Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive
Meera Viswanathan1,2, Caroline Rains1,2, Laura C Hart3,4
1RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center.
Insights
Primary care interventions show no significant benefit in preventing child maltreatment reports or removals. Further research is needed to explore potential harms and the impact of social determinants on prevention efforts.
Area of Science:
- Public Health
- Pediatrics
- Preventive Medicine
Background:
- Child maltreatment has severe physical, psychological, and behavioral consequences.
- Primary care settings are crucial for identifying and preventing child maltreatment.
Purpose of the Study:
- To review evidence on primary care-feasible interventions for child maltreatment prevention.
- To inform the US Preventive Services Task Force recommendations.
Main Methods:
- Systematic review of randomized clinical trials (RCTs) up to age 18.
- Included studies published in English, with data extraction and meta-analyses where appropriate.
- Searched PubMed, Cochrane Library, and trial registries.
Main Results:
- Twenty-five RCTs (14,355 participants) were included; 23 involved home visits.
- No significant differences were found in reports to Child Protective Services or child removals.
- Evidence for other outcomes like emergency department visits and hospitalizations was limited or inconclusive; harms data were minimal.
Conclusions:
- Current evidence suggests primary care interventions do not significantly reduce child maltreatment.
- Screening and reporting practices vary, with potential for bias.
- Addressing social determinants of health may be important for effective prevention.
Importance:
Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences.
Objective:
To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force.
Data Sources:
PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023.
Study Selection:
English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment.
Data Extraction And Synthesis:
Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.
Main Outcomes And Measures:
Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms.
Results:
Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health.
Conclusion And Relevance:
The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.
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