Draft Recommendation Statement
Child Maltreatment: Primary Care Interventions
This opportunity for public comment expired on June 18, 2018 at 8:00 PM EST
Note: This is a Draft Recommendation Statement. This draft is distributed solely for the purpose of receiving public input. It has not been disseminated otherwise by the USPSTF. The final Recommendation Statement will be developed after careful consideration of the feedback received and will include both the Research Plan and Evidence Review as a basis.
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Draft: Recommendation Summary
|Children and adolescents age 18 years and younger|
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment.
See the Clinical Considerations section for suggestions for practice regarding the I statement.
Read the plain-language consumer summary of the draft Recommendation Statement.
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
In 2016, approximately 676,000 children were subjected to maltreatment (abuse, neglect, or both), with 75% of children experiencing neglect, 18% experiencing physical abuse, and 8% experiencing sexual abuse. Approximately 14% of abused children experienced multiple forms of maltreatment, and more than 1,700 children died as a result of child maltreatment.1
Benefits of Interventions
The USPSTF found inadequate evidence that interventions initiated in primary care can prevent maltreatment among children who do not already have signs or symptoms of such maltreatment. The research in this area is notable for a lack of accurate methods to predict a child’s individual risk of maltreatment, significant heterogeneity in types of preventive interventions for maltreatment, and limited and inconsistent reporting of outcomes.
Harms of Interventions
Potential harms of preventive interventions initiated in primary care include stigma, unnecessary involvement with Child Protective Services (CPS) or the legal system, and dissolution of the family. However, the USPSTF found inadequate evidence to assess the magnitude of these harms.
Evidence on interventions to prevent child maltreatment is limited and inconsistent; therefore, the USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of interventions initiated in primary care to prevent child maltreatment in children and adolescents.
Draft: Clinical Considerations
Patient Population Under Consideration
This recommendation applies to children and adolescents age 18 years and younger in the U.S. population who do not have signs or symptoms of maltreatment. The Centers for Disease Control and Prevention define child maltreatment as any act or series of acts of commission (abuse) or omission (neglect) by a parent or other caregiver (e.g., clergy, coach, or teacher) that results in harm, potential for harm, or threat of harm to a child.2 Words or actions that are deliberate and cause harm, potential harm, or threat of harm are considered acts of commission (e.g., physical, sexual, and psychological abuse).2 Failure to provide for a child’s basic physical, emotional, or educational needs or to protect a child from harm or potential harm constitutes an act of omission (neglect).2
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
Approximately 676,000 U.S. children were subjected to abuse or neglect in 2016.1 Of those, 1,700 died as a result of that maltreatment.1 Younger children appear to be the most vulnerable, with nearly 25 per 1,000 children younger than age 1 year identified as victims.1 Abuse and neglect can result in long-term negative physical and emotional consequences for victims. Risk factors of maltreatment in children include young age (<4 years), having special health care needs, and past history of maltreatment. Children are also at increased risk based on factors related to their caregiver or environment, including having young, single, or nonbiological parents or parents with poor educational attainment, low income, history of maltreatment, and social isolation. Additionally, living in a community with high rates of violence, high rates of unemployment, or weak social networks are linked to child maltreatment.3
The USPSTF reviewed risk assessment instruments used to identify children for whom preventive interventions might be indicated and found limited and inconsistent evidence on the validity and reliability of these tools.3
The USPSTF found a lack of evidence on the harms associated with interventions to prevent child maltreatment. Potential harms of preventive interventions include stigma, unnecessary involvement of the family with CPS or the legal system, and dissolution of the family.
Due to the recommended schedule of periodic health assessments, primary care clinicians, including pediatricians, family clinicians, and others, are uniquely positioned to identify child maltreatment. The Federal Child Abuse Prevention and Treatment Act sets minimum standards for state laws overseeing the reporting of child abuse and neglect.4 All states and the District of Columbia mandate that all professionals who have contact with children report suspected child maltreatment to CPS.4 An estimated 3.4 million CPS reports were filed in 2016;1 however, there is evidence that many cases of child abuse and neglect are not reported.5 Several factors may play a role in the underreporting of child maltreatment, including missed diagnosis of intentional child injury, fear of alienating caregivers, and stigma related to CPS involvement.6 Signs and symptoms of child abuse include, but are not limited to, frequent injuries or unexplained/inconsistent explanation of injury cause, signs of poor hygiene, or lack of medical care; frequent absences from school; being excessively withdrawn or fearful; unexplained changes in behavior; trouble walking or sitting; and displaying knowledge of sexual acts inappropriate for age.6 Preventive interventions initiated in primary care focus on preventing maltreatment before it occurs.
Although the USPSTF found insufficient evidence to recommend for or against preventive interventions in primary care settings, several strategies for preventing child abuse and neglect have been studied. Specific interventions include primary care programs designed to identify high-risk patients and refer them to community resources, parent education to improve nurturing and increase the use of positive discipline strategies, and psychotherapy to improve caregivers’ coping skills and strengthen the parent-child relationship.3 These interventions are delivered in settings such as primary care clinics, schools, and the community.
The majority of available research has studied home visitation programs.3 These programs are usually comprised of a professional (or paraprofessional, such as a peer educator or community health worker) providing periodic counseling, educational services, or support in a family’s home. Families are identified and referred most often by health care providers in the prenatal and immediate postpartum period. These services contain multiple components, including assessing family needs, providing information and referrals, providing clinical care, and enhancing family functioning and positive child-parent interactions.3 All states and the District of Columbia, as well as tribal and territorial entities, have home visitation programs to support families with young children.7 Eligibility criteria and services provided vary by location.7 The USPSTF reviewed evidence that included home visitation–based interventions. Although the USPSTF found insufficient evidence to assess the benefits and harms of preventing maltreatment among asymptomatic children, this recommendation does not assess the effectiveness of home visitation programs in other contexts (e.g., improving child/maternal health, encouraging positive parenting, or promoting child development) or other situations (e.g., secondary prevention of abuse and neglect).
The USPSTF has issued a recommendation on screening for intimate partner violence, elder abuse, and abuse of vulnerable adults.8 The Centers for Disease Control and Prevention provide Web-based resources for the prevention of child abuse and neglect.9 The Administration for Children and Families offers resources on child maltreatment, including definitions, identification of signs and symptoms, and statistics.4
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.
Most studies included home visitation, but the evidence review highlighted 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 in this area 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 (e.g., history of substance abuse in the home) and settings with limited accesses to social services. Finally, future research is needed to determine whether there are unintended harms from risk assessment and preventive interventions.
Burden of Disease
Rates of maltreatment are similar for girls and boys, but younger children are more likely to be victimized.1 Twenty-eight percent of victims are younger than age 3 years, with the highest rates among children younger than age 1 year (24.8 cases per 1,000 children).1 Younger children also have higher mortality rates, with nearly 70% of all fatalities occurring in children younger than age 3 years. Children younger than age 1 year fare the worst, with a case fatality rate nearly 3 times that among children age 1 year and older (21.6 vs. 6.5 deaths per 100,000 children).1
There are noted racial/ethnic disparities in the incidence of child maltreatment. White children experience maltreatment at a rate of 8.1 cases per 1,000 children, while the rate is nearly double in American Indian or Alaskan Native children (14.2 cases per 1,000 children), followed closely by African American children (13.9 cases per 1,000 children).1 These disparities persist in the number of fatalities attributed to maltreatment. The fatality rate in African American children (4.65 deaths per 100,000 children) is approximately 2 times greater than the rate in white children (2.08 deaths per 100,000 children) and 3 times greater than the rate in Hispanic children (1.58 deaths per 100,000 children).1
These adverse childhood experiences can affect child and adolescent development and have long-term consequences. Child abuse and neglect are considered to be forms of complex trauma and are associated with many negative physical and psychological outcomes, including long-term disability, chronic pain, substance abuse, and depression.3, 10
Scope of the Review
To update its 2013 recommendation,11 the USPSTF commissioned a systematic review3 of the published evidence on interventions to prevent maltreatment in asymptomatic children and adolescents. 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; CPS reports; and removal of the child from the home. Proxy measures include injuries with a high specificity of abuse, visits to the emergency room or hospital, and failure to provide for the child’s medical needs. 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 this review.
Effectiveness of Preventive Interventions
The USPSTF reviewed studies of asymptomatic children 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, controlled 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 trials, including the mother’s age (≥20 years) (15/22 trials), usual care comparator (19/22 trials), U.S. setting (16/22 trials), and, similar to the 2013 review, a home visitation component (21/22 trials).3
Although the majority of 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, eight 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 five to 41.3
Overall, evidence on the effect of interventions did not demonstrate benefit, or outcomes were mixed. Fourteen trials reported on reports to CPS 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 to 1.23]).3 Trials reporting additional results within 6 months or a year of the initial results also showed no significant difference between groups. Long-term followup (2.5 to 13.0 years after initial results) yielded mixed results, with two trials12-15 reporting statistically significant differences and one reporting no difference.16
Five trials reported on removal of the child from the home.17-22 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 removals at birth.21 This trial showed a nonsignificant effect for the intervention group compared with the control group (OR, 1.55 [95% CI, 0.61 to 3.94]).21
The evidence review demonstrated mixed results for several outcomes. Outcomes related to emergency room visits and hospitalizations were reported in 11 and 12 trials, respectively.3 Pooled analyses were not performed because of variation in outcome definitions and time periods. Statistically significant reductions in all-cause hospitalization, average number of hospital days, and rates of admission were demonstrated in a minority of trials.23-26 However, most studies of hospitalization-related outcomes showed no difference between study groups.3 Evidence was also inconsistent on the effects of emergency room visits. Only two studies that reported outcomes within 2 years of intervention noted statistically significant reductions in the average number of all-cause emergency room visits.23, 27 Long-term results (>4 years of followup) noted statistically significant reductions in emergency room visits in one of two studies.26, 28 Other outcomes with mixed results included internalizing (depression/anxiety) and externalizing (disruptive, aggressive, or delinquent) behavioral outcomes (3/6 trials reported statistically significant reductions in reported behaviors),12, 24, 25, 29, 30 child development (1/7 trials reported statistically significant improvements in developmental outcomes),30 and other measures of abuse and neglect (1/2 trials reported statistically significant reductions in abuse/neglect findings).31
Many of the outcomes reviewed by the USPSTF had limited evidence. Four trials reported on child mortality, all with followup periods between 6 months and 9 years.17, 20, 22, 32, 33 Variations in timing and outcome specifications did not allow for pooled analysis. None of the mortality outcomes reported reached statistical significance,17, 22, 32, 33 although one trial did report higher mortality rates in the intervention group.20 Five studies evaluated social, emotional, and other developmental outcomes;27, 28, 32-34 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.32, 33 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.20, 22
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.
Draft: 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.35 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.6, 36
1. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, Children’s Bureau. Child Maltreatment 2016. Washington, DC: U.S. Department of Health and Human Services; 2018.
2. Leeb RT, Paulozzi LJ, Melanson C, Simon TR, Arias I. Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements. Version 1.0. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.
3. Viswanathan M, Pan H, Morgenlander M, et al. Primary Care Interventions to Prevent Child Maltreatment: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 170. AHRQ Publication No. 18-05241-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2018.
4. Child Welfare Information Gateway. Definitions of Child Abuse and Neglect. Washington, DC: U.S. Department of Health and Human Services, Children's Bureau; 2016.
5. Sedlak AJ, Mettenburg J, Basena M, et al. Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress, Executive Summary. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families; 2010.
6. Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-54.
7. Health Resources and Services Administration, Maternal and Child Health Bureau. Home visiting. https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview. Accessed May 9, 2018.
8. U.S. Preventive Services Task Force. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(6):478-86.
9. Centers for Disease Control and Prevention. Child abuse and neglect prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html. Accessed May 9, 2018.
10. National Child Traumatic Stress Network. Complex trauma. https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma. Accessed May 9, 2018.
11. U.S. Preventive Services Task Force. Primary care interventions to prevent child maltreatment: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(4):289-95.
12. Lowell DI, Carter AS, Godoy L, Paulicin B, Briggs-Gowan MJ. A randomized controlled trial of Child FIRST: a comprehensive home-based intervention translating research into early childhood practice. Child Dev. 2011;82(1):193-208.
13. Olds DL, Eckenrode J, Henderson CR Jr, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA. 1997;278(8):637-43.
14. Eckenrode J, Ganzel B, Henderson CR Jr, Smith E, Olds DL, Powers J, et al. Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence. JAMA. 2000;284(11):1385-91.
15. Zielinski DS, Eckenrode J, Olds DL. Nurse home visitation and the prevention of child maltreatment: impact on the timing of official reports. Dev Psychopathol. 2009;21(02):441-53.
16. DuMont K, Mitchell-Herzfeld S, Greene R, et al. Healthy Families New York (HFNY) randomized trial: effects on early child abuse and neglect. Child Abuse Negl. 2008;32(3):295-315.
17. Barlow J, Davis H, McIntosh E, Jarrett P, Mockford C, Stewart-Brown S. Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation. Arch Dis Child. 2007;92(3):229-33.
18. McIntosh E, Barlow J, Davis H, Stewart-Brown S. Economic evaluation of an intensive home visiting programme for vulnerable families: a cost-effectiveness analysis of a public health intervention. J Public Health (Oxf). 2009;31(3):423-33.
19. Brayden RM, Altemeier WA, Dietrich MS, et al. A prospective study of secondary prevention of child maltreatment. J Pediatr. 1993;122(4):511-6.
20. Brooten D, Kumar S, Brown LP, et al. A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants. N Engl J Med. 1986;315(15):934-9.
21. Marcenko MO, Spence M. Home visitation services for at-risk pregnant and postpartum women: a randomized trial. Am J Orthopsychiatry. 1994;64(3):468-78.
22. Quinlivan JA, Box H, Evans SF. Postnatal home visits in teenage mothers: a randomised controlled trial. Lancet. 2003;361(9361):893-900.
23. Finello KM, Litton KM, deLemos R, Chan LS. Very low birth weight infants and their families during the first year of life: comparisons of medical outcomes based on after care services. J Perinatol. 1997;18(5):365-71.
24. Fergusson DM, Boden JM, Horwood LJ. Nine-year follow-up of a home-visitation program: a randomized trial. Pediatrics. 2013;131(2):297-303.
25. Fergusson DM, Grant H, Horwood LJ, Ridder EM. Randomized trial of the Early Start program of home visitation. Pediatrics. 2005;116(6):e803-9.
26. Olds DL, Henderson CR Jr, Kitzman H. Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life? Pediatrics. 1994;93(1):89-98.
27. Olds DL, Henderson CR Jr, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics. 1986;78(1):65-78.
28. Minkovitz CS, Strobino D, Mistry KB, et al. Healthy Steps for Young Children: sustained results at 5.5 years. Pediatrics. 2007;120(3):e658-68.
29. Duggan A, Caldera D, Rodriguez K, Burrell L, Rohde C, Crowne SS. Impact of a statewide home visiting program to prevent child abuse. Child Abuse Negl. 2007;31(8):801-27.
30. Caldera D, Burrell L, Rodriguez K, Crowne SS, Rohde C, Duggan A. Impact of a statewide home visiting program on parenting and on child health and development. Child Abuse Negl. 2007;31(8):829-52.
31. Bugental DB, Schwartz A. A cognitive approach to child mistreatment prevention among medically at-risk infants. Dev Psychol. 2009;45(1):284-8.
32. Kitzman H, Olds DL, Henderson CR Jr, et al. Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA. 1997;278(8):644-52.
33. Olds DL, Sadler L, Kitzman H. Programs for parents of infants and toddlers: recent evidence from randomized trials. J Child Psychol Psychiatry. 2007;48(3-4):355-91.
34. Robling M, Bekkers MJ, Bell K, et al. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet. 2016;387(10014):146-55.
35. American Academy of Family Physicians. Primary care interventions to prevent child maltreatment. 2013. https://www.aafp.org/patient-care/clinical-recommendations/all/child-maltreatment-prevention.html. Accessed May 9, 2018.
36. Flaherty EG, Stirling J Jr; American Academy of Pediatrics, Committee on Child Abuse and Neglect. Clinical report—the pediatrician's role in child maltreatment prevention. Pediatrics. 2010;126(4):833-41.
Internet Citation: Draft Recommendation Statement: Child Maltreatment: Primary Care Interventions. U.S. Preventive Services Task Force. May 2018.