A public health approach to child maltreatment requires a systematic and comprehensive prevention effort directed at the whole population. Preventive efforts integrated into settings where children spend their time (e.g. families, schools) should be supplemented by targeted prevention directed towards groups of children and families at risk for child maltreatment (e.g. families struggling with poverty, drug use, severe mental illness). Moreover, families who experience child maltreatment must have easy access to more intensive interventions. Numerous attempts to change the fate of vulnerable children, families and societies are embedded in a systematic and comprehensive public health approach. A growing body of evidence indicates any welfare system needs to be shaped by ‘what works’ and evidence-informed implementation to improve the ability of systems to benefit children and families (Lipsey, 2009; Malik et al., 2022; Mildon et al., 2014; Mildon & Shlonsky, 2011; Weisz et al., 2012). Thus, realising the potential of public health approaches for child maltreatment relies on identifying and selecting evidence-informed approaches and ensuring that these can be implemented effectively.

As outlined by Higgins et al. (2021), Core Component 4 of a public health approach focuses on identifying and selecting effective interventions. Most evidence of ‘what works’' comes from licensed and manualized programs demonstrated to reduce child maltreatment (Doyle et al., 2022; van der Put et al., 2018), commonly referred to as evidence-based programs (EBPs). EBPs are being implemented across multiple countries and jurisdictions (e.g. Schoenwald et al., 2008; Sethi et al., 2014), but there is debate on whether their effects are significant enough to warrant costly efforts to implement them (Littell et al., 2021; van Aar et al., 2017; Weisz et al., 2017), and there are challenges with scaling, financing and sustaining EBPs (Doyle et al., 2022; Waterman, 2021). This article explores current challenges to implementing EBPs for child maltreatment across systems and at scale and describes an innovative alternative common elements approach to evidence-informed intervention design that has the potential to support the scaling of public health approaches.

Current Challenges for Mobilising the Evidence Base

Challenges with Child Maltreatment Systems

Several challenges exist in secondary and tertiary prevention levels within child maltreatment systems. Policy, governance, structure, workforce and service population make it hard to implement EBP’s well system-wide (Aarons & Palinkas, 2007). In addition, such systems are often the focus of reform. Across jurisdictions, despite decades of reform in child, youth and family welfare systems, the number of children in contact with statutory child protection services continues to climb (Australian Institute of Health & Welfare, 2021; Bennett et al., 2020; Ministry of Social & Family Development, 2021; United Kingdom Statistics Authority, 2021). In South Australia, this has been estimated to be as high as 1 in every 4 children (Pilkington et al., 2017).

The ongoing system reform efforts result in frequent changes in funding that affect the availability of programs, services and referral pathways through the system. Increasing demand, alongside system reform, has flow-on effects for the workforce operating in a high-stress and high workload environment. Significant turnover and staff shortages are characteristic of child protection systems in several developed countries (see MacAlister, 2022; Radey & Wilke, 2021; United Kingdom Statistics Authority, 2022). Frontline staff are also a diverse workforce, with various qualifications, training and experience—they work across many different service environments, each with its constraints and parameters.

Child maltreatment systems struggle to provide the stability, infrastructure and finances needed to support and scale EBPs (e.g. Waterman, 2021). For example, it is difficult to recruit staff with the necessary skills (e.g. some EBPs require Master’s level qualifications which may be rare in the child maltreatment workforce in some jurisdictions) and retain qualified staff trained in an EBP. Manualized EBPs often require high training, material costs and substantial coaching and support time. Required conditions for delivering EBPs, such as low caseloads and intensive supervision, are often difficult to achieve in systems characterized by escalating demand and workforce shortages. In summary, although we have several EBPs which may benefit children and families, the nature of child maltreatment systems means that EBPs are typically implemented in limited parts of the system for a small proportion of families, as the conditions and infrastructure required to support their broad implementation, sustainment and scale-up are not available.

Challenges With Flexibility and Adaptation

There is a persistent tension between the necessary flexibility in adapting EBPs to real-world settings versus implementing with fidelity to ensure effects that are on par with those obtained in research settings (Aarons et al., 2012). An exploration of this issue is beyond the scope of this article; however, emerging evidence suggests that adaptation may be more strongly related to improved outcomes compared to adoption of a program from overseas (see Sundell et al., 2016). Yet, barriers remain for understanding how to best adapt interventions for complex systems across countries (Movsisyan et al., 2019) and factors contributing to successful adoption (Gardner et al., 2016). In the best of circumstances, implementing EBPs with quality implies navigating licensing restrictions and negotiating adaptation in a continuing process between several parties which remains a challenge for child welfare systems and public health interventions (see Moore & Evans, 2017). Few EBPs were explicitly developed for child welfare systems, where the complexity of family problems is arguably more significant than in other contexts. EBPs may lack the flexibility to address the dynamic set of issues contributing to child maltreatment. This presents challenges for scaling, as multiple programs may be needed to address the needs of all families.

A further challenge is that many EBPs for child maltreatment have been developed in the USA and are not necessarily designed to meet the needs of diverse cultural groups or for use in particular systems. For example, this issue is significant in the Australian context, where Indigenous children are over-represented in child maltreatment systems (Australia Institute of Health & Welfare, 2021). In Singapore, practitioners often need to adapt program practices for families from multi-ethnic communities. Likewise, in Europe, there is a perceived need to reduce the over-reliance on imported programs and develop effective approaches tailored to the local context (e.g. Waterman, 2021).

To successfully mobilize evidence across child welfare systems, evidence needs to be operationalized for practice in a way that (1) provides flexibility to address the broad and changing range of issues contributing to child maltreatment and (2) allows for adaptation for service system context to maximize its utility, acceptability and uptake across the service system. Whilst this seems difficult to achieve, innovations in intervention design may address some of the challenges outlined above. Therefore, we believe the conversation needs to move beyond ‘what works?’ to include questions such as ‘what is implementable?’, ‘what is scalable?’ and ‘what is sustainable?’ in particular systems and contexts.

Mobilizing ‘What Works’ Through the use of Common Elements

EBPs will remain an essential part of service provision for particular families where the right system conditions are present to support these programs. However, such programs are unlikely to be the solution for mobilizing evidence across whole systems. The challenge researchers, policymakers and practitioners face is how we can innovate and build upon existing evidence to achieve more significant mobilization of ‘what works’' to address child maltreatment.

EBPs provide a comprehensive set of practices, and there are commonalities that can be consolidated–a strategy that may support a public health approach. In response to the challenges outlined above, an alternative approach has been proposed to identify discrete practices or elements that are common across multiple EBPs with demonstrated efficacy: which is referred to as the ‘common elements’ approach (Chorpita & Daleiden, 2009; Garland et al., 2008). Once identified, the common elements can be implemented flexibly by practitioners with the support of decision-making tools and implementation strategies. This enables practitioners to tailor their practice according to clients’ needs and contexts, potentially increasing the feasibility and acceptability of their intervention to serve a range of diverse populations.

Chorpita and colleagues proposed using the term ‘practice element’ to refer to discrete practices, strategies, techniques and components found in multiple and manualized programs (Chorpita et al., 2005). Practice elements must be explicitly defined and coded reliably (e.g. using a definition or coding manual) (Chorpita et al., 2005). Once practice elements are distilled from the literature, ‘common elements’ can be identified—i.e. elements that are found in programs that demonstrate significant effects. The predominant approach used to identify common elements involves (1) distilling individual practice elements from a variety of sources (e.g. stakeholder engagement, expert input, programs manuals and recordings of treatment sessions); (2) identifying the practice elements that are found across multiple EBPs, (3) identifying common elements and (4) an optional step that involves matching common elements to a variety of client characteristics and needs.

Several methodologies have been developed. One is the distillation and matching model (Chorpita & Daleiden, 2009; Chorpita et al., 2002, 2005), whereby an a priori set of practice elements nominated by subject matter experts and stakeholders is used to form a codebook. EBPs found in a literature review are coded for these elements. This is followed by a process used to identify the common elements in EBPs that demonstrate significant effects. A final matching process can then be conducted wherein characteristics of a service setting (e.g. client characteristics) are matched to common elements to determine what common elements are the best for a particular context.

A second methodology involves an open-ended, ground-up approach (Garland et al., 2008; McLeod et al., 2017; Sutherland et al., 2019). Practice elements are coded iteratively through reviewing EBP manuals, typically identified through a systematic review. The final list of practice elements is validated through a survey with subject matter experts. A meta-regression approach constitutes the third methodology (Lipsey, 2009). Following a systematic review to identify EBPs, a meta-analysis is conducted to determine the size of the effects that each type of program (e.g. counselling, psychoeducation) has on the target outcome. The common element is defined as the predominant type of intervention delivered. Finally, elements can be empirically distilled from observational fidelity measures through exploratory and confirmatory factor analysis (Hogue et al., 2017, 2019, 2021).

Common elements have been identified for the prevention and reduction of child maltreatment and to support reunification in several studies. A study by Barth and Liggett-Creel (2014) identified the practice elements of three programs (i.e. Triple P—Positive Parenting Program, SafeCare and Child-Parent Psychotherapy). Common elements included positive reinforcement, modelling and role play. Kaye et al. (2018) examined home visitation programs to prevent child maltreatment and identified common content, process and sustainability elements. Common content elements (i.e. information or skills shared with clients) included teaching parents about problem-solving, providing information or activities focused on establishing a safe and clean home environment, and accessing social support. Common process elements (i.e. the mode and methods by which content was delivered) included lesson-focused instruction, problem-focused discussion and modelling. Common sustainability elements (i.e. program factors used to prolong and sustain program effects after completion of services) included providing referrals and assisting parents to build social networks. A recent systematic review identified eight practices from evidence-based reunification programs (Luu et al., 2022), namely awareness-raising, building motivation, goal setting, parent coaching, parent training, role-modelling, parent homework and parent partnering.

Principles of the common elements approach are also found in precision prevention science, a response to challenges in recruitment and retention of participants in public health interventions (Supplee et al., 2018). The promising new area of precision home visiting (The Home Visiting Applied Research Collaborative: HVARC, 2018) also focuses on identifying elements or ‘active ingredients’ from home visiting programs that are essential to achieving desired outcomes for particular subgroups of children and families to enable practitioners to tailor programs to meet their clients’ needs and desired outcomes (HVARC, 2018).

Interventions based on common elements appear to offer advantages in acceptability and feasibility. The small but growing number of evaluations thus far has demonstrated generally favourable results (e.g. Chacko & Scavenius, 2018; Chorpita & Weisz, 2009; Kane et al., 2017). The use of common elements equips practitioners with techniques that can be applied to a diverse range of clients across multiple practice areas, rendering more flexibility and responsiveness to client presentation, needs and priorities (Barth et al., 2014; Bruns et al., 2014; Chorpita et al., 2005, 2007; Hogue et al., 2017; Institute of Medicine, 2015; Marchette & Weisz, 2017; Rotheram-Borus et al., 2012). This approach can be less taxing for organisations to implement than multiple EBPs and potentially more sustainable (Hogue et al., 2017). However, this approach is still in an emerging and experimental stage. There is limited research on the effectiveness of elements in isolation from, or in different combinations from, the EBPs from which they are taken (Swartz, 2015). Without this, elements need to be regarded as ‘best bets’, and their application rigorously evaluated before claims about effectiveness can be made. Most importantly, their use must be supported with a full range of implementation strategies, tools and resources. The resources required may compare favourably with those involved in the implementation of multiple EBPs, but should not be under-estimated.

Evidence-informed Implementation

One strength of EBPs is their attention to supporting and monitoring the quality of implementation, which is intrinsic to achieving intended outcomes (Durlak & Dupre, 2008). Focusing on evidence-informed approaches without attention to implementation is “like a serum without a syringe; the cure is available, but the delivery system is not” (Fixsen et al., 2010).

As with EBPs, the success of common element interventions depends on their implementation (i.e. how to support the delivery of the intervention) and the content (i.e. which common elements are included). Recent evaluations of common element intervention that tested reduced implementation support (Merry et al., 2020; Thomassin et al., 2019) found less favourable results than earlier trials which involved more intensive support. A complete set of implementation strategies needs to be designed, planned and embedded alongside the use of common elements in practice.

Common elements have often been implemented using a modular approach—see for instance, the modular approach for treatment of children with anxiety, depression, trauma and conduct problems (MATCH-ADTC: Chorpita & Weisz, 2009); the CBT + Initiative (Dorsey et al., 2016; Lyon et al., 2014); the common elements treatment approach (CETA) (Murray et al., 2014, 2018) and, specifically in the area of child maltreatment, the ‘Hope for Children’ and families (HfCP) intervention resources (Bentovim & Elliot, 2014). Several approaches, such as MATCH-ADTC, have developed specific assessment and decision-making resources to support their implementation. When a common element approach is implemented in child maltreatment systems, implementation strategies need to be planned based on an analysis of implementation barriers and facilitators at multiple levels of the system—individual practitioner, team, organisation and the broader system (Damschroder et al., 2009; Waltz et al., 2019). This involves developing protocols and practice resources for individuals and teams to support behavioural change, engage practitioners in support of change, and support implementation through training, coaching and supervision. At an organisational level, it involves implementing strategies to address the fit with organisational processes. Local implementation teams and data systems to monitor implementation progress, fidelity and support continuous quality improvement are essential aids to implementation. At a systems level, implementation strategies are needed to align common elements interventions with the service delivery context—for example, the fit with existing practice frameworks, legislation, policy and funding parameters. In the authors’ collective experience implementing evidence-informed approaches for child maltreatment, a significant focus is often placed on achieving practice change in front-line staff through implementation strategies such as training. Less attention is given to the system-level factors required to support these new ways of working, and lack of attention to these factors often hamper implementation efforts.

The Next Steps for Mobilizing ‘What Works’ in Child Maltreatment

The identification, application and implementation of common elements is a recent development. There is a small, growing amount of evidence behind the effectiveness of this approach. Interventions based on common elements are often seen as substitutes for EBPs (Chorpita et al., 2007); however, they are not yet a proven methodology, and their utility should be further explored. For example, Australia’s reform efforts focus on implementing and evaluating EBPs alongside a common elements approach for scaling a state-wide response to child maltreatment (Morris et al., 2021; Department of Families, Fairness & Housing, 2021).

To explore the potential of common elements for mobilizing evidence, continued work on robust approaches related to their identification is needed. Combining common elements from diverse fields, where underlying theory may differ or conflict, is required. The flexibility of common elements may lead practitioners to select and implement in an inconsistent manner (Barth et al., 2011; Weisz et al., 2012). More work is needed to understand how to support the systematic selection of practices to fit varying presentations and priorities.

The consolidation of literature on elements has also been hampered by the lack of a common language (Institute of Medicine, 2015). The terminology has included ‘practice elements’, ‘common practice elements’, ‘core components’, ‘common active ingredients’ and ‘common factors’ (e.g. Gubbels et al, 2019). As a result, the level or nature of elements is not always clear or consistent. A full exploration of this issue is beyond the scope of this article. However, we propose the distinction needs to be made between practice elements (techniques found across multiple programs) and common elements (techniques found across multiple programs that demonstrate significant effects on target outcomes). This distinction is critical, and further standardisation of the terminology is needed to progress the research and application of these approaches.

In conclusion, we believe one of the significant challenges for implementing a public health approach to child maltreatment is that currently, the evidence is not always ‘implementable’ in real-world systems. Further research and evaluation efforts should explore the most effective and least restrictive ways that evidence can be mobilized to address child maltreatment. Approaches that draw on common elements alongside tailored implementation strategies offer a promising way forward for achieving the flexibility and adaptability needed to apply evidence in real-world systems in a way that can be scaled and sustained.