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Final Research Plan

Final Research Plan for Child Maltreatment: Primary Care Interventions

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.

Analytic Framework

Text Description is below the image.

* The World Health Organization defines child maltreatment as including "all forms of physical and/or emotional ill-treatment, sexual abuse, neglect, or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power."1 Maltreatment includes physical abuse, neglect, sexual abuse/exploitation, emotional abuse, parental substance abuse, and abandonment.2

Text Description.

This figure is an analytic framework depicting the key questions that will guide the systematic evidence review for this topic. This figure illustrates the intervention pathway for the population of interest, namely children and adolescents from birth to age 18 years with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment. The first key question examines whether primary care–feasible or referrable interventions result in reduced exposure to abuse and neglect; improved behavioral, emotional, physical, and mental well-being; or reduced mortality. The second key question evaluates whether any harms result from such interventions.

Key Questions to Be Systematically Reviewed

  1. Do primary care–feasible or referable interventions to prevent child maltreatment reduce exposure to abuse or neglect; improve behavioral, emotional, physical, or mental well-being; or reduce mortality among children and adolescents without obvious signs or symptoms of abuse or neglect?
  2. What are the harms of primary care–feasible or referable interventions to prevent child maltreatment?

Contextual Question

The contextual question will not be systematically reviewed and is not shown in the Analytic Framework.

  1. What is the validity and reliability of risk assessment tools to identify children and adolescents who are at risk of child maltreatment?

Research Approach

The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions (KQs).

  Included Excluded
Population Children and adolescents (birth through age 18 years) with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment Symptomatic children and adolescents undergoing diagnostic evaluation for conditions related to abuse or neglect (e.g., those presenting with a broken bone or other signs of physical abuse or neglect, trauma symptoms associated with domestic violence exposure), asymptomatic children with known exposure to child maltreatment, perpetrators of maltreatment, and children who have maltreatment perpetrated against them by a caregiver
Interventions
  • Services that could result from a referral by a primary care provider; services may be implemented by a nonclinician, and may include home visiting programs, primary care–based programs, respite care, parent education programs, and family support and family strengthening programs
  • Family-focused interventions may be directed at the caregiver and may not include components directed at the child
Communitywide interventions only, such as public awareness campaigns or public service announcements, without specific interventions linked to clinical settings
Comparisons Usual care, delayed intervention, or active interventions that allow for assessment of the independent contribution of the primary care—feasible or referable preventive intervention (e.g., clinical interventions plus media campaigns vs. media campaigns) Comparators that do not allow for assessment of the independent contribution of the primary-care–feasible or referable preventive intervention (e.g., clinical interventions plus media campaigns vs. usual care)
Outcomes KQ 1: Direct or proxy measures of abuse or neglect (required):
  • Physical, sexual, or emotional abuse perpetrated by a parent or caregiver against a child
  • Physical (e.g., failure to thrive), emotional, dental/medical (e.g., lack of immunizations or well-child visits), or educational neglect
  • Reports to Child Protective Services
  • Removal of the child from the home
  • Injuries such as broken bones, bruises, burns, and other injuries with a high specificity for abuse
  • Visits to the emergency department
  • Hospitalizations

Behavioral, emotional, mental, or physical well-being*:

  • Decreased internalizing behaviors (depression, anxiety)
  • Decreased externalizing behaviors (disruptive, aggressive, or delinquent behavior)
  • Healthy social-emotional development (e.g., attachment problems, peer relationships); reduced developmental delays (language, cognitive)
  • Decreased incidence of reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, or posttraumatic stress disorder
  • Decreased incidence of traumatic stress symptoms, such as impairments in attachment, self-regulation, under- or overcontrolling behaviors (e.g., irritable/angry outbursts, self-destructive behavior, food hoarding), executive functioning, and self-concept; hypervigilance; exaggerated startle response; dissociation; concentration problems; somatic problems (e.g., headaches, gastrointestinal problems); sleep disturbances; and nightmares
  • Decreased suicidality and self-injurious behaviors
  • Improved school attendance and performance
  • Reduced risky behaviors and outcomes (e.g., sexually transmitted diseases)
  • Mortality
KQ 2: Any harms that result as an effect of the intervention (e.g., stigma, labeling, legal risks, risk of further harm to the child, dissolution of the family); worsening of outcomes listed for KQ 1
KQ 1: Outcomes not otherwise specified; studies without direct or proxy measures of abuse or neglect

KQ 2: None
Clinical settings Primary care–feasible or referable settings, including pediatric, primary care, family medicine, school-based clinic, or other settings where primary care services are offered; services that could result from an assessment by a clinician  (including delivery hospitals, in-home settings, and nonspecialty settings) Settings that are not primary care–feasible or referable; populations or services/interventions that are not applicable to U.S. practice
Country Research conducted in the United States or in populations similar to U.S. populations, with services and interventions applicable to U.S. practice (i.e., conducted in countries categorized as "Very High" on the Human Development Index (as defined by the United Nations Development Programme) Research not relevant to the United States (i.e., conducted in countries not categorized as "Very High" on the Human Development Index)
Study designs KQ 1: Randomized, controlled trials; systematic reviews

KQ 2: Randomized, controlled trials; controlled clinical trials; systematic reviews; cohort trials with a control group; and case-control studies
KQ 1: Nonrandomized cohort trials, case-control studies, case series, or case studies

KQ 2: Case series or case studies
Timing Any timing None
Languages Full text published in English Languages other than English
Publication type Original research and systematic reviews Editorials, commentaries, or narrative reviews

* Studies reporting these outcomes for KQ 1 that do not also report at least one child maltreatment outcome will be excluded.

Response to Public Comment

The draft Research Plan was posted on the USPSTF Web site for public comment from May 12 to June 8, 2016. The USPSTF received several comments requesting clarification on the inclusion and exclusion criteria. In response, the USPSTF revised the analytic framework to specify the population of interest as "children and adolescents from birth to age 18 years" and the inclusion criteria to no longer exclude children and adolescents with serious behavioral problems. The USPSTF also clarified that the evidence review will include family-focused interventions, which may be directed at the caregiver and may not include components directed at the child, and that interventions will include primary care–feasible or referable interventions conducted in delivery hospitals, in-home settings, and nonspecialty settings, in addition to other settings specified earlier. The USPSTF added two new outcomes: improved school attendance and performance and reduced risky behaviors and outcomes (e.g., sexually transmitted diseases). Information on how children, adolescents, or their caregivers are selected for interventions (former Contextual Question 1) will be included in the evidence review and will not require an explicit question.

References:
  1. World Health Organization and International Society for Prevention of Child Abuse and Neglect. Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence. Geneva, Switzerland: World Health Organization; 2006. http://www.who.int/violence_injury_prevention/publications/violence/child_maltreatment/en.
  2. Children's Bureau. Definitions of Child Abuse and Neglect. Washington, DC: U.S. Department of Health and Human Services; 2014. https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/define.
Current as of: August 2016

Internet Citation: Final Research Plan: Child Maltreatment: Primary Care Interventions. U.S. Preventive Services Task Force. August 2016.
https://www.uspreventiveservicestaskforce.org/Page/Document/final-research-plan/child-maltreatment-primary-care-interventions1

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