Parental domestic violence and abuse (DVA), mental ill-health (MH), and substance misuse (SU) are three public health issues that tend to cluster within families, risking negative impacts for both parents and children. Despite this, service provision for these issues has been historically siloed, increasing the barriers families face to accessing support. Our review aimed to identify family focused interventions that have combined impacts on parental DVA, MH, and/or SU. We searched 10 databases (MEDLINE, PsycINFO, Embase, CINAHL, Education Research Information Centre, Sociological Abstracts, Applied Social Sciences Index & Abstracts, ProQuest Dissertations and Theses Global, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials) from inception to July 2021 for randomised controlled trials examining the effectiveness of family focused, psychosocial, preventive interventions targeting parents/carers at risk of, or experiencing, DVA, MH, and/or SU. Studies were included if they measured impacts on two or more of these issues. The Cochrane Risk of Bias Tool 2 was used to quality appraise studies, which were synthesised narratively, grouped in relation to the combination of DVA, MH, and/or SU outcomes measured. Harvest plots were used to illustrate the findings. Thirty-seven unique studies were identified for inclusion. Of these, none had a combined positive impact on all three outcomes and only one study demonstrated a combined positive impact on two outcomes. We also found studies that had combined adverse, mixed, or singular impacts. Most studies were based in the U.S., targeted mothers, and were rated as ‘some concerns’ or ‘high risk’ of bias. The results highlight the distinct lack of evidence for, and no ‘best bet’, family focused interventions targeting these often-clustered risks. This may, in part, be due to the ways interventions are currently conceptualised or designed to influence the relationships between DVA, MH, and/or SU.
Trial registration: PROSPERO registration: CRD42020210350.
Citation: Allen K, Melendez-Torres GJ, Ford T, Bonell C, Finning K, Fredlund M, et al. (2022) Family focused interventions that address parental domestic violence and abuse, mental ill-health, and substance misuse in combination: A systematic review. PLoS ONE 17(7): e0270894. https://doi.org/10.1371/journal.pone.0270894
Editor: Bronwyn Myers, South African Medical Research Council, SOUTH AFRICA
Received: December 7, 2021; Accepted: June 18, 2022; Published: July 29, 2022
Copyright: © 2022 Allen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The research data supporting this review are available within the paper and its Supporting Information files.
Funding: This report is independent research funded by a PhD studentship awarded to KA by the National Institute for Health Research Applied Research Collaboration South West Peninsula (Award Reference Number: NIHR200167; Funder website: https://arc-swp.nihr.ac.uk/). The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Parental domestic violence and abuse (DVA; defined as violence and abuse between parents/caregivers), mental ill-health (MH; defined as common mental health disorders experienced by parents/caregivers), and substance misuse (SU; defined as alcohol and drug use experienced by parents/caregivers) are three commonly experienced adverse childhood experiences (ACEs) in the UK [1–3] and worldwide [4–8] (see S1 Appendix for full definitions). There is evidence to suggest that DVA, MH, and SU not only co-occur (i.e., happen in the same time and space; ) but also cluster (i.e., are associated with one another, interact, and modify/reinforce the risk of the other occurring; ) [10–16]. Families experiencing a combination of these issues are likely to be particularly vulnerable and in need of targeted support [17, 18]. At a conservative estimate, 3.6% of children in the UK are living in households where all three issues are present , which has likely been exacerbated by COVID-19 and the resulting government-related restrictions [20–22]. This is concerning given that these issues can have a negative impact on parents’ health, parenting capacity [23, 24], and risk of child maltreatment [25–27]. Additionally, children experiencing these ACEs within the family are at increased risk of developing problems themselves with internalising and externalising behaviour during childhood  and violence, MH, and SU later on in life [24, 29, 30].
Although the clustering of risk is likely to require a response that addresses the mechanisms for these outcomes in combination , service provision and commissioning of services for DVA, MH, and SU remain largely siloed [32–34]. This creates additional barriers to access for families experiencing a combination of these issues and results in provision that fails to address the complexity of families’ needs [18, 35, 36]. In light of this, recent UK reports have emphasised a need for more interdisciplinary working between services targeting these issues, particularly within the family context [32, 36, 37]. This has led to initiatives such as the ‘Troubled Families’ programme [38, 39] and changes in the way some local authorities (LAs) commission services [40, 41]. For example, several LAs have created ‘group alliances’ funding services that respond to needs in multiple domains (see http://lhalliances.org.uk/).
While policy and practice communities are making strides to support families at risk of, or experiencing, clustered parental DVA, MH, and SU, evidence-based guidance for choice of intervention is lacking. Systematic reviews have tended to examine the effectiveness of family focused or psychosocial interventions targeting DVA, MH, and SU in isolation (e.g., [42, 43–45]). Promising approaches include advocacy, counselling/therapy, and skill-building for DVA [43, 46], counselling/therapy and home-based approaches for MH , and brief interventions, intensive case management, and motivational approaches for SU . However, findings are often mixed or limited which may partly reflect failure to address co-occuring or clustering issues in combination . Furthermore, studies and reviews that have examined combined impacts have focused on risk dyads in adults, such as DVA and MH , DV and SU , or MH and SU [50, 51], rather than all three combined or focusing on parents/families specifically. While recognising the limited evidence-base, such reviews have highlighted the potential importance of integrated interventions addressing issues in combination, trauma-informed approaches, and tailoring of interventions to meet individual needs.
This review aims to fill the gap in the evidence-base by examining whether interventions are effective in impacting outcomes in combination and, if so, what are the current ‘best bet’ family focused interventions. This review is the first of its kind and reflects current UK and global priorities for focusing on prevention [52, 53]. Our review aims to examine whether preventive, psychosocial, family focused interventions have combined impacts on parental DVA, MH, and/or SU.
This systematic review is reported in line with PRISMA guidelines  (S1 Appendix). The protocol for this review was registered on PROSPERO (CRD42020210350) and the full protocol is publicly available on the first author’s staff profile page (https://arc-swp.nihr.ac.uk/about-penarc/people/kate-allen/).
Studies were eligible for inclusion if they met the following criteria: 1) employed a randomised controlled trial (RCT) design; 2) targeted a population that included parents/carers at risk of, or experiencing, one or more of DVA (restricted to physical, sexual, emotional, coercive control, or economic violence and abuse between parents/caregivers), MH (restricted to common mental health disorders experienced by parents/caregivers), and/or SU (restricted to alcohol and/or drug misuse or dependence experienced by parents/caregivers), or targeted the children in their care; 3) examined the effectiveness of an intervention that was family focused, psychosocial and preventive, aiming to prevent or reduce parental DVA, MH and/or SU or the negative impact of these experiences on the children in their care; and 4) measured two or more of the following outcomes: DVA (victimisation/perpetration between parents/caregivers), MH (depression, anxiety, PTSD, panic disorder, OCD, general mental health of parents/caregivers), or SU (alcohol, drug use, general SU of parents/caregivers) (S1 Appendix).
Our search strategy was developed in consultation with AB, an information specialist within the PenARC evidence synthesis team at the University of Exeter, and was conducted by KA. We searched ten electronic databases (MEDLINE, PsycINFO, Embase, CINAHL, Education Research Information Centre (ERIC), Sociological Abstracts, Applied Social Sciences Index & Abstracts (ASSIA), ProQuest Dissertations and Theses Global, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials (CENTRAL)) from inception to March 2020. Our search terms fell into five main categories combined as follows: [DVA OR MH OR SU] AND parents/family AND RCTs. All searches involved free-text searching and database specific MeSH subject headings (where appropriate), and were limited to ‘English Language’ only (S1 Appendix). We updated this search in July 2021 to ensure recent literature was captured.
Backwards and forwards citation-chasing was conducted on the included studies to identify any other relevant literature that may not have been captured by the search. In addition, study authors were contacted in order to identify any additional papers relating to RCTs included within the review.
Search results were imported to EndNote V9  and duplicates removed manually, matching records on; 1) author and title; 2) author and year; and 3) title and year. We then ran records through EPPI-Reviewer 4 RCT classifier  to categorise the search results based on their likelihood of reporting on an RCT and transferred back to EndNote V9 for screening.
Title and abstract screening was conducted by KA and a second independent reviewer (KF, AG, MF, ET, VB) where studies were classified by EPPI-Reviewer 4 as ≥20% likelihood of employing an RCT, and by KA alone where studies were classified as <20% likelihood of employing an RCT . Full-text screening was conducted by KA and a random 10% were screened by a second independent reviewer (KF and MF) to ensure inclusion/exclusion criteria were applied consistently across studies. In both instances, disagreements were resolved through discussion and/or consultation with a third reviewer (VB).
Data were extracted by KA using a standardised data extraction form (see S1 Appendix) which was piloted prior to use. Extracted data included study details (authors, date, study design, country, primary aim, the proposed relationship between DVA, MH, and SU as described by authors), study sample (recruitment setting, sample characteristics such as number, age, gender, and ethnicity, and study inclusion/exclusion criteria), intervention and control group details (guided by the TIDIER checklist; ), data collected on DVA, MH, and/or SU (data collection time-points, measures, and results), data collected on child MH outcomes (data collection time-points, measures, and results), other outcomes assessed (outcomes and measures), and authors’ conclusions and recommendations for future research. Data from a random 10% of included studies were also extracted by a second independent reviewer (KF and AG) to ensure accuracy. Disagreements were resolved through discussion and/or consultation with a third reviewer (VB).
Data were sought from the articles included in the review including associated supplementary material containing information on DVA, MH, and/or SU and weblinks provided in text to any additional information on these outcomes.
KA quality-appraised the studies using the Risk of Bias Tool 2 (RoB2) for RCTs  and cluster RCTs  and a random 10% were quality appraised by a second independent reviewer (VB, G.J.M-T, TF, CB). Disagreements were resolved through discussion.
Our review uses terms from the RoB2 to refer to study quality. The RoB2 assesses the risk of bias arising from the randomisation process, identification and recruitment of participants to cluster RCTs (in the case of cluster RCTs only), assignment to the intervention group, missing outcome data, measurement of the outcome, and selection of reported results [58, 59].
The significant heterogeneity in intervention types, outcome measures and length of follow-up precluded meta-analysis so we conducted a synthesis without meta-analysis in line with SWIM guidelines .
Standardised mean differences (SMD) (i.e., Cohen’s d) and associated 95% confidence intervals (CIs) were calculated for each primary outcome of interest within each study using the information available. These were calculated between intervention and control groups at post-intervention (operationalised as the closest data-collection point following intervention delivery) and follow-up (operationalised as the latest possible timepoint following data collection at post-intervention) using the Campbell Collaboration Effect Size Calculator  and guidance from Borenstein et al.  for conversion of odds ratios and calculation of SMD variance, where applicable. The direction of SMDs and CIs were multiplied by -1 where appropriate. Where studies reported no significant differences between groups and provided no further data, SMDs were imputed as 0 and SMD variance was estimated using Borenstein et al.  formula using imputed SMD and reported sample size [63, 64]. Four studies did not provide adequate information to allow us to calculate SMD, 95% CIs, and determine the direction of the SMD for two or more outcomes at post-intervention [65–68] and four at follow-up [66–69]. For these studies, findings are reported narratively based on the authors report. One study did not present sufficiently detailed results in text or tables and therefore, study authors were contacted to request means and SDs at post-intervention .
Our primary outcomes included parental DVA, MH, and SU. Where there were multiple measures assessing the same outcome, a decision tree was followed to decide which data to synthesise, giving priority to; 1) measures collecting and presenting data on the time-point of interest (i.e., post-intervention or latest follow-up); 2) continuous outcomes; 3) imputed data; 4) analyses controlling for the most covariates. Where multiple measures met these criteria, or where only dichotomous outcomes were available, all were included within the analysis.
We reported findings narratively, grouping studies based on the combination of outcomes measured, as examining combined impacts was the primary aim of the review. We summarised studies using tables which highlighted key study characteristics. Harvest plots were used to illustrate the direction of effect and certainty of effect (i.e., 95% CI are both positive, cross zero, or are both negative) for DVA, MH, and SU outcomes within each study, the number of SMDs these categorisations were based on, and the combination of outcomes each study examined. We also used harvest plots to highlight studies that had combined impacts on two or more outcomes, categorising in terms of whether the effects for DVA, MH, or SU favoured the control (all SMDs favoured control), were mixed (some SMDs favoured control and some favoured intervention), or favoured the intervention (all SMDs favoured the intervention) and highlighting where two or more of DVA, MH, and/or SU outcomes demonstrated SMDs with positive CIs, CIs that crossed zero, or negative CIs. Harvest plots were used as they provide a useful way to organise/synthesise data about differential effects of complex interventions that may not be appropriate for meta-analyses .
Patient and public involvement and engagement (PPIE)
Patient and public involvement and engagement (PPIE) of those with experience of DVA, MH, and/or SU, service providers, and commissioners was essential in informing the design and conduct of our review.
Our review focuses on clustering DVA, MH, and SU following calls from commissioners for help in finding better ways to prevent and respond to these issues. The scope of the review was further refined to focus on family focused interventions following direction from those with experience, who highlighted the intergenerational nature of these issues and the importance of working with parents and child when providing support; a view echoed by service providers and commissioners. In addition, almost all those with experience talked about the impact these experiences had on their children (who lived at home, or with whom they had regular contact).
Primary prevention approaches, which seek to intervene early to prevent DVA, MH, and SU later in life, tend to be predominately school based, child focused, and involve measuring changes in attitudes and beliefs rather than social, emotional, and behavioural outcomes (e.g., [72–74]). Therefore, we focused on other levels of prevention to capture family focused interventions that might measure direct impacts on DVA, MH, and SU. Engagement work with LA commissioners highlighted the need to define these preventive interventions as both secondary (targeting individuals/populations at risk of, or experiencing early signs of, a particular issue) and tertiary (preventing negative impacts associated with a particular issue) interventions [75, 76], and to expand the categorisation to include treatment interventions, in recognition of the fact that these interventions often have preventive elements and may be used by commissioners for preventive purposes. This addition considerably expanded the scope of the review, but ensured it was more useful to those who might seek to apply its findings.
Finally, PPIE helped to inform our interpretation and presentation of the results. Collaborators helped to shape how the findings were presented in study characteristics tables (e.g., highlighting the context in which the interventions are situated) and structure the discussion, where we highlight findings believed to be particularly important from a commissioner and service provider perspective.
Our original search returned 127,483 results, reduced to 78,796 following de-duplication. In total, 1,470 results were screened on full text, which resulted in 43 index papers and 10 linked papers (i.e., papers linked to included index papers that contained additional information on child outcomes and/or parental DVA, MH, and SU) corresponding to 35 unique studies (Fig 1). A further two eligible studies were identified through an updated search, resulting in a total of 37 unique studies identified for inclusion (Fig 1). Six additional linked papers were identified through contacting the authors/hand searching. Where there are multiple papers associated with one study, we use the primary reference to refer to the study.
Study characteristics are summarised in Tables 1–4. All studies were published as peer-reviewed journal articles bar two PhD theses [77, 78]. Three studies employed a cluster RCT [79–81] instead of an RCT randomised at the individual level and six employed a pilot RCT [65, 82–86] as opposed to a full-sized RCT. The type of control group varied across studies with 15 employing an active control [65–68, 77, 79, 82–85, 87–91], 11 a care as usual control [64, 69, 70, 80, 81, 92–97], six a minimal care control [86, 98–102], and three employing both active and usual care controls [63, 78, 103]. Two studies provided no information on the nature of the control group [104, 105]. Most studies were conducted in the U.S. [63, 64, 66–68, 78, 79, 82–84, 86–89, 91, 92, 95, 98–103, 105], with the remaining studies conducted in Australia , Canada , South Africa , New Zealand , China , UK [69, 94], Iran , Columbia , or an undisclosed country most likely to be the U.S. based on author affiliations [65, 85, 90, 104]. Family focused interventions worked with the mother [63, 66, 69, 70, 78–82, 85, 86, 88, 91–94, 98–103, 105, 106], mother and father [65, 77, 83, 87], or parents [68, 97] with the view that this would indirectly impact the child. However, three studies worked directly with the mother and child [64, 89, 104], two with the mother, father, and child [84, 90], and one with a parent and child . No studies worked solely with the child. Studies represented a range of different ethnic groups and, even where participants weren’t specifically targeted due to low socio-economic status (SES), demographic data indicated study populations were experiencing above average levels of low SES (see S1 Appendix).
The included studies comprised a mixture of secondary prevention [80, 86], treatment of DVA, MH, or SU [69, 70, 77, 82, 87, 88, 90, 92, 93], and tertiary prevention [68, 78, 83, 85, 91, 97–99, 101, 105, 106] interventions, and many provided support at multiple preventive levels [63–67, 79, 81, 84, 89, 94, 95, 100, 102–104].
The studies varied in terms of the type of intervention delivered which we categorised as follows; home visiting or parenting [67, 80, 94, 97–99, 101–103, 105, 106], home visiting or parenting supplements [63, 68, 78, 79, 97], therapy [65, 69, 70, 77, 84–86, 88–91], multi-component [66, 82, 83, 87, 92], empowerment/advocacy [81, 93, 104], coping skills [64, 95], and brief alcohol interventions  (S1 Appendix). Across these intervention types, there were three main approaches to addressing DVA, MH, or SU including approaches which treated these issues as: 1) co-occurring, intervening with DVA, MH, and SU in separate, distinct ways using the same intervention component or separate components, and not addressing the relationship between these issues [63, 64, 67, 68, 78, 79, 85, 91, 92, 94, 95, 97–99, 102, 103, 106]; 2) uni-directional, intervening by focusing on one main issue (either DVA [89, 97], MH [69, 88], or SU [77, 80, 83, 87, 90, 100] and hypothesising that this will lead changes in the others or by targeting the relationship between issues in one direction; or 3) bi-directional, intervening concurrently using the same intervention component and addressing the relationships between two or more of DVA, MH, and/or SU [65, 66, 70, 81, 82, 84, 86, 93, 104].
Studies varied in the combination of outcomes measured with eight measuring DVA and MH [70, 78, 81, 86, 92, 93, 97, 104], four measuring DVA and SU [65, 83, 98, 99], 13 measuring MH and SU [64, 66, 67, 77, 85, 87–91, 94, 95, 100], and 12 measuring all three outcomes [63, 68, 69, 79, 80, 82, 84, 101–103, 105, 106]. Outcomes were measured post-intervention [63–70, 77–94, 97–101, 104–106] or follow-up ranging from 6 weeks to 16 years post-intervention [63, 64, 66–69, 80, 82–86, 88, 90, 91, 95, 102–106].
Risk of bias
Table 5 reports quality appraisal, further details of which can be found in S1 Appendix. The overall risk of bias judgement for the majority of studies was either ‘some concerns’ or ‘high risk’ of bias. Common issues included the use of self-report measures for DVA, MH, and SU, which may be prone to bias given that participants were often aware of their group allocation (as this is unavoidable for RCTs of psychosocial interventions), and lack of a publicly available, pre-specified data-analysis plan, making it difficult to assess whether data analysis had been conducted as intended. Several studies also failed to account for missing outcome data or provided limited information on how this was completed (n = 19). Other issues included limited information on, or problems with, the randomisation process (n = 10), failure to use valid and reliable measures (particularly for SU outcomes for which many authors relied on single self-report questions over validated measures) (n = 9), baseline differences between groups that may indicate bias in the randomisation process (n = 8), deviations from intended group assignments due to trial context (n = 4), inappropriate analysis to examine effect of assignment to intervention (n = 2), and bias in selection of reported results (n = 1).
Findings are presented and synthesised under four main headings corresponding to the combination of outcomes that studies measured: 1) DVA and MH; 2) DVA and SU; 3) MH and SU; and 4) DVA, MH, and SU. Figs 2 and 3 summarise the direction of effects for DVA, MH, and SU outcomes within each of the 37 studies using calculated SMDs and 95% CIs. Where we have been unable to calculate SMDs and 95% CIs, findings are reported narratively. Tables containing all SMDs and 95% CIs and harvest plots illustrating the direction of effect for sub-categories of DVA, MH, and SU can be found in S1 Appendix.
Harvest plots A, B, and C: Bars represent studies; Placement of bars represents direction of effect for DVA, MH, and/or SU outcomes; Numbers above bars represent number of outcome measures the categorisation is based on displayed in the following order where applicable: DVA, MH, SU; Number in bars represent the study number; Colour represents whether any of the SMDs 95% confidence intervals are positive, cross 0, or are negative (see key). Harvest plot D is same as previous but with the following addition: Height of the bar represents direction of effect for SU.
Harvest plots A, B, and C: Bars represent studies; Placement of bars represents direction of effect for DVA, MH, and/or SU outcomes; Numbers above bars represent number of outcome measures the categorisation is based on displayed in the following order where applicable: DVA, MH, SU; Number in bars represent the study number; Colour represents whether any of the SMDs 95% confidence intervals are positive, cross 0, or are negative (see key). Harvest plot D is same as previous but with the following addition: Height of the bar represents direction of effect for SU.
Domestic violence and abuse and mental ill-health.
Eight studies measured a combination of DVA and MH (Table 1, Figs 2A and 3A). Three examined advocacy/empowerment interventions for mothers who had either experienced intimate partner violence (IPV) [93, 104] or were identified as psychologically distressed or had experienced IPV . The remaining five studies involved a multicomponent intervention for mothers experiencing IPV and/or depression , a home-visiting supplement for first-time pregnant women living in poverty , a parenting intervention and parenting intervention supplement for low-income parents living in areas characterised with high levels of violence , and therapy interventions for low-income pregnant women who were at risk of MH due to experiencing IPV  and pregnant women experiencing minor or moderate DVA .
One study examining a culturally informed empowerment intervention delivered as a one-off session demonstrated a positive impact on combined outcomes of DVA and MH. Tiwari et al.  found mothers in the intervention group demonstrated better outcomes in terms of psychological abuse (SMD = 0.47, 95% CI [0.08–0.85]), minor physical abuse (SMD = 0.47, 95% CI [0.09–0.86]), and depression (SMD = 0.75, 95% CI [0.26–1.24]) at post-intervention as compared to a care as usual control group. However, the intervention group fared less favourably on a measure of general MH (SMD = -0.54, 95% CI [-0.15 –-0.93]) and there was no impact on more severe forms of physical violence or sexual abuse. The authors did not assess outcomes at follow-up. This study was rated as ‘some concerns’ in terms of risk of bias but this was mainly due to the use of self-reported measures for DVA and MH and lack of a pre-specified data-analysis plan.
One study also demonstrated a positive singular impact on DVA. Dinmohammadi et al.  examined the effectiveness of a solution-focused therapy intervention as compared to a usual care control. They found the intervention group demonstrated more positive outcomes in terms of psychological abuse at post-intervention (SMD = 0.63, 95% CI [0.189, 1.076]) however, this was not the case for other forms of violence or general MH. This study was rated as ‘high risk’ of bias.
The remaining studies did not demonstrate any impacts on our primary outcomes at post-intervention or follow-up when comparing the intervention to care as usual [81, 92, 97], a minimal support control , an active control , or a control group that was not described .
Domestic violence and abuse and substance misuse.
Four studies measured a combination of DVA and SU (Table 2, Figs 2C and 3C). Two studies examined home-visiting interventions for young, first-time mothers  and new parents deemed at risk of child maltreatment ; one examined a multicomponent intervention for fathers who had been diagnosed with alcohol abuse/dependence and were voluntarily entering SU treatment ; and one examined a therapy intervention for fathers experiencing SU and DVA perpetration .
None of the studies demonstrated combined impacts on DVA and SU. However, two studies examining home-visiting interventions demonstrated impacts on singular outcomes. Jacobs et al.  found the intervention group demonstrated more positive outcomes in terms of marijuana use compared to the minimal-care control condition at post-intervention (SMD = 0.17, 95% CI [0.02, 0.32]) and LeCroy et al.  found intervention group mothers reported less physical violence victimisation as compared to the minimal-care control group at post-intervention (SMD = 1.13, 95% CI [0.80, 1.45]). The former was rated as ‘some concerns’, and the latter ‘high risk’, of bias. The remaining two studies did not demonstrate any differences between intervention and active control groups in terms of DVA and SU at post-intervention  and follow-up .
Mental ill-health and substance misuse.
Fourteen studies examined a combination of MH and SU outcomes (Table 3, Figs 2B and 3B). Seven focused on therapy interventions targeting fathers experiencing alcohol misuse , mothers who were diagnosed with heroin addiction , mothers who had experienced IPV and were living in a family homeless shelter , mothers with SU disorder and reported parenting problems , and mothers enrolled in outpatient SU services [85, 91]. Two studies examined multicomponent interventions for men using opioids with opioid-dependent pregnant partners  and mothers diagnosed with cocaine-dependency . Two studies involved home-visiting interventions targeting mothers due to a range of risk factors [67, 94]. Two studies focused on coping-skills interventions for mothers/parents living with HIV [64, 95] and one study examined a brief intervention for mothers screened at risk of alcohol misuse .
No studies had combined positive impacts on MH and SU. However, one therapy intervention had combined negative impacts on these outcomes compared to an active control. In Suchman et al. , mothers receiving individual mentalisation-based therapy sessions demonstrated worse general MH (SMD = -1.51, 95% CI [-1.03, -1.98]) and greater heroin use (SMD = -0.67, 95% CI [-0.24, -1.10]) at post-intervention, compared to those receiving a manualised parenting education intervention. Although this result was maintained for general MH at follow-up (SMD = -1.26, 95% CI [-0.80, -1.72]), the intervention group fared better in terms of heroin (SMD = 1.00, 95% CI [0.55, 1.45]) and cocaine use (SMD = 1.03, 95% CI [0.58, 1.48]) at follow-up. This study was rated as ‘some concerns’ in terms of risk of bias.
Two other therapy intervention studies had mixed impacts on MH and SU compared to an active control. Although one study  found intervention mothers had better depression outcomes (SMD = 0.66, 95% CI [0.09, 1.23]) they fared worse in terms of heroin use (SMD = -1.78, 95% CI [-2.42, -1.14]), drug use (SMD = -1.64, 95% CI [-2.27, -1.02]), and alcohol use (any use SMD = -1.84, 95% CI [-2.48, -1.19]; intoxication SMD = -1.27, 95% CI [-1.87, -0.67]; composite SU SMD = -1.44, 95% CI = [-2.27, -1.02]) at post-intervention. Another study demonstrated that, although intervention mothers had better cocaine use outcomes at post-intervention (SMD = 0.54, 95% CI [0.19, 0.89]), this effect was lost at follow-up and mothers demonstrated worse depression outcomes (SMD = -0.38, 95% CI [-0.73, -0.03]) . These studies were rated as ‘some concerns’ and ‘high risk’ of bias, respectively.
Three studies had a positive singular impact on SU outcomes. One study reported reductions in alcohol use at post-intervention as compared to a minimal control (mean number of drinks in previous 28 days SMD = 0.35, 95% CI [0.10, 0.61] and mean number of heavy drinking days SMD = 0.34, 95% CI [0.08, 0.60]) . One reported a reduction in current general substance use as compared with care as usual (SMD = 0.50, 95% CI [0.01, 0.88]) . One study reported reductions in cocaine use compared to an active control (authors report significant difference between groups in terms of change from baseline to follow-up favouring the intervention) . The first of these studies was rated as ‘low risk’ in terms of risk of bias for MH outcomes but ‘some concerns’ in terms of risk of bias for SU outcomes . The other two were rated overall as either ‘some concerns’ or ‘high risk’ of bias [66, 95].
Domestic violence and abuse, mental ill-health, and substance misuse.
Twelve studies measured a combination of parental DVA, MH, and SU outcomes (Table 4, Figs 2D and 3D). The majority of these studies examined home-visiting interventions [80, 101–103, 105, 106] or home-visiting supplements [63, 68, 79] targeting mothers/parents for a range of demographic or contextual risk factors. Two studies focused on a therapy intervention for fathers experiencing SU and DVA perpetration  and for pregnant women meeting criteria for depression . One study examined a multicomponent intervention for homeless mothers experiencing SU .
No studies demonstrated a combined impact on two or more of parental DVA, MH, or SU outcomes and only four had an impact on one of these outcomes. Two home-visiting studies demonstrated positive singular impacts on outcomes. One found improved general MH in a paraprofessional delivered home-visiting intervention (SMD = 0.21, 95% CI [0.02, 0.40]) and less physical victimisation in a nurse delivered home-visiting intervention (past six-month physical victimisation SMD = 0.42, 95% CI [0.05, 0.78]; past 12-month physical victimisation SMD = 0.28, 95% CI [0.01, 0.55]) as compared to a minimal-care control at follow-up . Another found improved depression in the intervention group as compared to a care as usual control at follow-up (SMD = 0.14, 95% CI [0.01, 0.27]) . These studies were rated as ‘some concerns’  and ‘high risk’  of bias. One multi-component intervention demonstrated positive outcomes in terms of alcohol use compared to an active control group at post-intervention (SMD = 0.56, 95% CI [0.04, 1.07]) but this was not maintained at follow-up . One study examining a therapy intervention reported that fathers in the active control group receiving a manualised intervention involving clinician support and parenting education demonstrated greater reductions in physical violence perpetration (SMD = -0.62, 95% CI [-0.67, -0.11]) and victimisation (SMD = -0.810, 95% CI [-1.33, -0.29]) compared to the intervention group at three months follow-up . However, this study was rated as ‘high risk’ of bias.
None of the other studies had an impact on DVA, MH, or SU outcomes at post-intervention or follow-up as compared to care as usual [69, 101, 106], minimal control , active control [63, 68, 79], or a control group that was not described . One of these studies was rated as ‘low risk’ of bias , whereas the others were rated as either ‘some concerns’ [63, 79] or ‘high risk’ [68, 101, 102, 105, 106] of bias.
Commissioners and service providers are seeking better ways to prevent and respond to families with multiple and complex needs, including clustered parental DVA, MH, and SU. However, there remains a lack of evidence-based guidance for them to draw upon. To address this gap, we synthesised evidence from 37 studies to examine the effectiveness of family focused interventions targeting DVA, MH or SU. Our aim was to examine whether interventions are effective in addressing these outcomes in combination and, if so, to identify the current ‘best bet’ preventive family focused interventions.
Of the 37 studies we examined, no studies demonstrated combined positive impacts on all three of these outcomes within the timeframes examined and only one intervention had a combined positive impact on two of these outcomes. This study targeted DVA and MH, used a brief, one-off empowerment-based approach, and treated these issues as bi-directional, offering concurrent support for DVA and MH, recognising and addressing the relationships between them. Studies targeting MH and SU often demonstrated more mixed or negative impacts on outcomes which could be related to the type of intervention delivered , or perhaps because they remove a trauma coping mechanism without providing additional support to manage this. There were also several studies that demonstrated singular impacts on outcomes despite attempting to tackle DVA, MH, and SU in combination. Most of the studies were rated as either ‘some concerns’ or ‘high risk’ of bias, reducing our confidence in any positive findings.
Most interventions either implicitly or explicitly conceived the relationship between DVA, MH, and SU as co-occurring, providing support for each issue in separate, distinct ways without addressing the relationship between them, or were uni-directional, providing support targeting one main issue in the expectation that this will lead to changes in the others. However, these conceptual approaches resulted in interventions that appeared to be largely ineffective in addressing combined/clustered parental DVA, MH, and SU at post-intervention and follow-up. Uni-directional interventions tended to use therapy-based approaches to target SU as the primary issue (and MH as secondary) but failed to demonstrate any combined, or consistent singular, impacts across outcomes. Interventions that conceived these issues as co-occurring were more common; most utilised home visiting interventions or supplements, with an identification and onward referral approach for supporting these issues. However, these interventions too demonstrated no combined, and very few singular, impacts on outcomes. The commissioners and service providers we spoke to raised additional concerns with this approach indicating that, even where successful identification occurs, families are likely to be referred to existing siloed services which may present multiple barriers to access [18, 35, 36], providing another opportunity for intervention failure. Our findings here add to concerns already raised about the usefulness of uni-directional approaches within the context of complex behaviour change interventions  and question whether the ‘integrated’ nature of co-occurring approaches are integrated enough.
Integrated approaches to addressing co-occurring and clustering issues can take many forms and pose challenges for interventions targeting multiple behaviours . They can involve increasing communication, collaboration, or co-ordination between services, organisations, and/or systems; co-location of services addressing interrelated needs; introduction of multidisciplinary teams; or equipping practitioners with knowledge and understanding of co-occurring and clustered issues [131–133]. We suggest that integrated approaches for parental DVA, MH, and SU may need to go beyond these measures to concurrently recognise and address the bi-directional and complex nature of these issues [10–16], while also addressing the underlying risk factors that may give rise to, or exacerbate, them. Other researchers have highlighted the importance of adopting such an approach, particularly when working with women experiencing DVA, MH, and SU [134–136]. In our review, the only study that demonstrated combined impacts on two outcomes (DVA and MH) conceived the relationship between these issues as bi-directional; providing concurrent support for DVA and MH through a culturally informed, empowerment intervention, empathetic-understanding component, and social support from the person delivering the intervention . This provides some support for the use of such an approach, particularly where women are experiencing DVA. However, we also found interventions implicitly conceiving these issues as bi-directional that had very few or mixed impacts. These interventions were less likely to be explicitly culturally informed and/or adapted, and focused on different cultural groups, which may, in part, provide some explanation for differing impacts. Tiwari et al.  targeted the specific relationship between psychological abuse and psychological well-being considering the influences of cultural perceptions and norms. This specificity in the intervention target may have been important for its effectiveness however, the scarcity of evidence precludes us from drawing any strong conclusions.
Integration also applies to joined up working between adult and child services. Parental DVA, MH, and SU are intergenerational issues; within the family context they not only impact mothers and fathers , but also parenting capacity [23, 24] and children [24–27, 29, 30]. Whole family approaches that work with the mothers, fathers and children have been advocated to effectively address parental DVA, MH, and SU and the negative impact these issues can have on children [see 137 for example]. Our review sought family focused approaches that provide integrated support for parents and children, recognising the interrelated nature of their needs . Of the 37 studies included in our review, only eight studies attempted to directly work with children alongside their parents. These studies involved the child in family therapy , parent and child groups and/or child-only groups focused on strengths-based advocacy , empowerment and goal-setting , coping skills [64, 95], or restorative parent sessions [65, 84]. Furthermore, the majority targeted mothers alone and only six studies explicitly involved working with the father. In three studies, work with fathers occurred in parallel with working with the mother [77, 83, 87] and, in three, the mother and child [65, 84, 90]. Where studies did involve the father, this was where fathers already displayed established DVA perpetration or SU. No studies explicitly targeted fathers due to MH or for risk factors related to DVA, MH, or SU (as they did mothers). These findings echo that of previous work which highlighted that practices working at the intersection of DVA, MH, and SU tend to ‘converge’ on mothers, which may reinforce victim-blaming, monitoring of mothers, and invisibility of abusers . Although working with mothers is important, evidence suggests that paternal DVA, MH, and SU also adversely impacts child outcomes by negatively impacting mother-child relationships  or through paternal depression and diminished ability to co-parent in the case of DVA perpetration . We did not identify any clear patterns in terms of parental outcomes and who the intervention targeted. To effectively address DVA, MH, and SU, we believe one of the first steps is to redesign family focused interventions in this space to recognise and work with the whole family.
Although there were few studies in our review that demonstrated combined or singular impacts on outcomes, it is important to note that those that did were more likely to compare the intervention group with a ‘care as usual’ or ‘minimal care’ control group as opposed to an active control. However, reporting of what ‘care as usual’ involved varied across studies making it difficult to assess the generalisability of the results to other contexts/countries. Careful documentation and reporting of the ‘usual care’ control groups receive is important given that this can vary considerably across different locations and time , helps readers interpret the applicability of findings, and is important for the interpretation of null findings . Furthermore, fifteen studies included in our review used ‘active’ control groups and some of these demonstrated reductions in both groups over time (e.g., ); this could reflect regression to the mean  or be indicative of both intervention and control having positive impacts on outcomes, making these active control interventions worth further exploration.
Limitations of individual studies
Studies included in our review demonstrated several common limitations. Firstly, outcome measurements for DVA, MH, and SU varied greatly across studies and, in the case of SU, studies often relied on their own scales or single questions rather than measures with established reliability and validity. Although this may have been done to reduce participant burden , it makes synthesis across studies difficult and lowers our confidence in the findings. We encourage future authors to utilise resources on core outcomes (see https://www.comet-initiative.org/) alongside PPIE to guide selection of appropriate, reliable, and valid DVA, MH, and SU outcomes . Secondly, many studies lacked detailed information on theory, behaviour-change techniques, and mechanisms of change underpinning the interventions. This is essential to allow for an in-depth synthesis of complex interventions that is useful for decision makers . However, in the context of our review, even where these were reported, theories of change were quite distinct, and impacts on outcomes sporadic, making a synthesised family focused model for clustered risk unlikely at this stage. Thirdly, several studies failed to provide adequate data to allow us to calculate SMDs and CIs for post-intervention and follow-up timepoints. Fourthly, most studies were rated as either ‘some concerns’ or ‘high risk’ of bias when assessing quality using the RoB2 (see  for exception).
Strengths and limitations of the review
Our review is the first to examine the effectiveness of preventive family focused interventions in addressing a combination of parental DVA, MH, and SU. Its strengths include having a publicly available pre-defined protocol, examining the high-quality evidence (RCTs), a comprehensive search strategy that was developed in consultation with information specialists, broad inclusion/exclusion criteria, and being informed by PPIE work with those with lived experience, service providers, and commissioners in terms of the design, conduct, and interpretation of the results. It is unique in synthesising evidence on multiple outcomes in this space and adds to previous literature that has done this in relation to other risk behaviours (e.g., ).
As well as considering its strengths, our review should also be considered within the context of its limitations. Firstly, our searches focused specifically on RCTs to ensure it was feasible and captured the highest quality effectiveness evidence available . Consequently, our review does not include other useful forms of evidence (e.g., natural experiments such as quasi-experimental trials, ‘before-and-after’ trials, or qualitative studies) which may be preferable on pragmatic or ethical grounds [148, 149]. Future work should consider what we can also learn from the wider evidence base; we are aware of one research team already beginning to explore this area . Secondly, the parameters of our search mean that there are interventions that could be effective in preventing and addressing the combination of DVA, MH, and SU that did not meet our inclusion criteria, for example of targeting outcomes in parents (rather adults generally). There is a growing body of evidence on multisystemic therapy in emerging adults which has demonstrated some positive impacts in terms of violence, anti-social behaviour, MH, and SU in adolescents . Furthermore, RCTs that measure proxies of parental DVA, MH, and/or SU (rather than these outcomes specifically) would not have been identified by our review but may be a useful avenue for future research, particularly in the context of secondary prevention. Finally, our search strategy (designed for both the current review and a larger, intervention components analysis) resulted in a large number of search results. Although we consider our comprehensive search strategy a strength of the review, the additional time and resource needed to screen titles and abstracts, and consequent opportunity for error, is a notable limitation. Using a combination of automated filters and second screening is a useful way to make screening for such reviews more manageable and accurate, and we encourage others to adopt a similar approach when undertaking reviews on combined impacts.
Our review focuses on interventions to address one specific ACE cluster: parental DVA, MH, and SU. We examined interventions addressing this cluster due to the increased policy and practice focus on these three public health issues [32, 36, 37], the adverse impacts they can have on both parents and children [17, 24, 29, 30], and calls from commissioners, service providers and academics to advance our knowledge of interventions to address ACE clusters [152, 153]. There are undoubtedly other ACE clusters that are important to consider, and other ACEs that could be considered in combination with parental DVA, MH, and SU. For example, recent work has demonstrated that poverty is an important risk factor influencing the expression of parental DVA, MH, and SU  and that upstream approaches to supporting families (e.g., financial support, housing, income supplementation) offer promise in reducing children’s exposure to various ACEs . Although we did not include poverty as an intervention target in our review, several studies targeted parents due to low-income and the majority of study samples displayed above average levels of low socio-economic status based on indicators of income, education, and unemployment. Notably, the only study demonstrating combined impacts on two outcomes  was one of the few studies which included a sample that was not characterised by low SES across indicators. While being mindful not to make interventions so multifaceted and complex as to be implausible, considering poverty alongside DVA, MH, and SU is likely to be important target for future interventions.
Future research directions
Family focused interventions included in our review not only aimed to address parental DVA, MH, and SU, but also the negative impact these issues might have on the child. They did this by working directly with the mother (and in some cases the father) with the view this might indirectly impact the child or, in a few cases, by working directly with both the mother (and in some cases the father) and the child/ren . In addition, some studies collected direct and indirect impacts on the children’s emotional and behavioural development [64, 67, 80, 82, 83, 88–90, 94, 95, 98, 101–106]. Despite the limited positive impacts on parental outcomes, these studies may offer important insights into key intervention types and mechanisms that have the potential to ameliorate child outcomes in the context of parental DVA, MH, and SU. Furthermore, future work may also want to explore whether family focused interventions might be useful in reducing the impact DVA, MH, and SU may have on other outcomes (e.g., family functioning, parent-child interactions); outcomes many of the included studies measured.
Given the dearth of effective, targeted, family focused interventions for parental DVA, MH, and SU, we also now need to turn our attention to what an effective ‘best bet’ intervention might look like for families at risk of, or experiencing, parental DVA, MH, and/or SU. One way we can do this is examining whether there are shared intervention components that have common impacts across these three public health issues, and those which may have iatrogenic effects. We are currently undertaking work to address this, which will help highlight key intervention components that are more/less helpful and guide the development of future interventions and provision of current services in this space. An exploration of the wider literature, e.g., process evaluations, might also elucidate whether there are commonalities in why studies in our review largely failed to demonstrate combined impacts on parental outcomes. For example, issues around intervention fidelity and family engagement were occasionally cited by study authors to, in part, explain null findings and could be an important focus for future work. Furthermore, although we did not restrict our search to studies from high-income countries, we identified very few studies from low- and middle-income countries. Others have identified a similar gap in the literature , and we know of one review which will explore this in more depth; reviewing interventions addressing DVA, MH, and/or SU in low- and middle-income countries, specifically . Future work should seek to fill this gap in the evidence-base, taking into account lessons that can be learnt from high-income countries and their implementation of integrated interventions .
Parental DVA, MH, and SU are three public health issues that not only co-occur but cluster and can create an intergenerational cycle of disadvantage exacerbated by the historically siloed nature of service provision. Our systematic review highlights the distinct lack of family focused interventions that have demonstrated combined impacts in this space. This is likely to be due to the design and function of family focused interventions which often fail to address whole family needs and the interrelationships between DVA, MH, and SU. Academics are encouraged to join forces with colleagues in policy and practice and those with lived experience to explore new ways to target these clustering issues, recognise and address their bi-directional nature, and better support families most at risk.
S1 Appendix. Supporting information.
All supporting information tables and figures.
We would like to thank all those who contributed to the PPIE work that informed the design, conduct, and interpretation of our review including those with lived experience, service providers, and commissioners. Particular thanks go to Kristian Tomblin and Nicola Gregg at Devon County Council, Gary Wallace at Plymouth City Council, and Sue Ford at Torbay Council for their time and invaluable input. We would also like to extend our thanks to Alison Bethel for her support with the search strategy and excellent advice on de-duplication and screening. Finally, we thank Emily Taylor and Esther Smith for their help with second screening titles and abstracts.
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