Draft Research Plan

Prevention of Child Maltreatment: Primary Care Interventions

February 17, 2022

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.

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The framework begins on the left with the population of interest: children or adolescents from birth to less than age 18 years without signs or symptoms of current or past abuse or neglect. To the right is an overarching arrow for the framework representing KQ1. It begins with "Primary care–relevant preventive interventions" of child maltreatment on the left and ends with a box on the far right that represents the final outcomes: "Reduced exposure to abuse or neglect; improved behavioral, emotional, mental, or physical well-being; and reduced mortality." From this main arrow is a second arrow descending to an oval with the text "Harms" to illustrate the focus of KQ2.

  1. For children without obvious signs and symptoms of abuse or neglect, do primary care–feasible or referable preventive interventions reduce exposure to abuse or neglect; improve behavioral, emotional, physical, or mental well-being; or reduce mortality? Does the effectiveness of interventions differ by populations of interest (e.g., defined by child or caregiver characteristics such as age, sex, gender identity, race and ethnicity, sociodemographic characteristics, or special needs)?
  2. What are the harms from interventions intended to prevent child maltreatment? Do the harms of interventions differ by populations of interest (e.g., defined by child or caregiver characteristics such as age, sex, gender identity, race and ethnicity, sociodemographic characteristics, or special needs)?

Contextual Questions will not be systematically reviewed and are not shown in the Analytic Framework.

  1. What are current practices for a) identifying children at risk of maltreatment, b) referring children or families to prevention programs, c) reporting children or families to Child Protective Services, and d) diagnosing child maltreatment outcomes? Do current practices in identification, referral, reporting, and diagnosis of outcomes of child maltreatment differ by race or ethnicity of the child or caregiver? If evidence exists of practice differences, what factors might explain these differences?
  2. What are the validity and reliability of risk assessment tools to identify children and adolescents who are at risk of child maltreatment? Does the reported validity and reliability (of risk assessment tools) differ by race and ethnicity? If yes, what might explain these differences? Is there evidence that these tools alter or increase inequity?

The Proposed 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.

Category Included Excluded
Population Children or adolescents (younger than age 18 years) with no known exposure to maltreatment and no specific signs or symptoms of current or past maltreatment Symptomatic children and adolescents undergoing diagnostic evaluations for conditions related to abuse or neglect (e.g., those presenting with a broken bone or other signs of physical abuse or neglect, or trauma symptoms associated with domestic violence exposure), children with known exposure to child maltreatment and perpetrators of maltreatment, and children of caregivers who perpetrated maltreatment toward them
Interventions Primary care–based programs or services; services that could result from a referral by a primary care provider

Services may include home visiting programs, respite care, parent education programs, and family support and family strengthening programs

Services may be implemented by nonclinicians

(Interventions may be directed at the caregiver and may or may not include components directed at the child)		 Communitywide interventions such as public awareness campaigns or public service announcements only, without specific interventions linked to clinical settings
Comparisons Usual care, delayed intervention, active interventions that allow for the assessment of the independent contribution of primary care–relevant preventive intervention (e.g., clinical interventions + media campaigns vs. media campaigns) Comparators that do not allow for the assessment of the independent contribution of the effect of primary care–feasible or referable preventive interventions (e.g., clinical interventions + media campaigns vs. usual care)
Outcomes KQ 1: Direct or proxy measures of abuse or neglect (required):
  • Physical abuse, sexual abuse, or emotional abuse perpetrated by a parent or caregiver against a child (not parent reported)
  • Physical (e.g., failure to thrive), emotional, dental/medical (for needed dental, medical, or mental health treatment), or educational neglect
  • Child Protective Services reports
  • Removal of the child from the home
  • Injuries such as broken bones, bruises, burns, and other injuries with a high specificity for abuse
  • Emergency department visits
  • Hospitalizations

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

  • Quality of life or functional status measures (using validated instruments)
  • Internalizing behaviors: depression, anxiety
  • Externalizing behaviors: disruptive, aggressive, delinquent behavior
  • Child development (including school readiness and academic performance): social-emotional (e.g., attachment problems, peer relationships, community involvement), developmental delays (language, cognitive)
  • Incidence of reactive attachment disorder
  • Incidence of disinhibited social engagement disorder
  • Incidence of acute stress disorder
  • Incidence of posttraumatic stress disorder
  • Incidence of traumatic stress symptoms: attachment, self-regulation, under- or overcontrolling behaviors (e.g., irritable/angry outbursts, self-destructive behavior, food hoarding), executive functioning, self-concept, hypervigilance, exaggerated startle response, dissociation, concentration problems, somatic problems (e.g., headaches, gastrointestinal problems), sleep disturbance, nightmares
  • Unintended pregnancy, sexually transmitted diseases, or termination of pregnancy
  • Suicidality and self-injurious behaviors

KQ 2: Any harms that result as an effect of interventions (e.g., stigma, labeling, legal risks, risks of further harm to the child, or dissolution of families), or worsening of outcomes listed for KQ 1

 KQ 1: Outcomes not otherwise specified, studies without direct or proxy measures of abuse of neglect, and parent-reported measures of exposure to abuse or neglect

KQ 2: None specified
Clinical settings Pediatrics, 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 nonspecialist settings) Not a primary care–feasible or referable setting, populations or services/interventions not applicable to U.S. practice
Geographic setting Research conducted in the United States or in populations similar to U.S. populations, with services and interventions applicable to U.S. practice (countries categorized as “very high” on the United Nations Human Development Index, as defined by the United Nations Development Programme) Research not relevant to the United States in countries categorized as less than “very high” on the Human Development Index
Study designs KQ 1: RCTs

KQ 2: RCTs, controlled clinical trials, systematic reviews; cohorts with controls, and case-control studies

Systematic reviews will be hand searched for additional eligible studies

 KQ 1: Systematic reviews, nonrandomized cohort trials, case-control, case series, and case studies

KQ 2: Systematic reviews, case series and case studies
Timing Any timing No exclusion based on timing
Languages Full text published in English Non-English language
Publication type Original research and systematic reviews Editorials, commentaries, and narrative reviews

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

Abbreviations: KQ=key question; RCT=randomized, controlled trial.