindergarten; primary/elementary school; high schoolChildren in kindergarten through year 10 (aged 5 to 16 years) in primary or high school PreventionPrograms that were delivered from a school base, focused on working with children (not parents or teachers), focused on child sexual abuse primary prevention, did not focus on physical, emotional, or ritualistic abuse or neglect, and did not focus only on children and young people with learning difficulties.Walsh, 2015 To systematically assess evidence of the effectiveness of school-based education programmes for the prevention of child sexual abuse.High 12-16Randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTsSexual abuseSexual abusePrimary/elementary school; secondary/high schoolChildren (aged 5 to 12 years) andadolescents (aged 13 to 18 years) attending primary (elementary)or secondary (high) schools.PreventionIncluded interventions were school-based education programmes focusing on knowledge of sexual abuse and sexual abuse prevention concepts, or skill acquisition in protective behaviours, or both.Zwi, 2007To systematically assess evidence of the effectiveness of school‐based education programmes for the prevention of child sexual abuse. Specifically, to assess whether: programmes are effective in improving students' protective behaviours and knowledge about sexual abuse prevention; behaviours and skills are retained over time; and participation results in disclosures of sexual abuse, produces harms, or bothModerate 6-11Primary/elementary school; secondary/high schoolSchool aged children from kindergarten to 18 years Intervention characteristics (Primary studies)Author, Publication yearDesign and statusCountry Maltreatment type/sSetting Child Target population and ageIntervention delivery personnel/ approachAlignment with INSPIREIntervention type and focusStrategies/ description Baker, 2012QEDUSSexual abuseElementary schoolChildren in the third grade()Train the trainer approach: school staff including teachers, counselors, social workers, and human resource professionals given an overview of relevantinformation about child abuse and how to teach sensitively and deal with abuse disclosure. Education and life skillsPrevention: Increase children’s knowledge of sexual abuse and safety skills for dealing with it.MBMB curriculum: ( My Body My Boundries), consists of topics to help children identify types of sexual abuse, recognise and respond to unsafe and unwanted behaviours, learn how to identify and tell others if they have been abused, understanding personal boundaries and learning to stay safe from internet predators.Baker-Henningham, 2016RCT (ongoing)JamaicaPhysical abuse Preschools Children in 4-year-old preschool classes(4 years old)Trained classroom teachers Education and life skillsPrevention: Classroom behaviour management and in strategies to promote children’s social-emotional competence.The Irie Classroom Toolbox: Training for teachers delivered through five full-day workshops, monthly in-class coaching over two school terms, and weekly text messages, provision of resources (guidance booklet, lesson plans, games, song books, picture cards)Barron, 2013RCTSexual abuse, physical abuse, and emotional abuseSecondary school (high school and secondary colleges)Children in grades 6, 7, and 8 from urban areasPresenters who have received a 1-hour training delivered by the program authors in program aims/objectives, content, delivery style, confidentiality limits, and response to disclosureEducation and life skillsPrevention: Increase student identification of safe a risky people and situations as well as who to disclose to. The Tweenees program (Matthew & Laurie, 2002) has two main aims: to enable students to be aware of potentially abusive situations and to disclose CSA and other abuses. Lessons are 50 minutes long.Blumberg, 1991RCTUSSexual abusePublic school (elementary)Children in kindergarten through to third-grade (5-9 years old)Trained volunteers. social workersPresentations were also delivered by educators, counselor, school nurse and teachersEducation and life skillsPrevention: Increase awareness and understanding of child sexual abuse and to teach safety skills.Role play modeling, rehearsal and discussion, presentations. Toys such as teddy bears, puppets were used to demonstrate and initiate discussion. A film was also shown to learn about self- protection, sexual abuse and strangers.Bustamante, 2019RCTEcuadorSexual abusePublic elementary schoolsChildren in public elementary schools(7–12 years old)“Train the trainer” - Trained psychologist guided schoolteachers on how to conduct the program. Teacher then had one week to prepare before leading the weekly activity in his/her class.Education and life skillsPrevention: Increase children’s knowledge of child sexual assault and self-protection strategiesSpecific activities for each session were organised in a workbook given to each child and teacher. Sessions involved interactive activities, and discussion of the lessons from the activity through a set of “powerful questions.”Cecen-Erogul, 2013RCTTurkey Sexual abuse Elementary school Children in 4th Grade(9-10 years old)Not reportedEducation and life skillsPrevention: Personal rights, ‘my body belongs to me’, good touch-bad touch discrimination, breaking promise, body safety rules, say “No”, and bad secrets, talking with a grown-up who believes the child, sexual abuse is never a child’s faultOne-hour session, on four consecutive days. Videos and lecture, role-playing, modeling, and rehearsal teaching techniques. Cerezo, 2004QEDSpainNeglect,Physical Abuse,Sexual Abuse,Emotional AbuseMixed (Health and social services agencies and schools)Phase 1, all children under 18 years old. Phase 2, preschool and primary school ages (3-10 years old) Not reportedResponse and support servicesThe training focused on detecting signs of child maltreatment and how to follow a protocol about reporting cases to child protection to increase detection of child maltreatment. Based on motivation interviewing approaches.Chen, 2012RCTTaiwan Sexual abusePrimary schoolChildren in primary school(6-13 years old)Not reported Education and life skillsPrevention: (a) sexual abuse knowledge and prevention and (b) abduction prevention. included the following: (a) body ownership, (b) distinguishing appropriate from inappropriate touches or requests to touch and the responsibility associated with inappropriate touching, and (c) distinguishing types of secrets.Skills-based child sexual abuse prevention program. Tunc, 2018RCT TurkeySexual abusePreschool Preschool age children(3-5 years old)Not reportedEducation and life skillsPrevention: To teach preschoolers about body safety by adopting a behavioral approach. The first five sessions cover “general safety” topics and the remaining five sessions focus on “body safety.”Body Safety Training Program :10 sessions, each session lasts between 20 and 25 min and is implemented in small groups (6–10 children).In each session, the children participated in various (interactive and experiential) exercises and exchange views about the topics, e.g., they discuss situations in which touches or kisses from adults feel like a boundary violation and how to deal with such situations.Conte, 1985RCT USASexual abuseAll day and after school programChildren in school program(4- 10 years old) Deputy sheriffs who have gone through general training on the problem of sexual abuse of children and have been trained specifically in sexual abuse prevention.Education and life skillsPrevention: Increasing children’s awareness of the problem of sexual abuse and teaching basic prevention conceptsThe programme is presented on three consecutive days for one hour each day. The programme teaches children personal safety awareness, assertiveness training, and practical self-protection skills (e.g., where it is safe to walk in the city). Children are also taught to assertively say no when touched in not-OK ways and to say no, run, and tell as a basic protective response to threatening situations. Through role plays, children practice ways of saying no to adults who may touch them inappropriately.Crowley, 1989RCTUSASexual abusePublic school in an underprivileged area Children in fourth and fifth gradeCertifies school psychologists, social workers, and school nurse/teacher who received at least two training sessions from the program developersEducation and life skillsPrevention: The program aims to teach children about sexual abuse which could help them avoid situations dangerous situations, or seek out appropriate help if they are in an abusive situation Good Touches/Bad Touches (GT/BT) program: Uses a structured lesson format combined with activities for the children, a film, and extensive discussion sessions. The program was designed to be presented to children from kindergarten through grade six and is conscious of the developmental level of the students. The GT/BT program teaches a core of concepts present in other sexual abuse programs.Czerwinski, 2018QEDGermany Sexual abuse Primary school Children in third grade(8-9 years old)The programme is implemented by teachers who have undergone training in two workshops and received all the necessary materials for its implementation.Education and life skillsPrevention: The broad goal is to strengthen the children’s ability to protect themselves from sexualized violence by improving their knowledge of sexual abuse as well as their skills in handling the misbehavior of others. In addition, the programme aims to raise the school personnel’s awareness of sexual abuse and enable them to identify inappropriate situations and react adequately.The programme comprises seven school sessions. In each session, the children participate in various (interactive and experiential) exercises and exchange views about the topics, e.g., they discuss situations in which touches or kisses from adults feel like a boundary violation and how to deal with such situations. Involves two-day training workshop for teachers. materials and implementation support. Daigenault, 2012RCTCanadaSexual abusePublic primary school in an underprivileged areaChildren in grades one through four(Ages 5-11 years)Not reportedEducation and life skillsPrevention: Enhance children’s knowledge of inappropriate touching and their abilities to recommend appropriate behavioural responses to an abusive situation.ESPACE consists of a 90 min workshop delivered by 3 community workers. Activities include role-playing, guided discussions, behaviour modelling to enhance, promote and teach children awareness of personal right, self-assertions skills and responses to abuse. Booster sessions included a revision of the ESPACE workshop. Daigneault, 2015RCT CanadaSexual abuse High school Youth in high school(15-17 years old)Facilitated by two female sexual assault advocacy centre staffEducation and life skillsPrevention: Sexual assault awareness and preventionOne 75-minute workshop delivered to one classroom at a time. Dake, 2003RCT USAPhysical, sexual, and emotional abuse and neglectPublic schoolsChildren in third grade (8-9 years old)Delivered by child abuse prevention agency employees and trained volunteersEducation and life skillsPrevention: Workshop covered child sexual abuse, physical abuse, and emotional abuse; child neglect and domestic violenceTwo 1-hour sessions. Curriculum included class discussions of abuse concepts and teacher role-plays depicting abusive scenarios to increase children's knowledge of child abuse and confidence to responddel Campo Sanchez, 2006RCTSpainSexual abusePublic and private primary schoolsChildren in grades three through sixNot reported. (Before the intervention, a training session with teachers and parents was conducted to offer knowledge and prepare them to interact with the children during and after the intervention)Education and life skillsPrevention: Increase students’, teachers’, and parents’ knowledge and awareness of sexual abuse and ability to have conversations about sexual abuse and sexuality The intervention itself consisted of 2 sessions of one hour during school hours on sexual abuse prevention.Dhooper, 1995QEDUSAPhysical abuse and sexual abusePublic and parochial primary schoolsChildren in grades three through fiveNot reportedEducation and life skillsPrevention: Enhance children’s understanding of child abuse and their ability to recognise abuse and to interrupt and/or avoid abusive situationsThis school-based educational program provided by the Family Nurturing Center of Kentucky (an agency specializing in child abuse issues and responsible for offering prevention programs in schools)is based on the belief that complete learning requires not only the thinking process but internalizing concepts on a feeling level as well. It uses the KIDS ON THE BLOCKTM puppets and skits. Puppets serve as models with which children can identify on both affective and cognitive levels.Dryden, 2014QEDUSAPhysical, sexualHigh school Min age:13 and max 21, median age in the various groups were 17, 19 and 16 with cognitive and/or physical disabilities(13-19 years old)Teaching team includes one instructor who coaches students through these scenarios and a second instructor who plays the role of an unsafe, untrustworthy, or challenging individual.Education and life skillsPrevention: The aim of the programme is to increase participants’ knowledge, confidence, and skills to communicate assertively, protect themselves from imminent harm, resist isolation behaviors, and bribery that are common tactics used by perpetrators, and advocate for themselves.IMPACT:Ability: consisting of ten 90-minute weekly class sessions; 8 classes focused on IMPACT and 2 focused on MASS curriculum. During the MASS classes, participants discuss the meaning of self-determination and self-advocacy with a facilitator, engage in creative activities around future goals, develop an action plan towards one goal, and identify people that can help them reach that goal. Edwards, 2019RCT United StatesPhysical and sexual abuse.High school Children in grades 9 to 12(14-18 years old)Vast majority of sessions co- facilitated by one facilitator who identifies as male and one facilitator who identifies as femaleNorms and valuesPrevention: Teaches students how to safely and effectively intervene before, during, and after situations of relationship abuse and sexual assault to both prevent and stop these forms of abuse from happening, as well as supporting victims in the aftermath of these experiences.Bringing in The Bystander (BITB): seven-session curriculum delivered to a mixed sex audience in class periods (approximately 45 min per session) and include lectures, large and small group discussions, hands-on and experiential exercises, skill-building activities, and video segments. In addition to student programming, the BITB-HSC includes a 60- min School Personnel Workshop that trains teachers and other school staff skills to be positive bystanders in situations of adolescent interpersonal violence. Feldmann, 2018RCT GermanySexual abuseKindergarten (Day-care)Children attending a Kindergarten(3-6 years old)Taught to children by early childhood educators. Educators receive a 1-day pre-service training and then administer the programme on their own without further implementation support. Education and life skillsPrevention: The programme is structured into four competency domains: Emotions, Body, Relations, and Language. The ReSi program = Teaching is based on "exercises" and "play", with exercises being structured into obligatory "core" exercises and optional exercises. Each exercise is described in a manual, and educators use dolls, picture books, an "emotion rubric" and decks of cards to support exercises. Fryer, 1987RCTUSASexual abusePrimary schoolChildren in kindergarten, first grade, and second gradeNot reportedEducation and life skillsPrevention: The program aimed to change children’s awareness of and behaviour around personal safetyEight-day program, with 20 minute presentations eah day, addressing misconceptions about personal safety. Children were taught to follow rules including 1) Stay an arm's reach away, 2) Don't talk or answer questions, 3) Don’t take anything, 4) Don't go anywhereGrendel, 1991RCTUSASexual abusePublic primary schoolsChildren in first grade (6-8 years old)Classroom teachers and special services personnel are trained to present the program, to recognise and respond to children who are currently being abused and to report the abuse properly. Parents are educated through a seminar and supplementary materials the children bring home daily.Education and life skillsPrevention: The program aimed increase children’s knowledge of sexual abuse and prevention skillsThis curriculum provides child abuse prevention training at three levels. The third phase of the Program is classroom instruction for children ages three through ten using video tape as the initial teaching tool for cognitive learning and teacher-directed roleplay for skills development. The children's training includes prevention of sexual, physical and emotional abuse, prevention of abuse and abduction by strangers and safety for children in self-care. These prevention techniques are taught in the context of building life skills such as communication, decision-making, choices, assertiveness and enhancing self-esteem.Gushwa, 2018RCT USASexual AbuseK-12 schoolChildren in grades kindergarten to year 12(5-18 years old)N/AEducation and life skillsPrevention: The training addresses signs and symptoms of CSA, grooming, and sexual misconduct behaviors, reporting responsibilities and requirements (including consequences for failure to report), with the focus on debunking some of the misconceptions and fears/biases associated with responding to and reporting suspected abuse/misconduct. Enough! Preventing Child Sexual Abuse in My School: Online training available in a 1- hour interactive course that learners can choose to take in one session or in separate 20-minute segments. Conveys information through two teacher avatars who seek to both engage and inform. Harvey, 1988RCTUSASexual abusePrimary school in rural areaChildren in kindergartenTwo college-educated experimenters with substantial experience working with children delivered the programEducation and life skillsPrevention: Teach young children skills to prevent child sexual abuseGood Touch-Bad Touch: three ?- hour sessions occurring across three consecutive days with approximately 20 children in each session. The program consists of the following components: Defining sexual abuse; differentiating between good (e.g., holding hands with another child), bad (e.g., hitting and kicking others), and sexually abusive touches; delineating safety rules to prevent abuse; and identifying who can sexually abuse children (e.g., a stranger, a familiar adult, or teenager). Instructions, modeling, rehearsal, and social reinforcement were utilised as teaching procedures. In the first session the concepts and skills were taught by instruction, through a story and large storybook, and by playing a simple game. The second session consisted of reviewing the material covered in the first session, observing a film designed to prevent sexual abuse, and learning a simple song about body safety. The third session involved reviewing material covered in session two, reading a story about who sexually abuses children, and finally presenting two stories in which the concept that victims of sexual abuse are not bad is taught.Hazzard, 1991RCTUSASexual abusePrimary schoolChildren in the third and fourth gradeNot reportedEducation and life skillsPrevention: the intervention focused on cognitive, affective, and behavioural dimensions of learning to teach children and teachers about sexual abuse preventionThe program was a three-session format. Each session was an hour long and led by a female mental health professional with expertise in child sexual abuse. Each session included a 15-minute videotape, group discussions, and role-plays. In each classroom, a prevention poster was display and a silent question box which a child could anonymously ask a question.Herbert, 2001QEDCanadaSexual abusePrimary schoolChildren in the first and third gradeLed by specialized community workersEducation and life skillsPrevention: The content of the program is designed to enhance children’s awareness of their personal rights, and to teach them basic prevention concepts and skills.The ESPACE program adapted from the CAP program from the USA in-class program consists of a 60–75 minute workshop, and uses roleplaying, guided discussions, behavior modeling, and rehearsal. Children are taught self-assertion skills, a self-defense yell, and are encouraged to ask friends for help and to tell a trusted adult if an incident of abuse occurs.Hillenbrand-Gunn, 2012QEDUSASexual abuseHigh schoolYouth in the 10th gradeDelivered by a sexual violence prevention expertEducation and life skillsPrevention: The program aims to teach high school students about and change their rape-supportive behaviours and attitudes.The Men As Allies intervention consists of the following themes: 1) in which participants read and discuss acts of courage challenging sexist, coercive, and abusive behavior or attitudes 2) music video sung by a male rap artist about men's role in preventing sexual violence, which focuses on men who stand up against violence against girls and women, 3) music video sung by a male rap artist about men's role in preventing sexual violence, which focuses on men who stand up against violence against girls and women, 4) emphasizing the key role of males in helping females who have been raped, including how affirming support from a male friend following a rape positively influences the rape survivors' recovery process; 5) incorporating a male role model, a respected coach, or a crisis counselor who introduces the presenter prior to the first session. Jin, 2017RCT ChinaSexual abusePrimary schoolPrimary school age children (6-12 years old)Delivered either by parents or teachersEducation and life skillsPrevention: (i) the concept of private parts, (ii) body safety rules (iii) recognition of appropriate/inappropriate touch, (iv) strategies for saying ‘no’ in life situations and (v) self-protection skills.For the teacher education group, the curriculum was administered to children by trained teachers and ?nished in three 30-min sessions. For the parent education group, the exact same curriculum contents as taught in the teacher education group were compiled into a handbook, so that parents could read and tutor their children.Kenny, 2012QEDUSASexual abusePreschool/day-carePreschool children(3-5 years old)Not reportedEducation and life skillsPrevention: Teach preschoolers and their parents safety skills to prevent child sexual abuseKids Learning about Safety (KLAS) program consists of 10 hours of psychoeducation focused on teaching preschoolers and parents safety skills. The program encompassed the Behaviour skills Training workbook and Talking about Touching curriculum. The components provided guidance on how to improve safety making decisions.Kolko, 1987QEDUSASexual abusePrimary schoolChildren in the third and fourth gradeAdult staff volunteers recruited from the community and teachers from each classroom were exposed to an extensive in-service training program conducted by caseworkers from Children and Youth Services which involv-ed didactic instruction, roleplaying, and group discussion. Education and life skillsPrevention: Assist children in developing the vocabulary needed to report cases of abuse to a trusted adult, to expedite reporting and investigation of individual cases of child abuse, and to teach children to say "no" to potential abusers and physically "get away" from potentially harmful situations. The ultimate goal was to begin to reduce the incidence of child sexual abuse. The program incorporates three service components: staff training, parent in services, and classroom training, child-directed classroom training implemented by teachers.Kolko, 1989QEDUSASexual abusePrimary schoolPrimary school age children (7-10 years old)Fourteen staff volunteers were recruited from the community or school to discuss the program materials in each classroom and received a formal in-service training program.Education and life skillsPrevention: Aimed to teach children prevention skills and concepts and offer follow-up guidance counselor reports of child involvement in personal incidents to prevent child sexual abuse.The content of the prevention skills training curriculum consisted of the RF/GF People Coloring Book (Williams, 1980) and the film "Better Safe Than Sorry II" (Film Fair Communications, 1979), which are described in Kolko et al. (1986). All children received a phone number to call if they wanted to speak with program staff or the guidance counselor regarding an experience of inappropriate physical touching. Volunteers made periodic school visits to provide reassurance and assistance to the children. Repeated emphasis was placed on reminding children that they were not at fault for being touched inappropriately and that, at times, they might not be able to avoid involvement in such incidents.Krahe, 2009RCTGermanySexual abusePrimary schoolChildren in grade one and grade twoThe intervention package includes a three-hour training session for teachers to prepare them for their task of guiding the children through the performance (the intervention) and a three-hour information evening for parents designed to provide facts and raise awareness about sexual abuse.Education and life skillsPrevention: Aimed to promote children’s self-protective skills in terms of the understanding of situations potentially leading to abuse and in recognising appropriate behavioural responses in interactions with adultsChildren watched a live performance of the play "(No) Child's Play"; watching a DVD version of the live performance of the play. (No) Child’s Play ([K]ein Kinderspiel), was developed by a team of experts (psychologists, teachers, theatre education professionals and police officers) for first and second grade primary school children. Lasting for about 60 minutes, it was designed to promote children’s skills in handling interactions with adults in which they feel uncomfortable, such as being asked to keep a secret about which they feel uneasy, and in promoting confidence in their ability to seek help.Krazier, 1991QEDUSASexual abuse, physical abuse, emotional abusePrimary school and preschoolChildren in preschool, kindergarten, first grade, second grade, and third gradeTrained teachersEducation and life skillsPrevention: Prevention of child sexual abuse by introducing concepts of safety and safety skillsThe Safe Child Program includes:a. prevention of sexual abuse by people known to the child,b. prevention of abuse and abduction by strangers,c. prevention of physical and emotional abuse, andd. safety for children in self-care.The program is designed to enable teachers to do what they do best by: a. presenting the information through video tapes and b. structuring the activities in a format which allows teachersKraizer, 1988RCT USASexual abuse Elementary schoolKindergarten, 1st and 2nd grade students(5-8 years old)Not reportedEducation and life skillsPrevention: Prevention of sexual abuse by people known to the child, safety for children in self-care, and prevention of abuse and abduction at the hands of strangersChildren Need To Know: Personal Safety Training Program: a scripted primary prevention programme delivered in a group classroom setting.Taught y through example, discussion, and extensive role play that allows children to actually experience implementing the rules. MacIntyre 1999QEDUK (Northern Ireland)Sexual AbusePrimary SchoolChildren in second and fifth grade classes (7 and years old)TeachersEducation and life skillsPrevention: Prevention of child sexual abuse designed to teach children safety knowledge and skillsThe Stay Safe program utilises a multimedia format and focuses on cognitive, affective and behavioural dimensions of learning by teaching strategies for dealing with bullying and child sexual abuse. The child’s training was conducted over 12 sessions for 7 year olds and 10 sessions for 10 year olds. Sessions were of 30–40 minutes duration and included structured lesson plans and written, video, and audio teaching materials. McElearney, 2018(protocol) RCT UK (Northern Ireland)Neglect, sexual abusePrimary schoolChildren in primary school(4-11 years old)Teachers and school staff Education and life skillsPrevention: Designed to teach children how to keep safe from all forms of maltreatment carried out online or using digital technology, abuse perpetrated by other children, and bullying. Premised on three core themes: healthy relationships, my body, and being safe. Multi component ‘Whole-School’ program. Provision of classroom-based materials across three themes of healthy relationships, my body and being safe, materials including 63 lesson plans (nine for each class group per year). School leaders will deliver a prepared assembly, one of twelve available, to introduce the theme for the term. Each teacher will then deliver three age appropriate lessons to their class and ask the children to complete the accompanying homework with their parents or carers. Parents will be engaged in directed homework activities with their children and are encouraged to attend a structured information session and expert workshops. Training and support for teachers and whole school staff provided in a blended package of training aimed at building the capacity of school leaders, teaching and non-teaching staff to teach and embed the programNeherta, 2017QEDIndonesiaSexual abusePrimary schoolChildren in primary school (6-12 years old)TeachersEducation and life skillsPrevention: Providing knowledge about the four important body parts that should not be touched by others and assertiveness behaviours that must be owned by the child when faced with an uncomfortable situation. Children received VAK learning modalities (Visual Auditory Kinesthetic) using a variety of learning media, such as movies, presentation, role play, discussion using pictorial sketch story, local language song, and leaflets. Interventions / training were carried out 4 times. Nkuba, 2018RCT TanzaniaPhysical abuseHigh / secondary schoolSchool children (13-17 years old)TeachersEducation and life skillsPrevention: Aims at preventing violent discipline and at improving teacher-student relationship by introducing essential interaction competencies with children in the daily work of teachers.Interaction Competencies with Children for Teachers program. Intervention components include sessions on (a) teacher-student interaction, (b) maltreatment, (c) effective discipline strategies, (d) identifying and supporting burdened students, and on (e) the implementation of ICC-T components in everyday school life. To implement the ICC-T intervention in the selected schools, one Tanzanian psychologist conducted the ICC-T training workshop with the help of three assistant facilitatorsOldfield 1996RCTUSASexual AbusePrimary SchoolChildren in grade 1-6High School students perform a play for primary school students, followed by a question-response sessionEducation and life skillsPrevention: Providing knowledge on maltreatment prevention, how to manage anxiety and reporting of abuseProject TRUST: trained high school students performed a play for primary school aged-students, lasting 30 minutes followed by a 15 min question-response period. Topics included were touch continuum, right to question and refuse touch, how to say no and perpetrators can be either people you know or strangers.Pulido, 2015RCT USSexual abuseElementary schoolChildren at least 7 years old and in second or third grade(7-9 years old)Two master’s-level clinical social workers or mental health counselors facilitated each workshop.Education and life skillsPrevention: Facilitators guide the children in making a list of what to do if they experience a not-safe touch and whom to tell, as well as in practicing the assertive language skills needed to express discomfort and to talk with a trusted adult about a not-safe touch. Safe Touches: classroom-based 50-minute interactive workshop in which racially ambiguous puppets are used to role-play scenarios that help children learn and practice safety concepts. Children are also given an age appropriate activity book on body safety to complete at home with caregivers.Ratto, 1990RCT USSexual abuseDay-care centresChildren in day-care (37-62 months old)Not reportedEducation and life skillsPrevention: The parent education meeting informs parents about sexual abuse and provides them with strategies to use with their children to protect them from sexual abuse. In the classroom, children learn to distinguish appropriate from inappropriate touch, to assert their rights to say no to touches that are uncomfortable or inappropriate, and to tell someone if they are uncomfortable about the touch.The programme consists of three components: teacher training, a parent education meeting, and a 5-day children’s curriculum for the classroom. The information is taught through the use of a picture book, a puppet show, discussion, activities, and role play. Rheingold, 2014RCTUSSexual abuseYouth service organisations (e.g., day-care centers, churches, schools).All children (0-18 years old)Child advocacy centerEducation and life skillsPrevention and response: Preventing (primary prevention), recognising, and responding to child sexual assault (secondary prevention).Stewards of Children: 2 1/2-h training workshop in two formats: (1) in-person with a facilitator presenting the curriculum and leading discussions and (2) an interactive web-based training. SaslawskyRCTUSASexual AbusePrimary SchoolChildren in K-1st grade, and 5th to 6th gradeGraduate student led the discussionEducation and life skillsPrevention: Aims to inform students of various forms of abusive incidents and teach skills to protect themselves A 35 minute film was shown to students portraying various abusive incidents and four different skills to prevent sexual abuse including 1) say No, 2) yell for help, 3) get away, 4) tell someone. Following the film was a discussion about the children's feelings, knowledge gained and reiteration of actions shown in the film.SnyderQEDUSASexual AbusePrimary SchoolChildren in fourth grade Sexual assault counselor Education and life skillsPrevention: Presentation to students teaching sexual assault and safety concepts including general safety skills, distinguishing between appropriate touching from sexual touching, understanding that sexual touches can come from strangers or even someone they know, how to seek help and recognizing an appropriate course of action when in a dangerous situationA presentation called ‘Good Secrets, Bad Secrets’ was delivered by a sexual assault counsellor. Ssenyonga, 2018(protocol)RCT UgandaPhysical abuseSchools/primary/elementary/highschool/ before and after-school care,Students in the 8th and 9th years of formal schooling(12-17 years old)Not reportedEducation and life skillsPrevention: Aims at improving teacher-student relationships, changing teachers’ attitudes and behaviors concerning the use of violent disciplinary measures, and preventing harsh and violent discipline in the school settingInteraction Competencies with Children for Teachers (ICC-T) program: training workshop for teachers, 5.5 days, with 8 hours spent in training on each full day. Includes sessions on teacher-student interactions, maltreatment prevention, effective discipline strategies, identifying and supporting burdened students, and practical implementation. Strategies include presentations, discussions, question and answer sessions, and supervised practical sessions. Sullivan, 1992QEDUSSexual abuseResidential school for the deafHearing impaired children between the ages of 12 and 16 The psychotherapy was undertaken by three clinical psychologists, and a supervising psychiatrist with specific training and expertise in the psychology of deafness and fluency in sign language.Response and support servicesTreatment: Goals included: 1. alleviation of guilt 2. treatment of depression; 3. learning to express anger in appropriate and productive ways; 4. providing basic information about normal human sexuality; 5. dealing with sexual preference and homosexual issues; 6. dealing with maltreatment issues;7. self-protection techniques; 8. vocabulary to label emotions and feelings; 9. attainment of emotional independence; 10. establishment of a meaningful and stable identity; 11. development of a personal value system; and 12. development of a capacity for lasting relationships Psychotherapy: Each child in the treatment group received 2 hr of individual therapy per week for 36 weeksTaal, 1997QEDAmsterdamSexual abuseElementary schoolStudents in grade 6th, 7th and 8th. (8 to 12 years)Lessons were delivered by actors and teachers Norms and values; Education and life skillsPrevention: self-protective skills when in potential abuse situationsRight to Security program encompasses major themes including an awareness of “yes” and “no feelings,” an awareness of the right to refuse unwanted sexual interactions with strangers and with trusted others, and seeking help after sexual abuse has occurred. Program consists of 8 lessons including role playing and discussion sessions. The main goal of this intervention is that children must be able to identify when they are in an unsafe situation. Taylor, 2010RCT USSexual abuseMiddle school Students from 6th and 7th grades(11-13 years old)One senior female staff member from a local sexual assault center taught nearly all the classroom sessions. In two of the seven participating school buildings, the regular classroom teacher implemented the curriculum instead of the rape crisis center educatorNorms and values; Education and life skillsPrevention: The interaction-based curriculum focused on setting and communicating boundaries in relationships; the formation of deliberate relationships/friendships and the continuum between friendship and intimacy; the determination of wanted/unwanted behaviors; and the role of the bystander as intervener.Lessons delivered in five classroom periods (designed to last 40 minutes each, once per week). Detailed instructions were included with each lesson.Telljohann, 1997RCTUSSexual Abuse Elementary SchoolStudents in 3rd grade(8-11 years old)Trained volunteers and staff from a social service agency taught the programNorms and values; Education and life skillsPrevention: The program objectives were for children to identify family and community as support systems, the various types of touches including safe, unsafe and secret, identify safety rules and recognize that sexual abuse should not be kept a secret and is never a child’s fault. Sexual Abuse Prevention program, Third Grade Curriculum: is delivered in two one-hour sessions. These sessions consisted of role plays, videos, demonstrations and discussions to teach behavioural skills and knowledge. Tutty, 1997RCTCanadaSexual abuseElementary schoolChildren from kindergarten to grade six(5-11 years old)Two trainers from the Calgary Communities Against Sexual AssaultEducation and life skillsPrevention: The emphasis is on giving information and permission to say no to unwanted touch, the issue of whether this means that children should be suspicious of all touches or adults is also addressed.Who Do You Tell program: offered at the request of elementary school principals. Includes parent information evening, teachers also receive an in-service workshop.Two trainers offer the programme in small groups (15 to 20). The programme is delivered to children in two sessions of 45-60minutes each, presented on consecutive days. Age-appropriate materials and videos are matched to the developmental level of the child.Van Lieshout, 2019RCTNetherlandsSexual abuseResidential careBoys in residential care (12- 18 years old)Freelance trainers working for Rutgers - Center for Sexual and Reproductive Health and RightsNorms and values; Education and life skillsPrevention: Main goal is to promote respectful (sexual) relationships and to prevent sexual harassment. Sub goals include, increasing awareness of differences in relationship expectations and teaching the boys how to control their wishes and desires if they are not in line with their partners’ wishes.Make a Move program: consists of eight weekly meetings in a group setting using groups of six to eight boys of 90 min each. The themes covered by the eight meetings are, in order, men, image, girls, sex, flirting, dating, pleasurable sex, and the future. Each meeting includes several exercises such as role play, discussion, and watching short movie clips.Warden, 1997QEDScotlandSexual abuse Primary School (6 and 10 years). Program is taught by teachers in a classroom settingNorms and values; Education and life skillsPrevention: Teaching skills to enhance their ability to identify and deal, when they are in an unsafe situation. Kidscape Safety Training program teaches children general personal safety rules, how to cope with bullies, not to talk to strangers, how and when to say no when presented in an uncomfortable situation. The program is taught using stories, drawing, painting, role-plays and discussion. Weatherley, 2012QEDMalaysiaSexual abusePrimary schoolSchool children (9 years old)Facilitated by Protect and Save the ChildrenEducation and life skillsPrevention: Purpose was to provide children information about their body, sage and unsafe situations, building a support system, and to impart safety strategies and skills.Six school-based units that use role-playing and gamesWhite, 2018RCTAustraliaSexual abusePrimary schoolYear 1 students (5-7 years old)Trained facilitators from the non-profit organization, Act for Kids.Education and life skillsPrevention: This program aims to improve children’s interpersonal safety skills in situations ranging from peer bullying to child sexual assaultThe Learn to be safe with Emmy and friends? program: held for five, 1-hour weekly sessions. Sessions were on school grounds with trained facilitators, independent to the research team. The content of the five sessions included: (i) Emotion recognition and early warning signs; (ii) Identification of safe/unsafe situations; (iii) Personal space and private body areas; (iv) Safe/unsafe secrets; and (vi) Identification of safe adults and safety networks for disclosure.Wolfe, 1986RCTUSPhysical and Sexual AbusePrimary SchoolChildren at 4th and 5th grade(9-12 years old)Trained medical studentsEducation and life skillsPrevention: Purpose is to educate children in child abuse awareness especially in areas including 1) someone you love and trust can also be abusive, 2) this can cause emotions such as anger, worry, fear and embarrassment, 3) you should tell someone, 4) it is not your fault, and 5) get help immediatelyProgram consisted of two, five-minute skits showing children in uncomfortable situations and how they handled it. Following the skit was a discussion about the nature and prevention of physical and sexual abuse. Wurtele, 1986RCTUSSexual abuseKindergarten and primary schoolChildren from Kindergarten to first grade and children from 5th to 6th grade(Mean age 6.1 years and 11.0 years)Female graduate studentsEducation and life skillsPrevention: Purpose of the program was to teach safety skills to children via two intervention approaches ( 1) film and 2) behavioural skills program) to prevent sexual abuseTwo intervention approaches were used. 1) Students watched a 35 minute film called ‘Touch’ where various abusive incidents were portrayed, including four skills to prevent abuse including a) say ‘No’, b) yelling for help, c) getting away and d) telling someone. Then followed a 15 minute discussion of the film that focused on knowledge that was gained and reiterating the 4 skills shown in the video. Wurtele, 1992aRCTUSSexual abusePreschool and homeHead start preschoolers (57 months old on average)Teachers and parents Education and life skillsPrevention: Covers: (a) that children are the bosses of their bodies: (b) to identify the location of their "private parts": (c) it is appropriate for doctors, nurses, or parents to touch children's private parts for health or hygiene reasons: (d) that otherwise, it is not okay especially if the person wants them to keep it a secret: (e) that it is wrong to be forced to touch a bigger person's private parts: and (f) that an adult's inappropriate touching of the child's private parts is never the child's faultBehavioural Skills Training (BST) programme delivered at school via a 4-day programme that taught children personal safety skills from a behavioral perspective. Working with small groups (ranging in size from 4 to 10), teachers instructed children on various topics related to personal safety and to prevent sexual abuse. Children practiced discriminating between appropriate and inappropriate touch requests, and were taught (via modeling, rehearsal, praise, and feedback) the appropriate verbal (e.g., say "No?") and motoric responses (e.g., get away, tell someone) to make in the inappropriate situations. Like the Teacher version, the Parent version included a script and accompanying pictures (to enhance children's attention to the program, different stories were used in the T+P parent version). The Parent version also included a "'Token Time" packet, stickers, and crayons for children to use to color the picturesWurtele, 1992bRCTUSSexual abuseOnly at preschool, only at home, both preschool and homeHead start Preschoolers (55.4 months old on average)(3-6 years old)Teachers and parents Education and life skillsPrevention: Covers: (a) that children are the bosses of their bodies: (b) to identify the location of their "private parts": (c) it is appropriate for doctors, nurses, or parents to touch children's private parts for health or hygiene reasons: (d) that otherwise, it is not okay especially if the person wants them to keep it a secret: (e) that it is wrong to be forced to touch a bigger person's private parts: and (f) that an adult's inappropriate touching of the child's private parts is never the child's faultBehavioural Skills Training (BST) programme delivered at school via a 4-day programme that taught children personal safety skills from a behavioral perspective. Working with small groups (ranging in size from 4 to 10), teachers instructed children on various topics related to personal safety and to prevent sexual abuse. Children practiced discriminating between appropriate and inappropriate touch requests, and were taught (via modeling, rehearsal, praise, and feedback) the appropriate verbal (e.g., say "No?") and motoric responses (e.g., get away, tell someone) to make in the inappropriate situations. Like the Teacher version, the Parent version included a script and accompanying pictures (to enhance children's attention to the program, different stories were used in the T+P parent version). The Parent version also included a "'Token Time" packet, stickers, and crayons for children to use to color the pictures. Zhang, 2014RCTChinaSexual abusePreschoolPreschool children(3-5 years old)Not describedEducation and life skillsPrevention: Focuses on: (1) Children are the bosses of their own bodies. (2) Identifying the locations of their ‘‘private parts.’’ (3) Recognising the appropriate requests to touch or look at children’s private parts (e.g., touching or looking at their own private parts is acceptable). (4) Otherwise, it is inappropriate for children to have their private parts touched or looked at by the bigger person and to be forced to touch the bigger person’s private parts. (5) Understanding that inappropriate touching is never children’s fault.Behavioural Skills Training programme consists of several stories (each story has an accompanying picture/pictures) about children in innocuous and potentially dangerous situations with various persons. In the program, children practiced differentiating between appropriate and inappropriate requests to touch or look at their private parts, and were taught self-protection skills including verbal (e.g., say ‘‘No!’’) and behavioral responses (e.g., leave the situations, tell the trusted persons) in the abusive situations. The self-protection skills were instructed by using teaching method of instruction, modeling, behavioral rehearsal, social reinforcement, and feedbackBucharest Early Intervention Project:Bick 2015Humphreys 2015Johnson 2010Smyke 2010Troller-Renfree 2015Wade 2018RCTRomaniaNeglectOut-of-home careIn initial trial, children enrolled between ages 6–31 monthsN/AResponse and support servicesTreatment: to examine effects of institionalisation. Children placed in institutional care were assigned either to be placed in foster care or to stay in institutional care.Good School Toolkit: Devries, 2015, 2017, 2018Merril 2018Knight 2018RCTUgandaPhysical abuse, sexual, and emotional abusePrimary school Primary school children(11-14 years old)Subsample of children with disabilitiesThe school-led activities are coordinated by two lead teacher “protagonists” and two student representatives in each school. Education and life skills; Norms and valuesPrevention: Activities are implemented over six steps in schools and relate to creating a better learning environment, respecting each other, creating opportunities for students to participate in decision-making processes, understanding power relationships, using nonviolent discipline, improving classroom management techniques, and promoting responsive school governance.The Good School Toolkit: The intervention involves head teachers, administration, teachers, and students. Targets multiple levels within the schools with multilayered training, processes, and school-led activitiesThe Toolkit materials consist of books, booklets, posters, and facilitation guides for about 60 different activities. The Toolkit itself has six steps, which are designed to be implemented in sequence to bring schools through a process of change.The protagonists and head teachers receive training at programme initiation. The schools receive one-on-one support visits and phone calls from Raising Voices staff throughout implementation.Definitions of the categories of intervention: prevention, disclosure, response, treatmentThe EGM divides the interventions into four categories – prevention, disclosure, response, treatment – which are defined as follows. 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 both interventions for any child / adult (‘universal populations’), as well as interventions targeted at specific populations. Examples of types of prevention interventions that could be included were school-based safety programmes, organisational guidelines or practices, or perpetrator targeted interventions to reduce reoffending.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, organisational guidelines).Response interventions were defined as any intervention that aimed to improve institutional responses to child maltreatment in relation to each of the target populations. Response interventions included enhancing safeguarding practices, legal and policy interventions, supporting the victim and/or family, working with child protection agencies, and providing training and crisis support to staff within organisations. 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 institutional perpetrators of child abuse. The Romania studies are included here, because foster care was provided as treatment for young children who spent their early lives in institutionalised care.ReferencesAlbers, B., & Mildon, R. (2016). Implementation best practice: A rapid evidence assessment (pp. 1–143). Melbourne: The Parenting Research Centre for the Royal Commission into Institutional Responses to Child Sexual Abuse. ‐list/Research%20Report%20‐% 20Implementation%20best%20practice%20a%20rapid%20evidence%20assesment%20‐%20Ensuring%20a%20positive%20impact.pdf.Albers, B., Fiennes, C., Shlonsky, A., Finch, M., Bj?rndal, L., Hennessy, J., & Mildon, R. (2019). PROTOCOL: Evidence and gap map protocol: Institutional responses to child maltreatment.?Campbell Systematic Reviews,?15(3), e1039.Allroggen, M., Ohlert, J., Rau, T., & Fegert, J. M. (2018). Sexual abuse prevalence rates of residents in institutional care settings compared with a population representative sample. Residential Treatment for Children & Youth, 35(4), 286–296.Baker, C. K., Gleason, K., Naai, R., Mitchell, J., & Trecker, C. (2013). Increasing knowledge of sexual abuse: A study with elementary school children in hawai ‘i.?Research on Social Work Practice,?23(2), 167-178.Baker-Henningham, H, Vera- Herna?ndez, M, Alderman, H & Walker, S. (2016). Irie Classroom Toolbox: a study protocol for a cluster- randomised trial of a universal violence prevention programme in Jamaican preschools. BMJ, 6. Doi: 0.1136/bmjopen-2016-012166Barron, I. G., & Topping, K. J. (2013). Exploratory evaluation of a school-based child sexual abuse prevention program.?Journal of Child Sexual Abuse,?22(8), 931-948.Blakemore, T, Herbert J. L., Arney F, & Parkinson, S, 2017, Impacts of Institutional Child Sexual Abuse on Victims/Survivors: A Rapid Review of Research Findings. Sydney, Royal Commission into Institutional Responses to Child Sexual Abuse. Blumberg, E. J., Chadwick, M. W., Fogarty, L. A., Speth, T. W., & Chadwick, D. L. (1991). The touch discrimination component of sexual abuse prevention training: Unanticipated positive consequences.?Journal of interpersonal violence,?6(1), 12-28. Bick, Johanna, Stamoulis, C, Fox, A. N., Zeanah, C & Nelson, A. C. (2015). Effect of early Institutionalization and Foster Care on Long-term White Matter Development: A randomized Clinical Trial. Early Institutionalization and Foster Care, 169(3). Blumberg, E. J., Chadwick, M. W., Fogarty, L.A., Speth, T. W. & Chadwick, D.L. (1991). The Touch Discrimination Component of Sexual Abuse Prevention Training: Unanticipated Positive Consequences.?Journal of Interpersonal Violence,?6(1),12–28.?, Gabriela & Andrade, María & Mikesell, Caley & Cullen, Clara & Endara, Pablo & Burneo, Verónica & Saavedra, Soledad & Ponce, Paulina & Andrade, Michelle. (2019). "I have the right to feel safe": Evaluation of a school-based child sexual abuse prevention program in Ecuador. Child Abuse & Neglect, 91, 31-40. Doi: 10.1016/j.chiabu.2019.02.009.Cecen-Erogul, A. R. & Hasirci, K. O. (2013). The effectiveness of Psycho-educational School-based Child Sexual Abuse Prevention Training program on Turkish Elementary Students. Educational Sciences: Theory & Practice, 13(2), 725-729. Cerezo, M. A & Pons-Salvador, G. (2004). Improving child maltreatment detection systems: a large-scale case study involving health, social services, and school professionals. Child Abuse & Neglect, 28(2004), 1153-1169. Chen, Y, Fortson, B & Tseng K. (2012). Pilot Evaluation of a Sexual Abuse Prevention Program for Taiwanese Children. Journal of child sexual abuse, 21, 621-45. 10.1080/10538712.2012.726699.Citak Tunc, G., Gorak, G. G., Ozyazicioglu, N, Ak, B, Isil, O & Vural, P.?(2018)?Preventing Child Sexual Abuse: Body Safety Training for Young Children in Turkey,?Journal of Child Sexual Abuse,?27 (4),?347-364,?DOI:?10.1080/10538712.2018.1477001Cochrane. Cochrane Methods Bias: Rob2: A revised Cochrane risk-of-bias tool for randomized trials. Retrieved from: , J. R. (1985). An evaluation of a program to prevent the sexual victimization of young children. Child Abuse & Neglect, 9, 319-328. Cochrane Methods Bias. (2019). RoB 2: A revised Cochrane risk-of-bias tool for randomized trials. Retrieved from: of Australia (2017) Royal Commission into Institutional Responses to Child Sexual Abuse. Canberra, Australia: Author. Crowley, K. J. (1990). Evaluation of good touches/bad touches: A program to prevent child sexual abuse in school-age children (Doctoral dissertation, Pace University, United States).Czerwinski, F, Fine, E, Alfes, J & Kolip P. (2018). Effectiveness of a school-based intervention to prevent child sexual abuse- Evaluation of the German IGEL program. Child Abuse & Neglect, 86, 109-122. Daigneault, I., Hébert, M., McDuff, P., & Frappier, J. Y. (2012). Evaluation of a sexual abuse prevention workshop in a multicultural, impoverished urban area.?Journal of Child Sexual Abuse,?21(5), 521-542.Daigneault, I, Hébert, M, Mcduff, P, Michaud, F, Vézina-Gagnon, P & Henry, A & Porter-Vignola, E. (2015). Effectiveness of a Sexual Assault Awareness and Prevention Workshop for Youth: A 3-month Follow-up Pragmatic Cluster Randomization Study. The Canadian Journal of Human Sexuality, 1, 1-12Dake, A. J., Price, H. J & Murnan, J. (2003). Evaluation of a Child Abuse Prevention Curriculum of Third-Grade Students: Assessment of knowledge and efficacy expectations. Journal of School Health, 73(2), 76-82.del Campo Sánchez, A., & Sánchez, F. L. (2006). Evaluación de un programa de prevención de abusos sexuales a menores en Educación Primaria.?Psicothema,?18(1), 1-8.\ Devries, K, Knight, L, Allen, E, Parkes, J, Kyegombe, Ni & Naker, D. (2017). Does the Good Schools Toolkit Reduce Physical, Sexual and Emotional Violence, and Injuries, in Girls and Boys equally? A Cluster-Randomised Controlled Trial. Prevention Science, 18, 839-853. 10.1007/s11121-017-0775-3.Devries, K, Kuper, H, Knight, L, Allen, E, Kyegombe, N, Banks, L. M., Kelly, S Naker, D. (2018). Reducing Physical Violence Toward Primary School Students With Disabilities. Journal of Adolescent Health, 62, 303-310 10.1016/j.jadohealth.2017.09.004.Devries, K Knight, L, Child, J, Mirembe, A, Nakuti, J, Jones, R, Sturgess, J, Allen, E, Kyegombe, N, Parkes, J, Walakira, E, Elbourne, D, Watts, C & Naker, D. (2015). The Good School Toolkit for reducing physical violence from school staff to primary school students: A cluster-randomised controlled trial in Uganda. The Lancet. Global health, 385, 378-86. 10.1016/S2214-109X(15)00060-1Dhooper, S. S., & Schneider, P. L. (1995). Evaluation of a school-based child abuse prevention program.?Research on Social Work Practice,?5(1), 36-46.Dryden, E, Desmarais, J &Arsenault, Lisa. (2014). Effectiveness of the IMPACT: Ability Program to Improve Safety and Self-Advocacy Skills in High School Students With Disabilities. The Journal of school health, 84 (12), 793-801. 10.1111/josh.12211.Edwards, K, Banyard, V, Sessarego, S, Waterman, E, Mitchell, K & Chang, H. (2019). Evaluation of a Bystander-Focused Interpersonal Violence Prevention Program with High School Students. Prevention Science, 20 (4) 10.1007/s11121-019-01000-wFryer Jr, G. E., Kraizer, S. K., & Mlyoshi, T. (1987). Measuring actual reduction of risk to child abuse: A new approach.?Child Abuse & Neglect,?11(2), 173-179.Fang, X., & Corso, P. S. (2007). Child maltreatment, youth violence, and intimate partner violence developmental relationships. American Journal of Preventive Medicine, 33(4), 281–290.Fang, X, Brown, D. S., Florence, C. S., Mercy J. A. The economic burden of child maltreatment in the United States and implications for prevention,Child Abuse & Neglect, Volume 36, Issue 2, 2012, Pages 156-165,ISSN 0145-2134Feldmann, J, Storck, C & Simone Pfeffer. 2018. Resi: Evaluation eines Programms zur Kompetenzforderung und Pravention sexuellen Missbrauchs im Kindergarten. Prax. Kinderpsychol. Kinderpsychiat, 67, 720-735 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258.Finkelhor, D., Turner, H., Ormrod, R., & Hamby, S. L. (2009). Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics, 124(5), 1411–1423.Finkelhor, D, Vanderminden, J, Turner, H, Hamby, S & Shattuck, A. (2014). Child maltreatment rates assessed in a national household survey of caregivers and youth. Child Abuse & Neglect, 38(9): 1421–1435.?doi:?10.1016/j.chiabu.2014.05.005Greger, H. K., Myhre, A. K., Lydersen, S., & Jozefiak, T. (2015). Previous maltreatment and present mental health in a high‐risk adolescent population. Child Abuse & Neglect, 45, 122–134.Grendel, M. A. (1991).?Cognitive and emotional effects of a brief child sexual abuse prevention program for first graders (Doctoral dissertation, University of Cincinnati, United States).Gushwa, M, Bernier, J & Robinson, D. (2018). Advancing Child Sexual Abuse Prevention in Schools: An Exploration of the Effectiveness of the Enough Online Training Program for K-12 Teachers. Journal of Child Sexual Abuse, DOI: 10.1080/10538712.2018.1477000 Harvey, P., Forehand, R., Brown, C., & Holmes, T. (1988). The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age children.?Behavior Therapy,?19(3), 429-435.Hazzard, A., Webb, C., Kleemeier, C., Angert, L., & Pohl, J. (1991). Child sexual abuse prevention: Evaluation and one-year follow-up.?Child Abuse & Neglect,?15(1-2), 123-138.Hébert, M., Lavoie, F., Piché, C., & Poitras, M. (2001). Proximate effects of a child sexual abuse prevention program in elementary school children.?Child abuse & neglect,?25(4), 505-522.Heidotting, T, Keiffer, S & Soled, S. W. (1994). A Qualitative Synthesis of Child Sexual Abuse Prevention Program. Child Sexual Abuse Prevention Review.Higgins, J.P.T., Sterne, J.A.C., Savovi?, J., Page, M.J., Hróbjartsson, A.,Boutron, I., … Eldridge, S. (2016). A revised tool for assessing risk of bias in randomized trials. In: Chandler J., McKenzie J., Boutron I., Welch V. (Eds.), Cochrane Methods. Cochrane Database of Systematic Reviews,Issue 10 (Suppl 1). ‐Gunn, T. L., Heppner, M. J., Mauch, P. A., & Park, H. J. (2010). Men as allies: The efficacy of a high school rape prevention intervention.?Journal of Counseling & Development,?88(1), 43-51.Hermenau, K, Goessmann, K, Rygaard, N. P., Landolt, M. A. & Hecker, T. (2017). Fostering Child Dveelopment by Improving Care Quality: A Systematic Review of the Effectiveness of Structural Interventions and Caregiver Training in Institutional Care. Trauma, Violence & Abuse, 18 (5), 544-561. Humphreys, K, Gleason, M. M., Drury, S. S., Miron, D, Nelson C. A., Fox, N. A. & Zeanah. C. H. (2015) Effects of institutional rearing and foster care on psychopathology at age 12 years in Romania: follow-up of an open, randomised controlled trial. Lancet Psychiatry, 2, 625-634. S2215-0366(15)00095-4 Jin, Y, Chen, J, Jiang, Y & YU, B. (2017). Evaluation of a sexual abuse prevention education program for school-age children in China: a comparison of teachers and parents as instructors. Health Education Research, 32(4), 364-373. Johnson, D, Guthrie, D, Smyke, A, Koga, S, Fox, N, Zeanah, C & Nelson, C. (2010). Growth and Associations Between Auxology, Caregiving Environment, and Cognition in Socially Deprived Romanian Children Randomized to Foster vs Ongoing Institutional Care. Archives of pediatrics & adolescent medicine, 164. 507-16. 10.1001/archpediatrics.2010.56.Kenny, M. C., Wurtele, S. K., & Alonso, L. (2012). Evaluation of a personal safety program with Latino preschoolers.?Journal of Child Sexual Abuse,?21(4), 368-385.Knight, L, Allen, E, Mirembe, A, Nakuti, J, Namy, S, Child, J, Sturgess, J, Kyegombe, N, Walakira, E, Elbourne, D, Naker, D & Devries, K. (2018). Implementation of the Good School Toolkit in Uganda: a quantitative process evaluation of a successful violence prevention program. BMC Public Health, 18(608),. 10.1186/s12889-018-5462-1.Kolko, D. J., Moser, J. T., Litz, J., & Hughes, J. (1987). Promoting awareness and prevention of child sexual victimization using the Red Flag/Green Flag program: An evaluation with follow-up.?Journal of family violence,?2(1), 11-35.Kolko, D. J., Moser, J. T., & Hughes, J. (1989). Classroom training in sexual victimization awareness and prevention skills: An extension of the Red Flag/Green Flag people program.?Journal of Family Violence,?4(1), 25-45.Krahé, B., & Knappert, L. (2009). A group‐randomized evaluation of a theatre‐based sexual abuse prevention programme for primary school children in Germany.?Journal of Community & Applied Social Psychology,?19(4), 321-329.Kraizer, S. (1991).?The safe child program for the prevention of child abuse: Development and evaluation of a school-based curriculum?(Doctoral dissertation, The Union Institute, United States).Krazier, K. S., Fryer, G. E. & Miller, M. (1988). Programming for preventing sexual abuse and Abduction: What does it mean when it works? Child Welfare League of America, 67(1). Lueger-Schuster, B, Knefel, M, Gluck, T. M., Jagsch, R., Kantor, V & Weindl, D. (2018). Child abuse and neglect in institutional settings, cumulative lifetime traumatization, and psychopathological long-term correlates in adult survivors: The Vienna Institutional Abuse Study. Child Abuse & Neglect, 76, 488-501.Lemaigre, C., Taylor, E. P., & Gittoes, C. (2017). Barriers and facilitators to disclosing sexual abuse in childhood and adolescence: A systematic review. Child Abuse & Neglect, 70, 39–52.Littell, J. (2018). Conceptual and practical classification of research reviews and other evidence synthesis. Campbell Methods Series: Discussion Paper 5, Campbell Collaboration. , M. J., Sims, S, O’Donnell, M, Gilbert, R. (2016). Out-of-Home-Care versus In-home care for Children who have been maltreated: A Systematic Review of Health and Wellbeing Outcomes. Child Abuse Review, 25, 251-272. DOI: 10.1002/car.2437 MacIntyre, D., & Carr, A. (1999). Evaluation of the effectiveness of the stay safe primary prevention programme for child sexual abuse.?Child Abuse & Neglect,?23(12), 1307-1325.Maniglio, R. (2009). The impact of child sexual abuse on health: A systematic review of reviews. Clinical psychology review. 29. 647-57. 10.1016/j.cpr.2009.08.003.McEalearney, A, Brennan-Wilson, A, Murphy, C, Stephenson, P & Bunting, B. (2018). Cluster randomised controlled trial of ‘while school’ child maltreatment prevention programme in primary schools in NorthernIreland: study protocol for Keeping Safe. BMC Public Health, 18 (590). Merrill, K, Knight, L, Namy, S, Allen, E, Naker, D & Devries, Karen. (2018). Effects of a violence prevention intervention in schools and surrounding communities: Secondary analysis of a cluster randomised-controlled trial in Uganda. Child abuse & neglect, 84, 182-195. 10.1016/j.chiabu.2018.06.007.Neherta M, Machmud R, Damayanti R, Afrizal. The difference in intervention of sexual abuse prevention by twovariance professions on primary school children in Padang 2015. Indian J Comm Health. 2017; 29 (1), 118-122. Nkuba M, Hermenau K, Goessmann K, Hecker T (2018) Reducing violence by teachers using the preventative intervention Interaction Competencies with Children for Teachers (ICC-T): A cluster randomized controlled trial at public secondary schools in Tanzania. PLoS ONE, 13(8). . pone.0201362 Oldfield, D., Hays, B. J., & Megel, M. E. (1996). Evaluation of the effectiveness of Project Trust: an elementary school-based victimization prevention strategy.?Child Abuse & Neglect,?20(9), 821-832.Paine, M. L., & Hansen, D. J. (2002). Factors influencing children to self disclose sexual abuse. Clinical Psychology Review, 22(2), 271–295. ‐7358(01)00091‐5Parenting Research Centre (2015). Implementation of recommendations arising from previous inquiries of relevance to the Royal Commission into Institutional Responses to Child Sexual Abuse. Sydney: Royal Commission into Institutional Responses to Child Sexual Abuse. ‐for‐royal‐commission‐onimplementation‐of‐recommendations/Pitts, C. (2015). Child sexual abuse prevention programs for pre-schoolers: A synthesis of current evidence. Sydney, Royal Commission into Institutional Responses to Child Sexual Abuse.Proeve, M, Malvaso, C & Delfabbro, P. (2016). Evidence and Frameworks for Understanding Perpetrators of Institutional Child Sexual Abuse. Sydney, Royal Commission into Institutional Responses to Child Sexual Abuse. Proctor, E, Silmere, H, Raghavan, R, Hovmand, P, Aarons, G, Bunger, A Griffey, R & Hensley, M. (2011). Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.?Administration and policy in mental health,?38(2), 65–76. doi:10.1007/s10488-010-0319-7Pulido, M, Dauber, S, Tully, B, Hamilton, P, Smith, M & Freeman, Katherine. (2015). Knowledge Gains Following a Child Sexual Abuse Prevention Program Among Urban Students: A Cluster-Randomized Evaluation. American journal of public health, 105, 1-7. 10.2105/AJPH.2015.302594.Pundir, P., Saran, A., White, H., Adona, J., Subrahmanian, R., (2019), The effectiveness of interventions for reducing violence against children: An evidence and gap map in low‐ and middle‐income countries, DOI 10.1002/cl2.1040Quadara, A., Nagy, V., Higgins, D. & Siegel, N. (2015). Conceptualising the prevention of child sexual abuse: Final report (Research Report No. 33). Melbourne, Australian Institute of Family StudiesRadford, L, Foster, R. H., Barter, C & Stanley, N. (2017). Rapid Evidence Assessment: What can be learnt from other jurisdictions about preventing and responding to child sexual abuse. London, Independent Inquiry into Child Sexual Abuse.Ratto, R & Bogat, G. (1990). A. An Evaluation of a Preschool Curriculum to Educate Children in the Prevention of Sexual Abuse. Journal of Community Psychology, 18.Rheingold, A. A., Zajac, K., & Patton, M. (2012). Feasibility and acceptability of a child sexual abuse prevention program for childcare professionals: Comparison of a web-based and in-person training.?Journal of Child Sexual Abuse,?21(4), 422-436.Rheingold, A, Zajac, K, Chapman, J, Patton, M, de Arellano, M, Saunders, B & Kilpatrick, D. (2014). Child Sexual Abuse Prevention Training for Childcare Professionals: An Independent Multi-Site Randomized Controlled Trial of Stewards of Children. Prevention Science : the official journal of the Society for Prevention Research, 16 10.1007/s11121-014-0499-6.Ricardo, C, Eads, C & Barker, G. (2011). Engaging Boys and Young Men in the Prevention of Sexual Violence: A systematic and global review of evaluated intervention. Washington, Sexual Violence Research Initiative, the Oak Foundation. R Core Team (2019). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL , A., & White, H. (2018). Evidence and gap maps: A comparison of different approaches, Campbell Methods Series: Discussion Paper 6, Campbell Collaboration. , D. A., & Wurtele, S. K. (1986). Educating children about sexual abuse: implications for pediatric intervention and possible prevention.?Journal of Pediatric Psychology,?11(2), 235-245.Scottish Child Abuse Inquiry. Retrieved from: . Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., Henry, D. A. (2017). AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non‐randomised studies of healthcare interventions, or both. BMJ, 21(358), 4008.Sherr, L, Roberts, J. K & Gandhi, N. (2017) Child violence experiences in institutionalised/orphanage care, Psychology, Health & Medicine, 22 (1), 31-57,DOI: 10.1080/13548506.2016.1271951Shlonsky, A., Albers, B., & Paterson, N. (2017). Rapid evidence review on the availability, modality and effectiveness of psychosocial support services for child and adult victims and survivors of child sexual abuse (pp. 1–85). Melbourne: University of Melbourne ‐ School of Health Sciences. ‐list/research_report_‐_rapid_evidence_review_on_the_availability_modality_effectiveness_of_psychosocial_‐_treatment.pdf.Smyke, A, Zeanah, C, Fox, N, Nelson, C & Guthrie, Donald. (2010). Placement in Foster Care Enhances Quality of Attachment Among Young Institutionalized Children. Child development, 81, 212-23. 10.1111/j.1467-8624.2009.01390.Snilstveit, B., Vojtkova, M., Bhavsar, A., & Gaarder, M. (2013). Evidence gap maps ‐ a tool for promoting evidence‐informed policy and prioritizing future research. Policy Research working paper no. WPS6725. Washington DC: World Bank Group.Snyder, C. M. (1987). An evaluation of the “Good Secrets, Bad Secrets” sexual assault prevention program (Doctoral dissertation, United States International University, United States).South, S, Shlonsky, A, & Mildon, R. (2014). Scoping Review: Evaluations of out-of-home care practice elements that aim to prevent child sexual abuse. Sydney, Royal Commission into Institutional Responses to Child Sexual Abuse. Ssenyonga, J, Hermenau, K, Nkuba, M & Hecker, T. (2018). Reducing violence against children by implementing the preventative intervention Interaction Competencies with Children for Teachers (ICC-T): Study protocol for a cluster randomized controlled trial in Southwestern Uganda. BMC, 19 (435). Stoltenborgh, M, Bakermans-Kranenburg, M. J., Alink, R. A. L & van IJzendoorn. (2015). The Prevalence of Child Maltreatment across the Globe: Review of a Series of Meta-Analyses. Child Abuse Review, 24(1), 37-50. Sullivan, P. M., Scalan, J. M., Brookhouser, P. E. & Schulte, L. E. (1992). The Effects of Psychotherapy on Behavior Problems of Sexually Abused Deaf Children. Child Abuse & Neglect, 16, 297-307. Taal, M., & Edelaar, M. (1997). Positive and negative effects of a child sexual abuse prevention program.?Child abuse & neglect,?21(4), 399-410.Taylor, B, Stein, N & Burden F. (2010). The Effects of Gender Violence/Harrassment Prevention Programming in Middle Schools: A Randomized Experimental Evaluation. Violence and Victims, 25(2). Telljohann, S. K., Everett, S. A., & Price, J. H. (1997). Evaluation of a third grade sexual abuse curriculum.?Journal of school health,?67(4), 149-153.Timmerman, M. C., & Schreuder, P. R. (2014). Sexual abuse of children and youth in residential care: An international review. Aggression and Violent Behavior, 19(6), 715–ping, K. J., & Barron, I. G. (2009). School-based child sexual abuse prevention programs: A review of effectiveness.?Review of educational research,?79(1), 431-463.Troller-Renfree S, McDermott J. M., Nelson C. A., Zeanah C. H. & Fox N. A. (2015). The effects of early foster care intervention on attention biases in previously institutionalized children in Romania.?Dev Sci, 18(5):713–722. doi:10.1111/desc.12261Tutty, M. L. (1997). Child Sexual Abuse Prevention Programs: Evaluating who do you tell. Child Abuse & Neglect, 21(9), 869-881. Van Lieshout, S, Mevissen, E. F. F., van Breukelen, G, Jonker, M & Ruiter, R. A. C. (2019). Make a Move: A Comprehensive Effect Evaluation of a Sexual Harassment Prevention Program in Dutch Residential Youth Care. Journal of Interpersonal Violence, 34(9), 1772-1800. Wade, M, Fox, A. N., Zeanah, C. H. & Nelson, C. A. (2019). Long-term effects of institutional rearing, foster care, and brain activity on memory and executive functioning. PNAS, 116(5), 1808-1813. Warden, D., Moran, E., Gillies, J., Mayes, G., & Macleod, L. (1997). An evaluation of a children's safety training programme.?Educational Psychology,?17(4), 433-448.Wolfe, D. A., MacPherson, T., Blount, R., & Wolfe, V. V. (1986). Evaluation of a brief intervention for educating school children in awareness of physical and sexual abuse.?Child Abuse & Neglect,?10(1), 85-92.Wurtele, S. K., Saslawsky, D. A., Miller, C. L., Marrs, S. R., & Britcher, J. C. (1986). Teaching personal safety skills for potential prevention of sexual abuse: A comparison of treatments.?Journal of Consulting and Clinical Psychology,?54(5), 688.Wurtele, S. K., Gillispie, E. I., Currier, L. L., & Franklin, C. F. (1992). A comparison of teachers vs. parents as instructors of a personal safety program for preschoolers.?Child Abuse & Neglect,?16(1), 127-137.Zhang, W, Chen, J, Feng, Y, Li, J, Liu, C & Zhao, X. (2013). Evaluation of a Sexual Abuse Prevention Education for Chinese Preschoolers. Research on Social Work Practice, 24. 428-436. 10.1177/1049731513510409.Walsh, K, Zwi, K, Woolfenden S, Shlonsky. (2015) A. School-based education programmes for the prevention of child sexual abuse. Cochrane Database of Systematic Reviews. 4. DOI: 10.1002/14651858.CD004380.pub3.Weatherley, R, Hajar, A. B. S., Noralina, O, Mettilda, J, Preusser, N & Yong, M. (2012). Evaluation of a school-based sexual abuse prevention curriculum in Malaysia. Children and Youth Services Review, 34, 119-125. 10.1016/j.childyouth.2011.09.009.Weird, K: American Psychological Association. (June, 2014). The lasting impact of neglect. Retrieved from , C, Shanley, D, Zimmer-Gembeck, M, Walsh, K, Hawkins, R, Lines, K & Webb, H. (2018). Promoting young children's interpersonal safety knowledge, intentions, confidence, and protective behavior skills: Outcomes of a randomized controlled trial. Child Abuse & Neglect. 82. 10.1016/j.chiabu.2018.05.024.Wickham, H. ggplot2: Elegant Graphics for Data Analysis. Springer-Verlag New York, 2016World Health Organization.?Global status report on violence prevention 2014.?Geneva: World Health Organization. Wurtele, S. K., Kast, C. L. & Melzer, M. A. (1992). Sexual Abuse Prevention Education For Young Children: A Comparison Of Teachers And Parents As Instructors. Child Abuse & Neglect, 16, 865-876. Zwi, K, Woolfenden, S, Wheeler, D. M., O’Brien, T, Tait, P & Williams, K. J. (2007). School-based education programmes for the prevention of child sexual abuse (Review). The Cochrane Collaboration, Issue 3. Art. No. D004380. DOI:10.1002/14651858.CD004380.pub2. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download