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Primary Care Interventions to Prevent Child Maltreatment: Updated Evidence Report and Systematic Review for the US
Meera Viswanathan1,2, Jenifer Goldman Fraser3, Huiling Pan1,2
1RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center.
Insights
Primary care interventions did not consistently prevent child abuse and neglect. Further research is needed to determine effective strategies for child maltreatment prevention and to assess potential harms.
Area of Science:
- Public Health
- Pediatrics
- Preventive Medicine
Background:
- Child maltreatment, encompassing abuse and neglect, has profound and lasting negative effects.
- Primary care settings offer opportunities for early intervention and prevention of child maltreatment.
Purpose of the Study:
- To evaluate the effectiveness of interventions delivered or referred through primary care for preventing child maltreatment.
- To update the evidence base for the US Preventive Services Task Force.
Main Methods:
- Systematic review and meta-analysis of English-language randomized clinical trials (RCTs) published up to July 2018.
- Included RCTs focused on children without prior maltreatment and assessed interventions feasible in primary care.
- Outcomes included direct measures of maltreatment (e.g., child protective services reports, removal from home) and proxy measures.
Main Results:
- Twenty-two trials (N=11,132) were analyzed.
- No significant association was found between interventions and reports to child protective services or child removal from home.
- Insufficient evidence exists for other outcomes, including emergency department visits, hospitalizations, child development, school performance, and prevention of death. No harms were identified.
Conclusions:
- Interventions provided or referred by primary care settings did not demonstrate consistent effectiveness in preventing child maltreatment.
- There is a lack of evidence regarding the harms associated with these interventions.
- Further research is necessary to identify effective primary care-based strategies for child maltreatment prevention.
Importance:
Child maltreatment, also referred to as child abuse and neglect, can result in lifelong negative consequences.
Objective:
To update the evidence on interventions provided in or referable from primary care to prevent child maltreatment for the US Preventive Services Task Force.
Data Sources:
PubMed, Cochrane Library, EMBASE, and trial registries through December 18, 2017; references; experts; literature surveillance through July 17, 2018.
Study Selection:
English-language fair- and good-quality randomized clinical trials that (1) included children with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment, (2) evaluated interventions feasible in a primary care setting or that could result from a referral from primary care, and (3) reported abuse or neglect outcomes or proxies for abuse or neglect (eg, injury with a specificity for abuse, visits to the emergency department, hospitalization).
Data Extraction And Synthesis:
Two reviewers independently assessed titles/abstracts, full-text articles, and study quality; a third resolved conflicts when needed. When at least 3 similar trials were available, random-effects meta-analyses were conducted.
Main Outcomes And Measures:
Direct measures (including reports to child protective services and removal of the child from the home) or proxy measures of abuse or neglect; behavioral, emotional, mental, or physical well-being; and harms.
Results:
Twenty-two trials (33 publications) were included (N = 11 132). No significant association was found between interventions and reports to child protective services within 1 year of intervention completion (10.6% vs 11.9%; pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]; 10 trials [n = 2444]) or removal of the child from the home within 1 to 3 years of follow-up (3.5% vs 3.7%; pooled OR, 1.09 [95% CI, 0.16-7.28]; 4 trials [n = 609]). No statistically significant associations were observed between interventions and outcomes for emergency department visits in the short term (<2 years), hospitalizations, child development, school performance, and prevention of death. Nonsignificant results from single trials led to a conclusion of insufficient evidence for injuries, failure to thrive, failure to immunize, school attendance, and other measures of abuse or neglect. Inconsistent results led to a conclusion of insufficient evidence for long-term (≥2 years) outcomes for reports to child protective services (ORs range from 0.48 to 1.13; 3 trials [n = 1690]), emergency department visits (1 of 2 trials reported significant differences) and internalizing and externalizing behavior symptoms (3 of 6 trials reported reductions in behavior difficulties). No eligible trials on harms of interventions were identified.
Conclusions And Relevance:
Interventions provided in or referable from primary care did not consistently prevent child maltreatment. No evidence on harms is available.
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