May 23, 2018, 01:10 pm Chris Crawford – In 2016, about 676,000 children experienced maltreatment (abuse, neglect or both), which can lead to injuries and death or long-term issues such as disability, substance abuse and depression.
On May 22, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement and draft evidence review on primary care interventions to prevent child maltreatment. As it did in 2013, the task force found insufficient evidence to assess the benefits and harms of primary care interventions to prevent child maltreatment -- an "I" statement.
The evidence the USPSTF reviewed on primary care interventions to prevent child maltreatment included parental education, psychotherapy and referral to community resources, as well as home visitation programs. The task force also examined research on how to best identify children who may need interventions to prevent maltreatment.
"No child should suffer from abuse or neglect," said USPSTF member Alex Kemper, M.D., M.P.H., M.S., in a news release.
"Unfortunately, we still do not have the evidence we need about what primary care clinicians can do to prevent child maltreatment before it occurs in children who do not show any signs of abuse or neglect."
The USPSTF said although evidence is limited, primary care clinicians still are in a unique position to monitor children for signs of abuse and neglect, and must be vigilant.
"The task force is calling for more research into ways primary care clinicians can help prevent maltreatment so we can better protect all children," said USPSTF member and family physician John Epling, M.D., M.S.Ed., in the release. "Future research should look at the benefits and harms of such interventions, as well as how best to identify children at greatest risk of maltreatment."
This draft recommendation is consistent with the task force's 2013 final recommendation, which the AAFP agreed with in its own recommendation at the time.
To update its 2013 recommendation, the USPSTF commissioned a systematic review of the published evidence on interventions to prevent maltreatment in asymptomatic children and adolescents.
Outcomes were reduced exposure to maltreatment; improved behavioral, emotional, mental or physical well-being; and reduced mortality. Direct measurements included direct evidence of physical, sexual, or emotional abuse or neglect; Child Protective Services reports; and removal of the child from the home. Proxy measurements included injuries with a high specificity of abuse, visits to the ER or hospital, and failure to provide for the child's medical needs.
Evidence on interventions in children with signs or symptoms of maltreatment, or known exposure to child maltreatment was outside the scope of this review.
The USPSTF reviewed 22 randomized, controlled trials of good or fair quality. Of these, 12 were included in the 2013 review and 10 were newly identified.
The task force said the majority of the trials featured home visits but the components of the interventions varied by content, personnel, intensity, duration and use of other supporting elements.
Fifteen of the 21 home visitation trials used clinical personnel in some capacity, including nurses (seven trials), mental health professionals (two trials), paraprofessionals (four trials) and peer home visitors (one trial). The remaining trials did not specify the training of the home visitors.
Eight of the 21 home visitation trials featured home visits as the sole intervention.
"Other associated components varied considerably but included transportation services, written materials, parent education and support groups, screening and referral services, and clinical care coordination," the draft recommendation statement said.
The duration of these interventions varied from three months to three years, and the number of planned sessions ranged from five to 41.
Overall, evidence on the effect of interventions did not demonstrate benefit, or outcomes were mixed. Also, no trials reported on the harms of interventions to prevent child maltreatment.
James Stevermer, M.D., of Fulton, Mo., and Kenneth Fink, M.D., of Kailua, Hawaii, both serve on the preventive services subcommittee of the AAFP's Commission on the Health of the Public and Science as the chair and vice chair, respectively.
Stevermer told AAFP News that although the USPSTF's evidence doesn't support interventions to prevent maltreatment in asymptomatic children and adolescents, family physicians should still monitor for any unusual injury pattern, both anatomic and chronologic. Additionally, inappropriate weight gain (too much or too little), behavioral issues and/or inappropriate developmental progress are also helpful clues for neglect/abuse.
"I think there's also a role for family physicians to work to support families in developing better parenting and communication skills, as well as advocacy and community support," Stevermer said.
He added that identifying emotional abuse is much harder. "Sometimes you can be clued in to the problem by watching the parent-child interaction, or getting information from others around," Stevermer said.
Children at higher risk for abuse include those under age 4 and those with disabilities.
"Children from families that are socially isolated, or where there's family disorganization or violence, are certainly at higher risk," he said.
Stevermer said child maltreatment has devastating long-term effects, with as many as 80 percent of children who experience maltreatment eventually meeting diagnostic criteria for a psychiatric disease by age 21, including depression, anxiety and suicide attempts.
"They are at higher risk for developing substance misuse disorders, and are more likely to be arrested as a juvenile, become a teen parent and not graduate high school," he said. "The chronic stress from abuse and neglect also leads to health consequences into adulthood, including heart disease, cancer and other chronic medical problems."
Fink told AAFP News it's important to note that the USPSTF reached a different conclusion in its draft recommendation statement about the effectiveness of interventions to prevent child maltreatment than did the Community Preventive Services Task Force, which recommended early childhood home visitation programs to reduce child maltreatment among high-risk families.
Factors that protect and buffer children from abuse and neglect, Fink said, include supportive family environments and social networks. According to the CDC, other factors, such as parental employment, adequate housing, and access to health care and social services, may also serve to protect against child abuse and neglect, he said.
"Unfortunately, no single factor tells the entire story about how and why child abuse and neglect occurs, and the risk and protective factors differ depending on the type of child abuse and neglect being studied,” Fink said.
Fink said more research is needed on the impact of adverse childhood experiences (ACEs), which call for necessary and effective primary prevention interventions.
"We can also improve early identification of and intervention for children with ACEs," he said. "This area seems ripe for primary care and public health integration, with an important role for schools."
Stevermer said child maltreatment is another example where social determinants have a direct impact on patient health.
"Children in situations where their social supports are stressed are at higher risk for abuse and neglect; and conversely, the victims of abuse and neglect are at higher risk to end up in challenging social circumstances, putting themselves and their families at risk for further harms," he said.
"This is another area where family physicians can work, along with the Academy, to improve these local and national determinants that play a role in childhood abuse and neglect."
The USPSTF is inviting comments on its draft recommendation statement and draft evidence review on child maltreatment.
The public comment window for the draft recommendation and draft evidence review is open until 8 p.m. EDT on June 18. All comments received will be considered as the task force prepares its final recommendation.
The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.
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USPSTF Draft Recommendation
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CDC: Child Abuse and Neglect Prevention