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Am Fam Physician. 2014;90(4):online

Related Putting Prevention into Practice: Primary Care Interventions to Prevent Child Maltreatment

Summary of Recommendation and Evidence

The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. This recommendation applies to children who do not have signs or symptoms of maltreatment (Table 1). I statement.

PopulationChildren and adolescents 0 to 18 years of age without signs or symptoms of maltreatment
RecommendationNo recommendation
Grade: I statement
Risk assessmentThere are numerous risk factors associated with child maltreatment, including but not limited to:
Young, single, or nonbiologic parents
Parental lack of understanding of children's needs, child development, or parenting skills
Poor parent-child relationships/negative interactions
Parental thoughts or emotions that support maltreatment behaviors
Family dysfunction or violence
Parental history of abuse or neglect in family of origin
Substance abuse within the family
Social isolation, poverty, or other socioeconomic disadvantages
Parental stress and distress
InterventionsAlthough the evidence is insufficient to recommend specific preventive interventions, most child maltreatment prevention programs focus on home visitation. Home visitation programs usually comprise a combination of services provided by a nurse or paraprofessional in the family's home on a regularly scheduled basis; most programs are targeted to families with young children and often begin in the prenatal or postnatal period.
Balance of benefits and harmsThe evidence on interventions in primary care to prevent child maltreatment among children without signs or symptoms of maltreatment is insufficient, and the balance of benefits and harms cannot be determined.
Other relevant USPSTF recommendationsThe USPSTF has made recommendations on screening for intimate partner violence and abuse of elderly and vulnerable adults. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

Rationale

IMPORTANCE

In 2011, approximately 680,000 children were confirmed victims of maltreatment, and approximately 1,570 died of such treatment.1 Approximately 78% experienced neglect, 18% physical abuse, and 9% sexual abuse; many experienced several forms of maltreatment.1

BENEFITS OF INTERVENTIONS

There is inadequate evidence that primary care interventions can prevent maltreatment among children who do not already have signs or symptoms of such treatment. Reasons for this conclusion include significant heterogeneity in study methods and interventions. There is also inconsistent and limited evidence on outcomes or how they were measured.

HARMS OF DETECTION AND EARLY INTERVENTION OR TREATMENT

Although there are numerous concerns about the possible harms of interventions for child maltreatment, evidence of these harms is limited.

USPSTF ASSESSMENT

The USPSTF concludes that the evidence is limited and inconsistent, and is therefore insufficient to determine the balance of benefits and harms of interventions in primary care to prevent child maltreatment among children without signs or symptoms of such treatment.

Clinical Considerations

PATIENT POPULATION

This recommendation applies to children in the general U.S. population from birth to 18 years of age who do not have signs or symptoms of maltreatment. Child maltreatment is defined by the Centers for Disease Control and Prevention as any act or series of acts of commission or omission by a parent or other caregiver that result in harm, potential for harm, or threat of harm to a child.2 Child abuse (acts of commission) includes physical, sexual, and psychological abuse. Child neglect (acts of omission) includes the failure to provide for a child's basic physical, emotional, health care, or educational needs or to protect a child from harm or potential harm.3

ASSESSMENT OF RISK

Numerous risk factors are associated with child maltreatment, including but not limited to young, single, or nonbiologic parents; parental lack of understanding of children's needs, child development, or parenting skills; poor parent-child relationships or negative interactions; parental thoughts or emotions that support maltreatment behaviors; family dysfunction or violence; parental history of abuse or neglect in the family of origin; substance abuse within the family; social isolation, poverty, or other socioeconomic disadvantages; and parental stress and distress.

INTERVENTIONS

Although the evidence is insufficient to recommend specific preventive interventions in a clinical setting, most programs for prevention of child maltreatment studied and recommended by others focus on home visitation, which is generally considered to be a community-based service. Home visitation programs usually comprise a combination of services provided by a nurse or paraprofessional in a family's home on a regularly scheduled basis. Most home visitation programs are targeted to families with young children and often begin in the pre- or postnatal period.

The services provided in home visitation programs often include parent education on normal child development, counseling, problem solving, free transportation to health clinic appointments, enhancement of informal support systems, linkage to community services, promotion of positive parent-child interactions, ensuring a source for regular health care, promotion of environmental safety, and classes for preparing for motherhood. The one trial reviewed by the USPSTF that was not a home visitation program used a multistep approach in a primary care clinic, with a social worker available to help parents who self-reported psychosocial problems, such as substance abuse.

SUGGESTIONS FOR PRACTICE REGARDING THE I STATEMENT

Potential Preventable Burden. Child maltreatment is a serious problem that affected more than 680,000 children and resulted in approximately 1,570 deaths in 2011. It can result in lifelong negative consequences for victims. Most child maltreatment is in the form of neglect (approximately 78%), and most deaths occur in children younger than four years (approximately 80%).1

Potential Harms. There is limited evidence on the harms of interventions to prevent child maltreatment. Reported potential harms include dissolution of families, legal concerns, and an increased risk of further harm to the child.

Current Practice. All states and the District of Columbia have laws mandating that all professionals who have contact with children, including all health care workers, report suspected maltreatment to child protective services.4 Pediatricians, family physicians, and other primary care clinicians are in a unique position to identify children at risk of maltreatment through well-child and other visits. However, although pediatricians state that preventing maltreatment is one of their primary roles,5 they rarely explicitly screen for family violence in practice or screen only in selected cases.6,7 All states have home visiting programs to support families with young children, but the services provided in these programs and the eligibility criteria vary by state.

USEFUL RESOURCES

The USPSTF has updated its recommendation on screening for intimate partner violence and abuse of elderly and vulnerable adults (available at http://www.uspreventiveservicestaskforce.org).

The Community Preventive Services Task Force has issued a recommendation on early childhood home visitation to prevent child maltreatment (available at http://www.thecommunityguide.org/violence/home/index.html).

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of USPSTF recommendation statements published in AFP is available at https://www.aafp.org/afp/uspstf.

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