On Nov. 27, The U.S. Preventive Services Task Force (USPSTF) posted a final recommendation statement(www.uspreventiveservicestaskforce.org) and final evidence summary(www.uspreventiveservicestaskforce.org) on primary care interventions to prevent child maltreatment.
The USPSTF found insufficient evidence to assess the benefits and harms of primary care interventions to prevent child maltreatment -- an "I" statement.(www.uspreventiveservicestaskforce.org)
The task force reviewed evidence on primary care-based interventions to prevent child maltreatment, including 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.
The USPSTF said that 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.
"More research is needed on ways to prevent maltreatment before it occurs so that we can better protect all children," said task force member and family physician John Epling, M.D., M.S.Ed., in a news release.(www.uspreventiveservicestaskforce.org) "Future research should look at the benefits and harms of such interventions as well as how best to identify children at greatest risk."
This final recommendation is consistent with the USPSTF's May draft recommendation and 2013 final recommendation,(www.uspreventiveservicestaskforce.org) which the AAFP supported at the time.
Final Recommendation Details
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 that were delivered in or referred from primary care.
- On Nov. 27, the U.S. Preventive Services Task Force (USPSTF) posted a final recommendation statement and final evidence review on primary care interventions to prevent child maltreatment.
- The evidence the USPSTF reviewed on such interventions included parental education, psychotherapy and referral to community resources, as well as home visitation programs.
- 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.
Outcomes examined 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 for 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 considered outside the scope of this review.
Overall, the USPSTF reviewed 22 randomized, controlled trials of good or fair quality. Of those, 12 had been included in the 2013 review and 10 were newly identified.
The task force said the vast 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.
For example, 15 of the 21 trials that included home visitation 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.
Although eight of the 21 home visitation trials featured home visits as the sole intervention, other intervention components varied widely, ranging from provision of written materials, to parent education and support groups, as well as screening and referral services.
The duration of 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.
Response to Public Comment
A draft version of this recommendation statement was posted for public comment on the USPSTF website from May 22 to June 18.
Some commenters said they were concerned that studies of other interventions (such as the Safe Environment for Every Kid [SEEK] model) were not adequately reviewed by the task force. However, the USPSTF said it reviewed all suggested studies and found that they did not meet eligibility requirements for inclusion, primarily because the studies were rated as poor quality or did not report eligible outcomes.
Studies that included the SEEK model were included in the sensitivity analysis but did not change outcomes, the final recommendation noted.
Commenters also voiced concern about the accuracy of disparities statistics, noting that racial biases can affect reporting of child maltreatment. In response to these comments, the USPSTF revised its recommendation.
Other commenters said the task force conflated the potential harms of primary prevention of maltreatment with harms associated with reporting maltreatment. In response, the USPSTF revised the recommendation's language to reflect only potential harms associated with preventive interventions.
Additionally, some commenters asked for clarification about clinicians' role in preventing child maltreatment, which prompted the task force to affirm the importance of identifying and reporting child maltreatment.
The Current Practice subhead in the Clinical Considerations section(www.uspreventiveservicestaskforce.org) of the recommendation statement now reinforces the point that this recommendation applies to children who don't have signs or symptoms of maltreatment and that professionals and caregivers are obligated by law to report suspected child maltreatment.
The AAFP's Commission on Health of the Public and Science plans to review the USPSTF's final recommendation statement and evidence summary and determine the Academy's stance on the recommendation.
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Leader Voices Blog: Child Abuse: We Have a Role to Play
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American Family Physician: Diagnosis and Management of Physical Abuse in Children
CDC: Child Abuse and Neglect Prevention(www.cdc.gov)