Public Comment on Draft Recommendation: Primary Care Interventions to Prevent Child Maltreatment

Agency for Healthcare Research and Quality (AHRQ) sent this bulletin at 01/22/2013 08:00 AM EST

Today, the U.S. Preventive Services Task Force posted for public comment its draft recommendation statement on primary care interventions to prevent child maltreatment. It is available for review and public comment from January 22 to February 18, 2013 by clicking here. The evidence report on which this draft recommendation is based was also published today in Annals of Internal Medicine and is available here.

U.S. Preventive Services Task Force

Draft Recommendation Statement

Note: This draft Recommendation Statement is not the final recommendation of the U.S. Preventive Services Task Force. This draft is distributed solely for the purpose of pre-release review. It has not been disseminated otherwise by AHRQ. It does not represent and should not be interpreted to represent an AHRQ determination or policy.
This draft Recommendation Statement is based on an evidence review that was published on January 22, 2013 (available at http://www.uspreventiveservicestaskforce.org/uspstf13/childabuse/childmaltreatart.htm).
The USPSTF makes recommendations about the effectiveness of specific clinical preventive services for patients without 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.
This draft Recommendation Statement is available for comment from January 22 until February 18, 2013, at 5:00 PM ET. You may wish to read the entire Recommendation Statement before you comment.

Primary Care Interventions to Prevent Child Maltreatment: U.S. Preventive Services Task Force Recommendation Statement
DRAFT

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.
This is an I statement.
See the Suggestions for Practice Regarding the I Statement in the Clinical Considerations for more information.
Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty about net benefit.

Rationale

Importance

In 2011, approximately 680,000 children were victims of maltreatment and approximately 1,570 children died from maltreatment. For 92% of these children, this was their first episode of maltreatment. Of these children, approximately 78% experienced neglect, 18% physical abuse, and 9% sexual abuse; many children experienced multiple forms of maltreatment (1).

Benefits of Interventions

There is inadequate evidence about primary care interventions to prevent child maltreatment in children who do not have signs or symptoms of maltreatment. This is because of significant heterogeneity in study methods, interventions studied, and how outcomes were measured. There is also inconsistent and limited evidence on outcomes important to patients.

Harms of Detection and Early Intervention/Treatment

Although there are a number of concerns regarding the possible harms of interventions for child maltreatment, there is limited evidence of these harms.

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 maltreatment.

Clinical Considerations

Patient Population Under Consideration

This recommendation applies to children in the general U.S. population from newborn to age 18 years who do not have signs or symptoms of maltreatment. Child maltreatment is defined by the Centers for Disease Control and Prevention (CDC) as any act or series of acts of commission or omission by a parent or other caregiver that results 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

There are numerous risk factors associated with child maltreatment, including but not limited to:

Young, single, or nonbiological 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 are supportive of 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.

Interventions

While the evidence is insufficient to recommend specific preventive interventions in a clinical setting, most child maltreatment prevention programs 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 prenatal 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 multistepped approach in a primary care clinic, with a social worker who intervened among families self-reporting high-risk behaviors.

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 1,570 deaths in 2011. Child maltreatment can result in lifelong negative consequences for the child. Most child maltreatment is in the form of neglect (approximately 78%) and most deaths occur in children younger than age 4 years (approximately 80%) (1).
Potential harms. There is limited evidence on 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 that mandate that all professionals who have contact with children, including all health care workers, report suspected maltreatment to Child Protective Services (CPS) (4). Pediatricians, family physicians, and other primary care providers are in a unique position to identify children at risk of maltreatment through well-child and other visits. However, while 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 published a new 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 has issued a recommendation on early childhood home visitation to prevent child maltreatment (available at http://www.thecommunityguide.org/violence/home/index.html).

Other Considerations

Research Needs and Gaps

The USPSTF recognizes the importance of this serious health problem and that research in a number of areas related to reducing child maltreatment should be a priority. The relationship between harsh punishment (such as spanking) and abuse needs to be further explored, as does the relationship between intimate partner violence and child maltreatment. Additional research is also needed to determine effective methods for physicians and other health care clinicians to identify children at risk or currently experiencing maltreatment. The lack of studies on the prevention of maltreatment of older children, which was identified in the previous USPSTF report as an important evidence gap, has yet to be addressed. Research is also needed to confirm the efficacy and expand the applicability of the observed benefits reported in some of the intervention studies included in the USPSTF's review. Standardization of interventions and outcomes would strengthen the evidence and allow quantitative meta-analysis. Research is also needed to determine whether there are unintended harms that result from screening, risk assessment, and interventions.

Discussion

Burden of Disease

In 2011, approximately 680,000 children were victims of maltreatment (1). Approximately 78% of children experienced neglect, 18% physical abuse, and 9% sexual abuse; many children experienced more than one type of maltreatment. In addition, 10.3% of children were victims of other types of maltreatment, including threatened abuse, parental drug/alcohol abuse, and lack of supervision. An estimated 1,570 children died from maltreatment in 2011 (2.1 per 1,000,000 children) (1). Rates of maltreatment are similar for boys and girls, but younger children are much more likely to be victims. In 2010, more than one third (34%) of all new victims were younger than age 4 years, and children younger than age 1 year had the highest rate of victimization, at 20.6 per 1,000 children. In addition, this age group also experienced the highest fatality rates. Of all child fatalities in 2010, 79.4% were in children younger than age 4 years. Almost half (47.7%) were younger than age 1 year.
Although the definition of child maltreatment varies by State (8), there are minimum standards under Federal law (42 U.S.C.A. §5106g), which defines child abuse and neglect as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm” (1, 9, 10).
For victims who survive childhood, there are many well-documented, long-term medical and psychological problems associated with a history of maltreatment. For example, possible long-term psychiatric effects include psychosis, personality disorders, and substance abuse, among others (11-19). Additionally, victims of child maltreatment more commonly have physical health abnormalities, from chronic pain (20, 21) and disabilities (22) to diabetes and autoimmune disorders (23, 24).

Risk Factors

The CDC (25) and recent studies report the following risk factors for child maltreatment: parental lack of understanding of children's needs, child development, and parenting; parental history of maltreatment from family of origin (26); substance abuse in the family; young, single (27), or nonbiological parents; parental thoughts and emotions that are supportive of maltreatment behaviors; and parental stress and distress, including depression or other mental health disorders. Family risk factors include social isolation (26); poverty (28, 29) and other socioeconomic disadvantages (26), including intimate partner violence; and poor parent-child relationships and negative interactions. Child-specific risk factors include being younger than age 4 years and having disabilities (1, 26, 27) or mental retardation, and being born at medical risk, such as preterm, born with addiction, or hospitalization in the neonatal intensive care unit (30).

Scope of the Review

In updating its 2004 recommendation (31), the USPSTF commissioned a systematic review (3) on interventions to prevent child maltreatment for children at risk. This update focuses on new studies and evidence gaps that were unresolved at the time of the 2004 recommendation. Beneficial outcomes considered include reduced exposure to maltreatment (primarily measured by CPS reports) and reduced physical or mental health harms or mortality. Although the original scope of the review focused on both screening and interventions, the USPSTF changed the scope to focus on preventive interventions rather than screening.

Effectiveness of Preventive Interventions

The USPSTF reviewed studies of asymptomatic children who received primary care accessible interventions to prevent child maltreatment. The main outcomes considered by the USPSTF were mortality, substantiated CPS reports, and removal from the home. The USPSTF found one fair-quality study of an intervention provided in a clinical setting and 10 fair-quality studies of home visitation programs to prevent child maltreatment. The one trial implemented in a clinical setting evaluated an intervention based on the Safe Environment for Every Kid (SEEK) model, which includes risk assessment, physician training, informational resources for parents and physicians, and social work services for families desiring them (32). The trial enrolled 729 patients who were newborn to age 5 years and assessed risk using the Parent Screening Questionnaire, a 20-item self-report of safety issues. Results indicated significantly reduced CPS reports (13% vs. 19%; p=0.03) among children randomized to the intervention group compared with usual care up to 44 months after the intervention. This study had limitations, including more than 20% loss to followup, with not enough information to determine if the trial maintained comparable groups throughout the study, and lack of intention-to-treat analysis.
Ten new trials of early childhood home visitation have been published since the previous USPSTF recommendation. Most trials enrolled patients based on the presence of risk factors for child abuse and neglect, including inadequate prenatal care; young age of parents; limited finances, education, and social support; or substance abuse history. All of the trials had some methodological limitations leading to an assessment as fair quality; these limitations include inadequate inclusion and exclusion criteria, inadequate randomization or allocation concealment, inadequate blinding, low adherence with the intervention, high loss to followup (>20%), dissimilar groups at baseline or followup, and lack of intention-to-treat analysis (3). Home visits were provided by trained paraprofessionals or nurses, and began either before or soon after birth and continued for 3 to 36 months. One trial reported mortality; this study included 743 children with 9 years of followup. Children receiving home visits by a nurse as infants were less likely to die by age 9 years than those in the usual care control group, although results were not statistically significant (1 vs. 10 deaths; p=0.08). In this study, the one death in the home visit group was the result of chromosomal abnormalities, whereas the 10 deaths in the control group were from complications of prematurity (n=3), Sudden Infant Death Syndrome (n=3), injury (n=3: homicide assault by firearm, accidental injury from firearm, and motor vehicle accident), and intestinal infection (n=1).
Six of the home visitation trials published since the last USPSTF review used CPS reports as an outcome (33-38). No trials reported differences in rates of CPS reports between home visit and control groups during the period of home visitation (33-38). However, one trial found that children visited by a professional clinical team had decreased CPS involvement at 3 years after enrollment (odds ratio for effect of the intervention, 2.1 [95% CI, 1.0 to 4.4]) (38). The previous USPSTF review found inconsistent effects on CPS reports in the three studies included in the review. In one trial with 15 years of followup (39), results of a subgroup analysis at 2 years found that poor, high-risk teenage mothers who were visited by nurses were less likely to commit acts of confirmed child abuse and neglect compared with mothers who did not receive visits (4% vs. 19%; p=0.07). However, there were no differences for the entire sample, and results at 3 and 4 years showed no differences (40). After 15 years of followup, children in the home visit group were less likely to be involved in substantiated CPS reports (incidence rate, 0.44 vs. 0.73; p=0.04) (41). Mothers who received home visits were less likely to be a substantiated perpetrator of child abuse (incidence rate, 0.32 vs. 0.65; p=0.01), toward the study child or other child, over the same 15-year period. Two other trials of visits by paraprofessionals found no differences in total CPS reports after either 1 (42) or 3 (43) years of followup.
Two recent trials reported removal of the child from the home (33, 34) and did not report a difference between the intervention versus control groups that was statistically significant over 18 (6% vs. 0%; p=not significant) (33) or 36 months of followup (1.8% vs. 0.8%; p=not significant) (34).

Estimate of Magnitude of Net Benefit

The evidence for interventions delivered in primary care to prevent child maltreatment is insufficient to assess the net balance of benefits and harms. There is a low level of certainty regarding both the magnitude of benefits and the magnitude of harms of these interventions.

Update of Previous Recommendation

This recommendation updates the child abuse and neglect portion of the 2004 recommendation on screening for family and intimate partner violence. The updated recommendation on screening for intimate partner violence and abuse of elderly and vulnerable adults was published separately. As previously discussed, the current recommendation differs from the previous recommendation in that it focuses on preventive interventions to prevent child maltreatment instead of screening and treatment. This recommendation is similar to the 2004 recommendation in that there is still insufficient evidence to assess the balance of benefits and harms.

Recommendations of Others

In 2010, the American Academy of Pediatrics published a clinical report advocating for the pediatrician's prominent role in the prevention of maltreatment and providing specific guidelines and information on risk factors and protective factors (5). The American Medical Association recommends routine inquiry about child abuse or neglect (44). Other organizations do not specifically recommend universal screening, but recommend that pediatricians and family practice clinicians remain alert for indications of maltreatment (45) or recommend screening in pediatric offices for intimate partner and family violence (46, 47). The Canadian Task Force on Preventive Health Care issued several recommendations related to child maltreatment in 2000 and recommended against screening aimed at identifying individuals at risk of experiencing or committing child maltreatment (grade D recommendation). However, it recommends home visitation for disadvantaged families from the prenatal period through infancy, but found no good evidence to include or exclude a referral for a comprehensive health care program, a parent education and support program, or a combined service program that includes case management, education, and psychotherapy in the prevention of child maltreatment (48). Disadvantaged families are defined as first-time mothers with one or more of the following characteristics: younger than age 19 years, single parent status, and low socioeconomic status. The Community Preventive Services Task Force recommends early childhood home visitation interventions to prevent child maltreatment (49).

Table 1: What the Grades Mean and Suggestions for Practice

Grade	Definition	Suggestions for Practice
A	The USPSTF recommends the service. There is high certainty that the net benefit is substantial.	Offer or provide this service.
B	The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.	Offer or provide this service.
C	Note: The following statement is undergoing revision. Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service.	Offer or provide this service only if other considerations support offering or providing the service in an individual patient.
D	The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.	Discourage the use of this service.
I Statement	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.	Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Table 2: Levels of Certainty Regarding Net Benefit

Level of Certainty*	Description
High	The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate	The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as: The number, size, or quality of individual studies. Inconsistency of findings across individual studies. Limited generalizability of findings to routine primary care practice. Lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low	The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies. Important flaws in study design or methods. Inconsistency of findings across individual studies. Gaps in the chain of evidence. Findings not generalizable to routine primary care practice. A lack of information on important health outcomes. More information may allow an estimation of effects on health outcomes.

*The U.S. Preventive Services Task Force defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

References

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AHRQ Publication No. 13-05176-EF-3
Current as of January 2013

Internet Citation:

U.S. Preventive Services Task Force. Primary Care Interventions to Prevent Child Maltreatment: Draft Recommendation Statement. AHRQ Publication No. 13-05176-EF-3. http://www.uspreventiveservicestaskforce.org/draftrec.htm