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Child Maltreatment, Interventions, 2018

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Recommendations: Interventions for Child Maltreatment

Discussion:

Burden of Disease

Rates of maltreatment are similar for girls and boys, but younger children are more likely to experience maltreatment.1 Twenty-eight percent of maltreated children are younger than 3 years, with the highest rates among children younger than 1 year (24.8 cases per 1000 children).1 Younger children also have higher mortality rates, with nearly 70% of all fatalities related to child maltreatment occurring in children younger than 3 years.1 Children younger than 1 year fare the worst, with a case fatality rate nearly 3 times that among children aged 1 year (21.6 vs 6.5 deaths per 100,000 children).1 Some data reveal racial/ethnic disparities in the incidence of maltreatment, but it is unclear as to whether this represents true disparity or reporting bias.

Childhood experiences of maltreatment can affect child and adolescent development and have long-term effects. Child abuse and neglect are considered forms of complex trauma and are associated with many negative physical and psychological outcomes, including long-term disability, chronic pain, substance abuse, and depression.314

Scope of the Review

To update its 2013 recommendation,15 the USPSTF commissioned a systematic review34 of the evidence on interventions to prevent maltreatment in children and adolescents without signs or symptoms of maltreatment. This includes interventions delivered in the primary care setting or by referral to other resources such as home visitation programs, respite care, parent education, and family support and strengthening programs. Outcomes were characterized as direct or proxy measures. Direct measures include direct evidence of physical, sexual, or emotional abuse or neglect; reports to CPS; and removal of the child from the home. Proxy measures include injuries with a high specificity of abuse, visits to the emergency department or hospital, and failure to provide for the child’s medical needs. Other measures reviewed include social, emotional, and developmental outcomes. The review focused on primary prevention; evidence on interventions in children with signs or symptoms of maltreatment or known exposure to child maltreatment is outside the scope of work of the USPSTF.

Effectiveness of Preventive Interventions

The USPSTF reviewed studies of children without signs or symptoms of maltreatment who received interventions to prevent child maltreatment delivered in or referred from primary care. The main outcomes were reduced exposure to maltreatment; improved behavioral, emotional, mental, or physical well-being; and reduced mortality. The USPSTF reviewed a total of 22 randomized clinical trials (from 33 publications) of good or fair quality. Of those 22 trials, 12 were included in the 2013 review and 10 were newly identified. There were several similarities in study characteristics across the 22 included trials, including the mother’s age (≥20 years) (15 trials), usual-care comparator (19 trials), US setting (16 trials), and, similar to the 2013 review, a home visitation component (21 trials).34

Although most trials featured home visits, 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. These personnel included nurses (7 trials), mental health professionals (2 trials), paraprofessionals (4 trials), and peer home visitors (1 trial).3 The remaining trials did not specify the training of the home visitors. Of the 21 home visitation trials, 8 featured home visits as the sole intervention.3 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 duration of interventions varied from 3 months to 3 years, and the number of planned sessions ranged from 5 to 41.3

Overall, evidence on the effect of interventions did not demonstrate benefit, or outcomes were mixed. Fourteen trials provided results on CPS reports and actions and included data collected during, at the end of, or within a year of completion of the intervention.3 Of the 10 studies included in the pooled analysis, there was no significant difference between intervention and control groups (pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]).3 Trials reporting additional results within 6 months or 1 year of the initial results also showed no significant difference between groups. Long-term follow-up (2.5 to 13.0 years after initial results) yielded mixed results, with 2 trials16-19 reporting statistically significant differences and 1 reporting no difference.20

Five trials reported on removal of the child from the home.21-26 Four trials were included in the pooled analysis, which measured results ranging from 12 months to 3 years after intervention. There was no significant difference between study groups (pooled OR, 1.09 [95% CI, 0.16 to 7.28]).3 The fifth trial not included in the pooled results reported removal at birth.25 This trial showed a nonsignificant effect for the intervention group compared with the control group (OR, 1.55 [95% CI, 0.61-3.94]).25

The evidence review demonstrated mixed results for several outcomes. Outcomes related to emergency department visits and hospitalizations were reported in 11 and 12 trials, respectively.3 Pooled analyses were not performed because of variation in outcome definitions and follow-up periods. Statistically significant reductions in all-cause hospitalization, average number of hospital days, and rates of admission were demonstrated in a minority of trials.27-30 However, most studies of hospitalization-related outcomes showed no difference between study groups.3 Evidence was also inconsistent on the effects of emergency department visits. Only 2 studies that reported outcomes within 2 years of intervention noted statistically significant reductions in the average number of all-cause emergency department visits.3132 Long-term results (>4 years of follow-up) noted statistically significant reductions in emergency department visits in 1 of 2 studies.3033 Other outcomes with mixed results included internalizing (depression or anxiety) and externalizing (disruptive, aggressive, or delinquent) behavioral outcomes (3/6 trials reported statistically significant reductions in reported behaviors),1628293234child development (1/7 trials reported statistically significant improvements in developmental outcomes),34 and other measures of abuse and neglect (1/2 trials reported statistically significant reductions in abuse and neglect findings).35

Many of the outcomes reviewed by the USPSTF had limited evidence. Four trials reported on child mortality, all with follow-up between 6 months and 9 years.2124263637 Variations in timing and outcome specifications did not allow for pooled analysis. None of the mortality outcomes reported reached statistical significance,21263637 although 1 trial did report higher mortality rates in the intervention group.24Five studies evaluated social, emotional, and other developmental outcomes;1621223337-39 all reported nonsignificant differences between study groups. One study reported on mental development at 24 months as well as school performance at 9 years and showed no statistically significant difference between control and intervention groups.3637 Trials that reported outcomes for failure to thrive (1 trial), injuries with a high specificity for abuse or neglect (1 trial), and failure to immunize (1 trial) all failed to demonstrate improvement in the intervention groups.2426

No trials reported on harms of interventions to prevent child maltreatment.

Estimate of Magnitude of Net Benefit

Overall, the USPSTF found limited and inconsistent evidence on the benefits of primary care interventions to prevent child maltreatment. It found no evidence related to the harms of primary care interventions to prevent child maltreatment. The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The level of certainty of the magnitude of the benefits and harms of these interventions is low.

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, 2018. Several comments expressed concern that studies of other interventions (such as the Safe Environment for Every Kid [SEEK] model) were not adequately reviewed by the USPSTF. The USPSTF 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. Comments also voiced concern about the accuracy of disparities statistics, noting that racial biases can affect reporting of child maltreatment. The USPSTF revised the recommendation in response to these comments. Comments noted that the USPSTF conflated the potential harms of primary prevention of maltreatment with harms associated with reporting maltreatment. The USPSTF revised the language to reflect only potential harms associated with preventive interventions. In addition, some comments asked for clarification about the clinician’s role in preventing child maltreatment. The USPSTF recognizes the important role clinicians play in identifying and reporting child maltreatment. The Current Practice section indicates that this recommendation applies to children who do not have signs or symptoms of maltreatment and that professionals and caregivers are obligated by law to report suspected child maltreatment. The USPSTF also made changes to the Summary of Recommendation and Evidence section to emphasize this point.

Other Sections:

Research Gaps and Needs

The USPSTF recognizes the importance of this serious health problem and calls for the prioritization of research to address gaps in numerous areas related to child maltreatment. There is limited evidence supporting the use of risk-assessment instruments to identify children at risk of maltreatment. Further research to determine effective methods for clinicians to identify children at increased risk should be a priority.

Although most studies included home visitation, there was significant heterogeneity in study design and outcome measurements. Standardization of outcome measurement across trials would greatly strengthen the evidence base and improve the ability to pool data. Additionally, research on home visitation should base interventions on proven and well-designed theoretical models. Without this type of contextual information, it will be difficult to interpret whether inventions are successful and, if so, how those interventions worked. When investigating interventions and outcomes, the inclusion of diverse populations and settings would help improve the applicability of study findings. These would include families with known risk factors for child maltreatment (eg, history of substance abuse in the home) and settings with limited access to social services. In addition, future research is needed to determine whether there are unintended harms from risk assessment and preventive interventions.

 

Recommendations of Others

There are varying recommendations related to the primary prevention of child maltreatment. In 2013, the American Academy of Family Physicians concluded that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment.40 The American Academy of Pediatrics has no recommendations on preventive interventions but strongly recommends clinician involvement in preventing child maltreatment and provides guidance and information on risk factors, protective factors, and clinical management.841

 

Update of Previous USPSTF Recommendation

n 2013, the USPSTF found insufficient evidence to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The current recommendation reaffirms this position.

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