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Final Evidence Summary

Child Maltreatment: Primary Care Interventions

January 15, 2013

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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Behavioral Interventions and Counseling to Prevent Child Abuse and Neglect

A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation

Release Date: January 2013

By Shelley S. Selph, MD, MPH; Christina Bougatsos, MPH; Ian Blazina, MPH; and Heidi D. Nelson, MD, MPH.

The information in this article is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This article is intended as a reference and not as a substitute for clinical judgment.

This article may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This article was first published in Annals of Internal Medicine on January 22, 2013 (Ann Intern Med 2013;22 Jan; https://www.annals.org). Select for copyright and source information.

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Abstract

Background: In 2004, the U.S. Preventive Services Task Force determined that evidence was insufficient to recommend behavioral interventions and counseling to prevent child abuse and neglect.

Purpose: To review new evidence on the effectiveness of behavioral interventions and counseling in health care settings for reducing child abuse and neglect and related health outcomes, as well as adverse effects of interventions.

Data Sources: MEDLINE and PsycINFO (January 2002 to June 2012), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the second quarter of 2012), Scopus, and reference lists.

Study Selection: English-language trials of the effectiveness of behavioral interventions and counseling and studies of any design about adverse effects.

Data Extraction: Investigators extracted data about study populations, designs, and outcomes and rated study quality using established criteria.

Data Synthesis: Eleven fair-quality randomized trials of interventions and no studies of adverse effects met inclusion criteria. A trial of risk assessment and interventions for abuse and neglect in pediatric clinics for families with children aged 5 years or younger indicated reduced physical assault, Child Protective Services (CPS) reports, nonadherence to medical care, and immunization delay among screened children. Ten trials of early childhood home visitation reported reduced CPS reports, emergency department visits, hospitalizations, and self-reports of abuse and improved adherence to immunizations and well-child care, although results were inconsistent.

Limitations: Trials were limited by heterogeneity, low adherence, high loss to follow-up, and lack of standardized measures.

Conclusion: Risk assessment and behavioral interventions in pediatric clinics reduced abuse and neglect outcomes for young children. Early childhood home visitation also reduced abuse and neglect, but results were inconsistent. Additional research on interventions to prevent child abuse and neglect is needed.

Primary Funding Source: Agency for Healthcare Research and Quality.

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In 2004, the U.S. Preventive Services Task Force (USPSTF) found, on the basis of the results of a previous review1,2, insufficient evidence to recommend for or against routine screening of parents or caregivers for abuse or neglect of children3,4. This systematic review is an update for the USPSTF that focuses on studies published since the previous recommendation and addresses the effectiveness and adverse effects of behavioral interventions and counseling to prevent child abuse and neglect for children at potentially increased risk. Separate reviews examine screening women for intimate partner violence5,6 and elderly and vulnerable adults for abuse6.

Approximately 695,000 children in the United States were victims of child abuse and neglect in 2010, and 1537 died7. Most of these deaths were in infants and toddlers7. Additional immediate health consequences of abuse and neglect include injuries and emotional and behavioral problems8,9. Associated long-term physical conditions include neurologic and musculoskeletal disorders; gastrointestinal problems; metabolic conditions, including diabetes; autoimmune disorders10,11; obesity12,13; chronic pain14,15; teen pregnancy and pregnancy complications16; and others17. Chronic mental health conditions include psychosis, anxiety and posttraumatic stress disorder, alcohol and substance abuse, risky sexual behaviors, depression and suicide, eating disorders, attention problems, and personality disorders12,18-25.

In the United States, child abuse and neglect have legal as well as medical implications. Federal legislation defines child abuse and neglect as any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk for serious harm26-28. Although laws vary, states are required to include the minimum standards of the federal law29. All states have laws that require physicians and other health care workers, as well as other professionals who interact with children, to report suspected child abuse and neglect to Child Protective Services (CPS)3, part of the larger U.S. Department of Health and Human Services that specifically responds to child abuse reports28.

Physicians and other health care providers who care for children and families are uniquely situated to identify children at risk for abuse and neglect during well-child and other visits and to initiate interventions to prevent harm. Although pediatricians consider screening for abuse and neglect one of their important roles31, it is rarely done in practice32,33. Barriers to screening include lack of experience, training, and confidence in handling abuse cases32,34-36.

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We developed and followed a standard protocol. A technical report that includes additional methods, search strategies, evidence tables, and descriptions of earlier trials is available at www.uspreventiveservicestaskforce.org 37. The USPSTF and Agency for Healthcare Research and Quality (AHRQ) determined the key questions for this update by using the methods of the USPSTF38. Investigators created an analytic framework incorporating the key questions and outlining the patient population, interventions, outcomes, and potential adverse effects (Appendix Figure 1).

The target population includes children from birth to age 18 years and their caregivers who interact with health care providers in clinical settings where primary care is delivered to children. This review does not include studies of children with signs, symptoms, or complaints of abuse or neglect because those findings would elicit evaluation outside the scope of primary prevention recommendations. Outcomes included in this review incorporate currently accepted definitions of child abuse and neglect, an understanding of a continuum of potential outcomes, and an acknowledgment that only some outcomes are actually measurable in research studies. Intermediate outcomes, such as referral rates, use of counseling services, or measures of parent–child bonding, are outside the scope of this review. Main outcomes include measures of reduced exposure to abuse and neglect (CPS reports, removal of the child from the home, and caregiver self-reports of abuse or assault), measures of health outcomes related to abuse (physical injuries, death, emergency department visits, and hospitalizations), and measures of child neglect (adherence with immunizations and well-child visits).

Search Strategies

In conjunction with a research librarian, we used the National Library of Medicine's Medical Subject Headings keyword nomenclature to search the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews through the second quarter of 2012 and MEDLINE and PsycINFO from January 2002 to June 2012 for relevant English-language studies, systematic reviews, and meta-analyses. We also reviewed reference lists of papers and, using Scopus, reviewed citations of key studies.

Study Selection

Investigators developed inclusion and exclusion criteria for abstracts and articles based on the target population, key questions, and outcome measures. We included research that was done in the United States or in similar populations that receive services and interventions applicable to medical practice in the United States and was published in 2003 or later. After an initial review of abstracts, investigators reviewed full-text articles and conducted a second review to ensure eligibility. Appendix Figure 2 shows the search and selection diagram.

We included trials of the effectiveness of behavioral interventions and counseling to reduce exposure to abuse or neglect or improve health outcomes. Studies were eligible for inclusion if they enrolled children without obvious signs or symptoms of abuse or neglect, used a method to identify families or children at risk that was applicable to primary care, evaluated an intervention that primary care clinicians could access or provide referral for measured outcomes related to abuse or neglect, and compared outcomes between intervention and nonintervention groups. We included all types of CPS reports (confirmed and unconfirmed) because research indicates no association between substantiation status and behavioral and developmental outcomes39. We excluded studies focused on clinician education, methods to increase screening rates, and perceptions and attitudes of physicians and other clinicians, as well as studies of public awareness campaigns or other interventions not applicable to primary care settings and studies of interventions directed at perpetrators. Studies of any design were included to describe potential adverse effects of behavioral interventions and counseling. Potential adverse effects include escalating levels of abuse and neglect; false-positive evaluations; adverse consequences as a result of the investigation process; labeling, stigmatizing, and psychological distress; dissolution of families; and legal issues.

Data Abstraction and Quality Rating

An investigator abstracted data about study design and setting; participant characteristics; data collection procedures; numbers enrolled and lost to follow-up; methods of exposure and outcome ascertainment; analytic methods, including adjustment for confounders; and outcomes. A second investigator confirmed the accuracy of data.

We used criteria developed by the USPSTF to assess the quality of studies38,40. We assessed the applicability of studies by using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) framework adapted to this topic41. Two investigators independently rated the quality and applicability of each eligible study as good, fair, or poor. Final ratings were determined by consensus.

Data Synthesis

We assessed the aggregate quality of the body of evidence for each key question as good, fair, or poor by using methods developed by the USPSTF based on the number, quality, size, and applicability of studies and the consistency of results between studies38. Studies were considered consistent if outcomes were generally in the same direction of effect and ranges of effect sizes were narrow. Consistency was determined by consensus of the investigators.

External Review

The draft report was reviewed by content experts, USPSTF members, AHRQ program officers, and collaborative partners.

Role of the Funding Source

The study was funded by AHRQ under a contract to support the work of the USPSTF. Staff at AHRQ and members of the USPSTF developed the scope of the work. Approval from AHRQ was required before the manuscript could be submitted for publication, but the authors are solely responsible for its content and the decision to submit it for publication.

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Key Question 1

For children without obvious signs and symptoms of abuse or neglect but potentially at increased risk, how well do interventions and counseling initiated in primary care settings reduce exposure to abuse or neglect, physical or mental harms, or mortality?

Eleven randomized trials evaluating the effectiveness of child abuse and neglect prevention interventions met inclusion criteria for this update (Table 1)42-52. One trial evaluated a clinic-based intervention44, and 10 trials evaluated early childhood home visitation, including the Healthy Start43,46, Early Start49, Healthy Families45,47, Child First51, and Family Partnership Model42 programs; long-term follow-up of an early home visitation trial based in Memphis, Tennessee52; and 2 other home visitation interventions48,50. All studies were rated fair-quality, rather than good-quality, because of specific methodological limitations or lack of information about methods. These included inadequate inclusion and exclusion criteria42, randomization or allocation concealment42,43,45,47,49-51,53, or blinding43,48,49; low adherence with the intervention (≤50%)45,47,53; high loss to follow-up (>20%)43-45,48-51; dissimilar groups at baseline or follow-up44,47,50,51,53; and lack of intention-to-treat analysis42-45,47-53.

All trials enrolled participants from primary care or maternity practices or settings. Although enrollment criteria for the trials varied, most included risk factors related to the child or parents (Table 2). Some trials used formal risk assessment instruments, such as the Kempe Family Stress Checklist45-47, Parent Screening Questionnaire44, or Parent Risk Questionnaire51, as either a primary or secondary step in determining risk.

Clinic-Based Interventions

A trial based in a pediatric clinic compared outcomes of children whose parents had risk assessment followed by physician and clinic-based social work interventions, as needed, with outcomes of children receiving usual primary care44. The trial was based on the Safe Environment for Every Kid (SEEK) model, which includes risk assessment during the course of usual primary care services, training physicians in addressing risk factors for abuse and neglect, providing informational resources for parents and physicians, and providing social work services to families desiring them. Outcome measures were obtained from CPS reports, children's medical charts, and parent responses on the Parent–Child Conflict Tactics Scale. Outcome data were collected at baseline and 3 years later.

The trial enrolled 729 participants from university-based, pediatric primary care resident continuity clinics serving low-income families in Baltimore, Maryland. Children were newborn to age 5 years, and most were African American with single mothers receiving Medicaid or aid from State Children's Health Insurance Programs. Clinics were randomly assigned in clusters to either the SEEK model or usual care on the basis of clinic day of the week. The usual care control group received standard pediatric care and services from an onsite human services worker with similar responsibilities as the social worker for the intervention group. For the intervention group, risk factor assessment was conducted using the Parent Screening Questionnaire, a 20-item, self-report questionnaire of safety issues that examines major risk factors for child abuse and neglect, such as parental depression and substance abuse. For participants with positive responses, trained physicians addressed concerns and provided educational materials, treatment, and referrals as needed. A social worker provided clinic-based interventions on a case-by-case basis (Dubowitz H. Personal communication.)44.

Results indicated that, although 12% of families in both groups were involved with CPS before the trial, families in the intervention group had fewer CPS reports than did those in the usual care group as long as 44 months after the intervention (13% vs. 19%; P = 0.03) (Table 3). These findings represented all CPS reports, except for cases where abuse or neglect were explicitly ruled out. Also, parents in the intervention group reported fewer episodes of severe or very severe physical assault (average weighted Parent–Child Conflict Tactics Scale score, 0.11 vs. 0.33; P = 0.04), fewer instances of nonadherence to medical care (5% vs. 8%; P = 0.05), and fewer delays in immunizations (3% vs. 10%; P = 0.002) than did parents in the usual care group.

Seventy-six percent of enrolled participants completed the study protocol. Factors that could have reduced differences between groups include diffusion of the SEEK model to the control group clinics when physicians changed clinic days or communicated with colleagues; similarity of services for intervention and control groups; and surveillance bias that increased detection of abuse and neglect, even in the absence of formal risk assessment. Applicability of the trial was limited by its being conducted in only 1 pediatric clinic setting serving a narrowly defined population but was enhanced by its use of existing health care services within primary care practices to integrate risk assessment into usual health care processes.

Home Visitation Interventions

Ten randomized trials evaluated the effectiveness of early childhood home visitation interventions to prevent child abuse and neglect and enrolled participants on the basis of risk assessment42,43,45-52. Most trials were modeled after nurse home visitation interventions initiated more than 15 years ago in Elmira, New York54, and Memphis, Tennessee55. The primary intervention included visits to the participant's home by either a paraprofessional, such as a layperson who completed a 9-week training course, or by a professional, typically a nurse. Home visits occurred postnatally or both prenatally and postnatally for 3 to 36 months after birth. Although the trials used the same basic approach, they differed in enrollment criteria, duration of intervention and follow-up, type of provider, outcome measures, and other important factors45,46,48,50. Outcomes of trials reporting at least 50% adherence to the interventions, including death, CPS reports, and health care measures, are summarized in Table 3.

In a long-term follow-up study of the Memphis trial that included 743 children, those receiving home visits from a nurse as infants were less likely to die by age 9 years than those in the usual care control group, although results were of borderline statistical significance (1 vs. 10 deaths; P = 0.08)52. In this study, the 1 death in the home visit group was the result of chromosomal abnormalities; of the 10 children who died in the control group, 3 died from complications of prematurity, 3 from the sudden infant death syndrome, 3 from injury (homicide by firearm, accidental injury from firearm, and motor vehicle accident), and 1 from an intestinal infection.

Five randomized, controlled trials provided CPS reports as an outcome, including confirmed CPS reports45-47, all types of CPS reports51, and parent descriptions of CPS reports49. No trials found differences in rates of CPS reports between home-visited children and control children while the studies were ongoing45-47,49,51. However, 1 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])51, whereas 2 others found no differences after 18 months42 or 36 months46. Two trials indicated that home-visited children were not removed from their homes at statistically significantly higher rates than control children42,46.

Three trials evaluated hospital emergency department visits by enrolled children45,49,50. A trial specifically evaluating visits for injuries or ingestions reported reduced hospital visits for home-visited children (odds ratio, 0.59 [CI, 0.36 to 0.98])49. Two other trials reported no differences in emergency department visits for ambulatory care–sensitive conditions (visits that might have been prevented if timely and appropriate care had been provided)45 or for all types of indications50.

Five trials reported no statistically significant effects of home visitation on the number or percentage of children hospitalized in general42,50, because of child abuse and neglect49, or for ambulatory care–sensitive conditions45,46. A trial with a 12-month nurse visitation intervention and an additional 12-month follow-up found that nurse-visited children had fewer episodes of hospitalizations for all indications (19 vs. 36; P < 0.01) and fewer mean hospitalization days (143 vs. 211; P < 0.001) at 24 months than control children50.

Three trials included measures of potential medical neglect, including nonadherence to recommended immunizations, well-child visits, or both48-50. In 1 trial, home-visited children received immunizations at an earlier age than control children, resulting in significant differences between groups through age 9 months (2.20 vs. 1.64 mean visits; P = 0.01) but not at 12 months48. Other trials indicated no differences in the second year with 24-month-old children50 or in the third year49. A trial reporting significant differences in the mean number of well-child visits at 9 months (3.14 vs. 2.18 mean visits; P = 0.0098) and 12 months (3.51 vs. 2.68 mean visits; P = 0.0098) also found that the more contact the children had with study personnel the more well-child visits they had at 12 months (P = 0.036)48. In another trial, home-visited children were more likely to be up to date with well-child visits (42% vs. 30%; P < 0.05) and enrolled for dental care (72% vs. 63%; P < 0.05) over a 36-month period than children who were not in the program49.

Studies using self-reported measures of abuse and neglect are subject to biased reporting, particularly because acknowledgment of child abuse and neglect is reportable to CPS. Five trials used the Parent–Child subscale of the Conflict Tactics Scale to assess mothers' self-reports of abusive and neglectful behaviors toward their children43,45-47,49. One trial found a significant difference in self-reported severe physical assault at 36 months (4% of home-visited mothers vs. 12% of control mothers; P < 0.01)49. Although another trial indicated no differences in the prevalence of abuse or neglect at 24 months, home-visited mothers reported one fourth as many acts of serious physical abuse, such as kicking or punching the child, compared with control mothers (P = 0.03)47. Two other trials reported no differences in child maltreatment between groups45,46. In a trial comparing a cognitive-based extension of the Healthy Start home visitation program with the usual Healthy Start program, there were few instances of self-reported abuse on the Conflict Tactics Scale43, although the prevalence of spanking or slapping was lower in the enhanced group than in the unenhanced group (21% vs. 35%; P = 0.03).

Key Question 2

What are the adverse effects of behavioral interventions and counseling to reduce harm from abuse and neglect?

Adverse effects of interventions were not explicitly evaluated in the trials, and additional studies of adverse effects were not identified by the literature searches. Although not described in the publication, during the SEEK trial, investigators maintained regular contact with the pediatric primary care practices involved in the trial and actively monitored potential adverse effects. No adverse effects were reported by participants (Dubowitz H. Personal communication.).

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Table 4 summarizes the evidence reviewed for this update. A trial of risk assessment and behavioral interventions and counseling in a pediatric clinic showed statistically significantly reduced measures of abuse and neglect for young children and observed no adverse effects from the interventions. Outcomes included reduced physical assault, CPS reports, medical care nonadherence, and immunization delay. This trial is, to our knowledge, the first to determine the effectiveness of a clinic-based intervention in preventing child abuse and neglect, and it demonstrated the feasibility of the SEEK model by integrating it into usual care processes of the clinic. The applicability of these results was limited by the enrollment of participants from only a single clinical site with a narrowly defined high-risk population. A second trial using the SEEK model included 66 pediatricians and 24 nurse practitioners in 18 private practices in mostly suburban areas with primarily white, middle-class patients56. Mothers in the SEEK practices reported less psychological aggression and minor physical assault than did mothers in usual care practices56; however, additional outcomes have not yet been published57.

Ten trials of early childhood home visitation indicated reduced death, CPS reports, emergency department visits, hospitalizations, and self-reports of abuse and neglect and improved adherence to immunizations and well-child care. However, some results were of borderline statistical significance or were inconsistent across trials. Although adverse effects of home visitation were not specifically stated, 2 trials indicated that home-visited children were not removed from their homes at statistically significantly higher rates than were control children42,46. These recent trials provide new information about the effectiveness of home visitation on long-term mortality, adherence with immunizations and well-child visits, and self-reported abuse and neglect.

The new trials also build on research considered in the previous USPSTF review1,2 and support findings of earlier trials37. Although most trials indicated that home-visited children did not have fewer CPS reports than did usual care children during the course of the trial, CPS reports were statistically significantly reduced after 3 years of follow-up in a recent trial of the Child First program51 and after 15 years of follow-up in the previously published Elmira trial58. Also, recent trials showing reduced use of health care services for home-visited children, such as emergency department visits49,50 or hospitalizations50, are supported by previous trials also showing statistically significantly reduced use of these services 54,55,59. The consistency of these results strengthens the findings.

Although home visitation programs are widespread—for example, Healthy Families America, which has 383 sites in 35 states and the District of Columbia60—specific services vary widely. Consequently, results of trials may not translate to all programs. The trials themselves are highly heterogeneous. Interventions were provided by individuals of varying skill levels, ranging from paraprofessionals with a high school diploma and some additional training47,53 to experienced nurses or other health care professionals52. Trials also differed in the number of home visitation sessions completed, from as few as 12 sessions50 to as many as 41 sessions42 over a period that ranged from 1 year48,50 to 3 years49 after birth and was often unclear. Most of the statistically significant benefits of home visitation were demonstrated by trials with more intense interventions, suggesting that they are more effective37. These include trials where children received home visitation services for longer periods, such as 24 months or more49,51,54,55,61, or from higher-level providers, such as nurses rather than paraprofessionals50,51,54,55,61.

The trials were limited by several factors, including an almost complete focus on home visitation, with only 1 trial evaluating a clinic-based intervention. Further research to develop and test approaches for clinical settings would address this important evidence gap. Trials often lacked predefined identification of primary and secondary outcomes. Outcome measures also differed, limiting comparisons between trials, and often included self-reported outcomes that are subject to bias. Surveillance bias confounded trials, as shown by CPS referrals from home visitors in 2 trials45,53. Definitions used in child abuse and neglect research also vary greatly29 and lead to difficulty in determining and collecting accurate measurements26,62.

The relationship between harsh punishment, such as spanking, and child abuse needs to be further explored. Although spanking is common in the United States, it has been associated with higher odds of physical child abuse63 and long-term developmental issues64. Escalation of violence along this continuum could be prevented if harsh punishment practices are recognized and alternatives are considered. The relationship between intimate partner violence and child abuse also requires additional research. Child abuse is more likely to occur in households where partner violence exists65. Interventions directed at identifying and reducing partner violence could potentially benefit children, although few studies have shown this effect66-68.

Additional research is needed to determine effective methods for physicians and other health care clinicians to identify children at risk for abuse or neglect. Emerging areas include the use of biomarkers to detect subclinical abuse. Elevations in serum or cerebrospinal fluid levels of neuron-specific enolase and myelin-basic protein, for example, provide measures of inflicted traumatic brain injury in otherwise normal-appearing infants69,70. Use of pancreatic and liver enzymes to screen for occult abdominal trauma in situations of possible physical abuse has also been explored71.

Approaches applicable to children of all ages need to be developed, validated, and tested. The lack of studies assessing older children, identified in the previous USPSTF review as an important evidence gap, has yet to be addressed. Efforts to improve identification of children at risk for abuse and neglect need to be coupled with development and evaluation of effective interventions to which they can be referred once identified. Additional research on the effectiveness of interventions is needed to support the results of current trials and expand their applicability. Standardization of interventions and outcomes would allow for quantitative meta-analysis. This research should also determine whether the interventions have unintended adverse effects.

In conclusion, trials of risk assessment and behavioral interventions and counseling in pediatric clinics and early childhood home visitation programs indicated reduced abuse and neglect outcomes for children, although all trials had limitations and trials of home visitation reported inconsistent results. Clinicians are well-positioned to identify children at risk for abuse and neglect and to connect families with appropriate prevention interventions. More research is needed in key areas to provide clinicians with effective methods of doing so.

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Source: This article was first published in Annals of Internal Medicine (Ann Intern Med 2013; 22 Jan).

Disclaimer: The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

Acknowledgment: The authors thank Tracy Dana, MLS, for conducting literature searches, and Peggy Nygren, MA, for providing additional contributions to the report.

Financial Support: By AHRQ under contract HHSA-290-2007-10057-I-EPC3, task order 3.

Potential Conflicts of Interest: Dr. Selph: Other (money to author and institution): This work was based on a report that was supported by AHRQ. Ms. Bougatsos: Other (money to author and institution): This work was based on a report that was supported by AHRQ. Mr. Blazina: Grant (money to institution): AHRQ; Support for travel to meetings for the study or other purposes (money to institution): AHRQ. Dr. Nelson: Grant (money to institution): AHRQ; Support for travel to meetings for the study or other purposes (money to institution): AHRQ; Payment for writing or reviewing the manuscript (money to institution): AHRQ.

Requests for Single Reprints: Heidi D. Nelson, MD, MPH, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Mail Code BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098; e-mail, nelsonh@ohsu.edu.

Current author addresses and author contributions are available at https://www.annals.org.

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Study, Year
(Reference)		 Population Duration Risk Assessment Intervention Comparison Mean Home Visits Completed, n Outcomes USPSTF Quality Rating
Clinic-based
Dubowitz et al, 2009 44 558 parents of children aged ≤5 y at a university-based, pediatric primary care resident clinic serving a low-income urban population in Baltimore, Maryland 3 y PSQ Clinic-based screening using the PSQ, physician training, materials about child abuse, and social work services (SEEK model) Usual care Not applicable CPS reports (reports excluded if abuse was ruled out)
Problems related to neglect documented in medical charts
Delayed immunizations
Self-reported severe or very severe physical assault (CTS)		 Fair*†‡
Home visitation
Barlow et al, 200742 131 women with newborns, predominantly white and living in poverty, attending general practitioner practices in the United Kingdom 1 y Midwives selected participants by using demographic and socioeconomic criteria Weekly home visits from a trained health visitor for 18 mo (Family Partnership Model) Usual care Intervention, 41; usual care, 9 Placement on the child protection register or care proceedings
Child removed from the home		 Fair†§a
Bugental and Schwartz, 200943 110 predominantly Latino families of newborns in Santa Barbara County, California 1 y Mothers identified at moderate risk for abuse were referred by physicians, social workers, and public health nurses based on FSC (score, 25–40) or medical risk factors Cognitive-based extension of the Healthy Start home visitation program (14–17 visits) Standard Healthy Start home visitation program Not reported Self-reported physical abuse (CTS)
Mean injury score (CIS)
Self-reported spanking (FSS, CIS)
Self-reported neglect (FSS)
Mean home safety maintenance score (FSS)		 Fair*†a**
Duggan et al, 200446 730 Pacific Islander or Asian women with newborns, many living in poverty, in Hawaii 2 y Referred by prenatal care providers and during birth hospitalization using risk factors and FSC (score ≥25) Weekly home visits for 3–5 y by trained paraprofessionals (Healthy Families Hawaii) Biweekly, monthly, or quarterly, with criteria for promotion Not reported CPS reports (confirmed reports)
Child removed from the home		 Fair†‡**††
Duggan et al, 200745 364 women with newborns, many living in poverty, with partner violence, depression, or substance abuse in Alaska 2 y Healthy Families protocol and FSC (score ≥25) Intensive home visits for 3–5 y, weekly for the first 6–9 mo and less frequent as family functioning improved (Healthy Families Alaska) Usual care First year, 22; second year, 20 CPS reports (confirmed reports)
Hospitalizations for injury or ingestion ED visits		 Fair*†**††
DuMont et al, 200847 1173 women with newborns at the University of Albany, New York 2 y FSC Home visits for 2 y by trained paraprofessionals (Healthy Families New York) Usual care First year, 22; second year, 14 CPS reports
Self-reported serious physical abuse (CTS)		 Fair†‡**††
El-Mohandes et al, 200348 286 women with newborns who received no or inadequate prenatal care, predominantly African American and living in poverty, in Washington, DC–area hospitals 1 y Demographic factors, reproductive history, use of prenatal care, drug and alcohol use, and infant health at delivery Home visits for 1 y, developmental play groups, parent support groups, and monthly support calls from a family resource specialist Usual care Not reported Mean immunization visits (at 4 and 12 mo)
Well-child visits (at least 1 at 4 mo; mean number at 9 mo)		 Fair*†
Fergusson et al, 200549 433 families, predominantly welfare-dependent, in New Zealand 3 y Nurse screening based on presence of 2 or more risk factors Needs assessment, resources, support, problem solving (Early Start program) Usual care Not reported Contact with agencies for child abuse/neglect (parent report)
ED visits for injury or ingestion
Hospitalizations for child abuse and neglect
Current with immunizations
Current with well-child visits
Enrolled for dental care
Self-reported severe physical punishment (CTS)		 Fair*†**
Koniak-Griffin et al, 200350 101 pregnant adolescents aged 14–19 y at ≤26 wk gestation with first child obtaining care at the County Health Department, San Bernardino, California 2 y Referral by Community Health Services Department Case management by public health nurses providing continuous care from pregnancy through 1 y after birth with education, counseling, and home visits Usual care Prenatal, 2; postnatal, 10 ED visits
Hospitalizations (number and days)
Current with immunizations		 Fair*†‡**
Lowell et al, 201151 157 families with children aged 6–36 mo, predominantly living in poverty, obtaining services in primary care clinics or WIC programs in Connecticut 22 wk Positive scores for social, emotional, or behavioral problems on the BITSEA and/or parent scored high for psychosocial risk on the Parent Risk Questionnaire Services delivered predominantly in the home by a clinical team on the basis of each family's needs (Child First program) Usual care 12 (plus 12 telephone contacts) CPS involvement (all types of reports at 36 mo) Fair*†‡**
Olds et al, 200752 1139 pregnant, predominantly unmarried African American women aged <18 y in a public obstetric clinic in Memphis, Tennessee Prenatal through 9 y Pregnant women at <29 wk gestation with no other children and at least 2 risk factors (unmarried, <12 y of education, unemployed) Transportation to clinic Transportation to clinic plus developmental screening and referral services at 6, 12, and 24 mo
Transportation to clinic plus 3 intensive home visitations
Transportation to clinic plus intensive home visitation services through age 2 y		 Prenatal, 7; postnatal, 26 Death Fair†

BITSEA = Brief Infant–Toddler Social and Emotional Assessment; CIS = Child Injury Survey; CPS = Child Protective Services; CTS = Conflict Tactics Scale; ED = emergency department; FSC = Kempe Family Stress Checklist; FSS = Framingham Safety Survey; PSQ = Parent Screening Questionnaire; SEEK = Safe Environment for Every Kid; USPSTF = U.S. Preventive Services Task Force; WIC = Supplementary Nutrition Program for Women, Infants, and Children.
* Loss to follow-up was greater than 20% or not reported or follow-up differed between groups.
† Analysis was not an intention-to-treat analysis or was not described.
‡ Randomized groups were not similar at baseline or follow-up.
§ Inclusion/exclusion criteria were inadequate or not described.
a Randomization method was inadequate or not described.
¶ Blinding was inadequate or not described.
** Unclear methods of allocation concealment.
†† No more than 50% adherence with the intervention.

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Criterion Study, Year (Reference)
Dubowitz et al, 2009 44 Barlow et al, 2007 42 Bugental and Schwartz, 200943 Duggan et al, 200446 Duggan et al, 200745 DuMont et al, 200847 El-Mohandes et al, 200348 Fergusson et al, 200549
 		 Koniak et al, 200350
 		 Lowell et al, 201151 Olds et al, 200752
Pregnancy factors
First pregnancy - - - - - - - - REC - REC
Unplanned pregnancy - - - - - - - EC* - - -
<26 or <29 wk gestation - - - - - - REC - REC - REC
Late, no, or poor prenatal care - - - EC - - - - - - -
History of unsuccessfully sought abortion - - - EC - - - - - - -
Adoption sought - - - EC - - - - - - -
Parent factors
Aged <18, <19, or <20 y - - - - - EC† - EC* REC - -
Single - - - EC - EC† - - - - EC‡
Low income or low socioeconomic status - - - EC - - - EC* - - -
<12 y education - - - EC - EC† - - - - EC‡
Unemployed - - - EC - - - - - - EC‡
Unstable housing - - - EC - EC† - - - - -
Low social support - - - EC - - - EC* - - -
History of substance abuse - - - EC EC - - EC* - - -
In permanent caregiving environment - - - - - - - - - EC§ -
Requested participation - - - - - - - - - - -
Poor mental health/depression/psychiatric care - - - EC EC - - - - - -
Domestic violence - - - - EC - - EC* - - -
No telephone - - - EC - - - - - - -
Marital or family problems - - - EC - - - - - - -
Criteria not further described - EC - - - - - - - - -
Child factors
Aged 6–36 mo - - - - - - - - - REC -
Aged 0–5 y REC - - - - - - - - - -
Infant at medical risk (cesarean delivery, medical issue) - - REC - - - - - - - -
Behavioral problem (BITSEA) - - - - - - - - - EC§ -
Health care factors
Parental risk factors on hospital chart - - - REC - - - - - - -
Nurse has concerns - - - - - - - EC - - -
Screening instruments
Kempe Family Stress Checklist scorea - - - EC EC EC** - - - - -
Parent Screening Questionnaire REC†† - - - - - - - - - -
Parent Risk Questionnaire - - - - - - - - - EC§ -

BITSEA = Brief Infant–Toddler Social and Emotional Assessment; EC = enrollment criteria; REC = required enrollment criteria.
* Nurse had concerns if fewer than 2 criteria were met.
† These risk factors were given as an example; others may be used.
‡ In addition to required elements, 2 of 3 criteria must be met.
§Child or adult may qualify. Child must be aged 6 to 36 mo with social, emotional, or behavioral problem or parent must screen as high-risk on the Parent Risk Questionnaire and be in a permanent caregiving environment.
a Checklist items include abuse history, prior Child Protective Services involvement, current crisis, history of partner violence, belief in harsh punishment, perception that the child is difficult, unrealistic child expectations, and parental ambivalence about the child.
¶ Kempe Family Stress Checklist score of 25 or greater.
** After meeting initial criteria, either parent must score 25 or greater.
†† Only the intervention group completed the Parent Screening Questionnaire.

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Outcome Measure Intervention Comparison Difference Reference
Child mortality at age 9 y Number of deaths 1 10 P = 0.08 Olds et al, 200752
Child Protective Services reports
Reports during study period Percentage 13 19 P = 0.03 Dubowitz et al, 200944
Contact with agency Percentage 20 21 P = 0.39 Fergusson et al, 200549
Placement on child protection register or care proceedings Relative risk (95% CI) – – 2.02 (0.46–2.54) Barlow et al, 200742
No report after the study period Odds ratio (95% CI) – – 2.1 (1.0–4.4) Lowell et al, 201151
Removal of child from home Percentage 6 0 NS Barlow et al, 200742
Use of health care services
Emergency department visits for injuries and ingestions Odds ratio (95% CI) – – 0.59 (0.36–0.98) Fergusson et al, 200549
Emergency department visits Percentage 64 89 NS Koniak-Griffin et al, 200350
Hospitalizations for abuse and neglect Percentage 1 2 NS Fergusson et al, 200549
Hospitalizations Percentage
Percentage		 21
8		 36
14		 NS
NS		 Koniak-Griffin et al, 200350
Barlow et al, 200742
Well-child care
Nonadherence to medical care Percentage 5 8 P = 0.05 Dubowitz et al, 200944
Immunization clinic visits by age 9 mo Mean number 2.20 1.64 P = 0.0125 El-Mohandes et al, 200348
Immunization clinic visits by age 1 y Mean number 2.44 2.00 P = 0.0867 El-Mohandes et al, 200348
Current with immunizations at age 2 y Percentage 77 87 NS Koniak-Griffin et al, 200350
Current with immunizations at age 3 y Percentage 93 92 P = 0.83 Fergusson et al, 200549
Delayed immunizations Percentage 3 10 P = 0.002 Dubowitz et al, 200944
Well-child visits at age 1 y Mean number 3.51 2.68 P = 0.0098† El-Mohandes et al, 200348
Current with well-child visits at age 3 y Percentage 42 30 P < 0.05 Fergusson et al, 200549
Enrolled for dental care at age 3 y Percentage 72 63 P < 0.05 Fergusson et al, 200549

NS = not significant.
* Studies with less than 50% adherence not shown in this table include Duggan et al45,46 and DuMont et al47.

† P < 0.05 for all periods (4, 6, 9, and 12 mo).

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Key Questions Studies Design Limitation Consistency Applicability Overall Quality Findings
For children without obvious signs and symptoms of abuse or neglect but potentially at increased risk, how well do behavioral interventions and counseling initiated in primary care settings reduce exposure to abuse or neglect, physical or mental harms, or mortality? 1 trial of a clinic-based program and 10 trials of early childhood home visitation RCT Trials were limited by heterogeneity, low adherence, high loss to follow-up, and lack of standardized measures Inconsistent for some outcomes Moderate Fair A trial in a pediatric clinic showed reduced physical assault, CPS reports, nonadherence to medical care, and immunization delay among screened children. Ten trials of early childhood home visitation reported reduced CPS reports, ED visits, hospitalizations, and self-reports of abuse and neglect, as well as improved adherence to immunizations and well-child care. Results were inconsistent.
What are the adverse effects of behavioral interventions and counseling to reduce harm from abuse and neglect? 1 trial of a clinic-based intervention RCT Studies of adverse effects were lacking Not relevant Moderate Not relevant The clinic-based trial observed no adverse effects from the interventions

CPS = Child Protective Services; ED = emergency department; RCT = randomized, controlled trial.

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Select Text Description below for details

Text Description.

This Figure depicts the analytic framework, which outlines the evidence areas covered in the review, including the populations, interventions, and outcomes. The population includes children without obvious signs and symptoms of current or past abuse or neglect, from which children potentially at increased risk for abuse or neglect are identified in a primary care generalizable setting. From this population, an arrow represents interventions initiated in primary care settings (key question 1) and points to the outcomes included in the review. Intermediate outcomes include reduced exposure to abuse and neglect, specifically Child Protective Services reports, removal of the child from the home, and reports of abuse or neglect. Clinical health outcomes include reduced physical or mental harms, specifically physical injuries; mental health conditions; use of health care services; adherence with immunizations and well-child visits; other relevant health measures; and mortality. A dotted line between the intermediate and clinical health outcomes represents the association between intermediate and clinical health outcomes, and a larger box surrounds the intermediate and clinical health outcomes, signifying that outcomes are considered to be on a continuum. An arrow from the intervention area of the framework also assesses harms of the interventions (key question 2).

Key Questions:
1. For children without obvious signs and symptoms of abuse or neglect but potentially at increased risk, how well do behavioral interventions and counseling initiated in primary care settings reduce exposure to abuse or neglect, physical or mental harms, or mortality?
2. What are the adverse effects of behavioral interventions and counseling to reduce harm from abuse and neglect?

* Child Protective Services reports, removal of the child from the home, and reports of abuse or neglect.
† Physical injuries, mental health conditions, use of health care services, adherence to immunizations and well-child visits, and other relevant health measures.

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Select Text Description below for details

Text Description

Appendix Figure 2. Summary of evidence search and selection. (Text Description)

This figure is a flow chart that summarizes the search and selection of articles. Abstracts of potentially relevant articles were identified through bibliographic databases, including MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, as well as through other sources, including expert reviewers and reference lists. There were 8,394 abstracts of potentially relevant articles reviewed. After excluding 7,781 abstracts, titles, and articles that were not relevant to the key questions, 613 full-text articles were retrieved for further review. A total of 602 full-text articles were excluded for the following reasons: wrong populations, including adults, elderly, symptomatic children, or perpetrator-focused studies (432); studies of screening tests (43); wrong interventions, including those not linked to screening or risk assessment or a clinic setting, or not a prevention focus (21); wrong outcome (27); wrong study design (5); no primary data, an editorial, or a nonsystematic review (35); risk factor, association, or prevalence study (19); systematic reviews with different inclusion criteria (14); and trials excluded for poor quality (6). For key question 1, 11 trials were included, and additional trials from the prior report are discussed contextually. For key question 2, no studies were included. Note that the search results include abstracts for child, adult, and elderly populations; studies of adults and elderly populations are included in a separate report.

* Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews.
† For example, identified by reference lists and suggested by experts.
‡ Includes search results for child, adult, and elderly populations. Studies of adults and elderly populations are included in a separate report6, as are studies of children that predate this update37.
§ Studies that meet inclusion criteria for key questions.

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