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Draft Recommendation Statement

Prevention of Child Maltreatment: Primary Care Interventions

August 29, 2023

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.

This document is available for Public Comments until Sep 25, 2023 11:59 PM EDT

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Recommendation Summary

Population Recommendation Grade
Children and adolescents younger than age 18 years without signs and symptoms of maltreatment The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. I

Additional Information

Tools
Related Resources
  • Primary Care Interventions to Prevent Child Maltreatment (Consumer Guide): Draft Recommendation | Link to File New Resource for Clinicians and Patients

Full Recommendation:

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 U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms to improve the health of people nationwide. 

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 decision-making 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. 

The USPSTF is committed to mitigating the health inequities that prevent many people from fully benefiting from preventive services. Systemic or structural racism results in policies and practices, including health care delivery, that can lead to inequities in health. The USPSTF recognizes that race, ethnicity, and gender are all social rather than biological constructs. However, they are also often important predictors of health risk. The USPSTF is committed to helping reverse the negative impacts of systemic and structural racism, gender-based discrimination, bias, and other sources of health inequities, and their effects on health, throughout its work.

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Child maltreatment, which includes child abuse and neglect, can have profound effects on health, development, survival, and well-being throughout childhood and adulthood.1,2 Prevalence of child maltreatment in the United States is uncertain and likely underestimated.1 In 2021, an estimated 600,000 children were identified by Child Protective Services (CPS) as victims of abuse or neglect and an estimated 1,820 children died of abuse and neglect.3

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Evidence on interventions to prevent child maltreatment is limited and results are inconsistent; therefore, the USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of primary care interventions to prevent child maltreatment in children and adolescents younger than age 18 years.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.4

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Patient Population Under Consideration

This recommendation applies to children and adolescents younger than age 18 years who do not have signs or symptoms of maltreatment. This recommendation statement does not apply to children and adolescents with signs or symptoms of maltreatment or known exposure to maltreatment. 

Definitions

Child maltreatment refers to any action, series of actions, or lack of action resulting in harm, potential harm, or threat of harm to children and adolescents younger than age 18 years.5 Child maltreatment may refer to abuse or neglect by a parent, caregiver, or anyone in the context of a “relationship of responsibility, trust, or power.”2 For this recommendation statement, child abuse includes, but is not limited to, physical abuse, sexual abuse, and psychological or emotional abuse.5 Child abuse refers to words or actions that cause harm, potential harm, or threat of harm to a child by a parent, caregiver, or person in a custodial role.5 Child neglect refers to failure to meet a “child’s basic physical, emotional, or educational needs or protect a child from harm or potential harm.”5,6

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Child maltreatment affects children of all ages and racial, ethnic, and socioeconomic backgrounds. Of the estimated 600,000 youth suffering abuse and neglect (per 2021 CPS reports), most were victims of neglect (76%), and many suffered physical abuse (16%), sexual abuse (10%), and sex trafficking (0.2%).3 Of the over 1,800 children who died in 2021, most were victims of neglect (78%), and nearly half suffered from physical abuse (43%) alone or in combination with another type of maltreatment (e.g., neglect and psychological maltreatment).3 Young children are most vulnerable to child maltreatment and death.3 About one-fourth of maltreatment victims (28%) are children between birth and age 2 years, and children younger than age 3 years comprise well over half (66.2%) of all child fatalities.3

A National Incidence Study of Child Abuse and Neglect report includes maltreatment estimates for youth investigated by CPS and for youth not reported to CPS, or not investigated by CPS yet recognized as maltreated.1,7 In its latest report from 2005–2006, 1 in every 58 children in the United States experienced maltreatment.7 Most suffered neglect (61%), while almost half (44%) experienced abuse.7 Of children who were abused, most experienced physical abuse (58%), but also emotional abuse (27%) or sexual abuse (24%).7 More recent reports suggest child maltreatment prevalence is more common. According to the National Survey of Children’s Exposure to Violence report from 2013–2014, which obtains prevalence and incidence estimates of a wide range of childhood violence, crime, and abuse through telephone interviews of children and adolescents younger than age 18 years, an estimated 1 in 7 U.S. children experienced maltreatment.8,9 

Potential Harms

The USPSTF found limited evidence on the harms associated with interventions to prevent child maltreatment. Some evidence suggests that participation in interventions could increase the likelihood of being reported to child welfare agencies.1 Given pervasive racial and ethnic disparities in child maltreatment reporting, investigation, and placement in the child welfare system, biases in identification of child maltreatment may disproportionately disadvantage Black, Native American/Alaska Native, and Hispanic families.1 These disadvantages may be related to complex intersections of factors, including racism, race, low socioeconomic status, living in neighborhoods of low socioeconomic status, and increased exposure to social service agencies and law enforcement contributing to increased likelihood of being reported for child maltreatment.1 Additional potential harms of preventive interventions include social stigma and effects on family functioning and dynamics. 

Current Practice 

Reporting. Children with signs or symptoms suggestive of maltreatment should be assessed and reported according to the applicable state laws.

Clinicians tend to disproportionately report abuse among Black and other “minority”10 children compared with White children.1 In addition, some studies demonstrate more missed cases of maltreatment in White children.1 Native American11 and Alaska Native youth are reported to CPS at higher rates than their representation in the population.1 Hispanic youth are overrepresented in child maltreatment reports in some U.S. states and underrepresented in others compared with their representation in the population.1 Sources of these inequities are complex and likely include racism resulting in subjectivity, inconsistency, and clinician bias12-14 in reporting child maltreatment.1 Social factors (e.g., socioeconomic status15 or insurance type) may be associated with clinician decisions to report child maltreatment.1,13

Identification. Due to the recommended schedule of periodic health assessments and relationship with families, primary care clinicians are uniquely positioned to identify child maltreatment. As maltreatment is rarely witnessed by persons other than a child and perpetrator, and there is no single test to confirm abuse or neglect, identification and diagnosis of child maltreatment can be challenging.1 Use of risk assessment tools are designed to assist in identifying youth for whom preventive interventions might be indicated. However, the USPSTF found limited and inconsistent evidence on the validity and reliability of risk assessment instruments. There is no gold standard for these tools; measures to validate tools (e.g., CPS reports) are imprecise and likely overreport or underreport true child maltreatment.1 A majority of risk assessment instruments are designed for emergency room or hospital setting use.1 These instruments appear more accurate in identifying children at risk for maltreatment than instruments designed for use in the primary care or home setting.1 Instruments that do not depend on clinician judgement (e.g., instruments based on relationships between risk factors and maltreatment rather than clinician perception of parental practices) appear better at predicting onset of maltreatment than instruments based primarily on the judgement of clinicians.1 

Diagnosis. Assessment for possible physical abuse may include a comprehensive medical and event history, physical examination, and further diagnostic workup (e.g., imaging or laboratory testing) as needed.1,16 Variations in practice and clinician bias may contribute to missed diagnoses, which has significant consequences for youth; up to half of children (39% to 50%) with unrecognized abuse suffer additional abuse-associated injuries within 1 year.1 Social factors (e.g., socioeconomic status15 or insurance type) may intersect with racism to impact clinician decisions to pursue diagnostic testing for child maltreatment.1 In studies of abusive head trauma, abuse appears more likely to be unrecognized and misdiagnosed in White children younger than age 3 years living with a mother and father compared with children of “minority races” or children who live in households in which both parents did not live together.17 Evidence suggests that use of clear and consistent diagnostic guidelines may reduce variations in medical practice and racial disparities.1 In a study evaluating the effects of guideline implementation on racial and socioeconomic disparities, after implementation of a protocol recommending all children younger than age 1 year with unwitnessed head trauma receive a skeletal survey, racial disparities declined.1,18 Prior to implementation of the protocol, Black children underwent more skeletal surveys than White children (91% vs. 69%; p= 0.1); after protocol implementation, skeletal survey differences were not statistically significant (92% vs. 85% of Black and White children, respectively; p=1.0).1,18 

Additional Tools and Resources

The Centers for Disease Control and Prevention’s report “Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities” offers a group of strategies based on best available evidence to assist in prevention of child abuse and neglect (https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-Technical-Package.pdf). The Centers for Disease Control and Prevention also offers “Preventing Adverse Childhood Experiences (ACES): Leveraging the Best Available Evidence,” a report on the best evidence to prevent adverse childhood experiences (https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf).

The U.S. Department of Health and Human Services developed a “Prevention Resource Guide” to support and promote family well-being and prevention of child maltreatment (https://www.childwelfare.gov/topics/preventing/preventionmonth/resources/resource-guide/). The Department also offers publications and additional resources that could be helpful to primary care clinicians (https://www.childwelfare.gov/). 

Other Related USPSTF Recommendations

The USPSTF has a recommendation statement on screening for intimate partner violence and abuse of older and vulnerable adults19 (update in progress).

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Scope of Review

To update its 2018 recommendation, the USPSTF commissioned a systematic review1 of the evidence on primary care–feasible or referable behavioral counseling interventions to prevent child maltreatment in children and adolescents younger than age 18 years without signs or symptoms of maltreatment. The review focused on interventions to prevent abuse or neglect from occurring and therefore was limited to studies in which maltreatment was not reported previously in the majority of (>50%) children in the studies.1 This scope is similar to that of the prior systematic review. In alignment with the USPSTF’s commitment to improving health equity, the evidence review included key questions evaluating the effectiveness of interventions in certain populations and contextual questions on the drivers behind and approaches to address disparities related to child maltreatment. 

Interventions

Interventions to prevent child maltreatment that have been studied include primary care programs designed to identify youth at increased risk for maltreatment who may benefit from parent education, referral to community resources, approaches to increase the use of positive discipline strategies, and psychotherapy to improve caregivers’ coping skills and strategies to strengthen the parent-child relationship.1,21 Interventions commonly address social determinants of health (e.g., economic stability and health care access) and include a home visiting component.1 Some evidence suggests that adverse social determinants of health (e.g., low socioeconomic status and food or housing insecurity) may increase risk for child maltreatment.1,22 The USPSTF considered whether interventions to prevent child maltreatment improved measures of social determinants of health and found inconsistent overall results.1 However, in populations with increased socioeconomic needs, interventions may improve social determinants of health.1 Due to risk of surveillance bias (increased exposure to opportunities for reporting abuse) for participants of interventions, additional and more accurate evidence is needed to clarify potential linkages between improvements in social determinants of health and child maltreatment prevention.1 Although the USPSTF found insufficient evidence to assess the benefits and harms of preventing maltreatment among children without signs or symptoms of maltreatment, this recommendation does not assess the effectiveness of interventions (e.g., home visitation programs) for other outcomes (e.g., improving child and family well-being).

Benefits of Counseling Interventions

The USPSTF reviewed evidence on the benefits of behavioral counseling interventions to prevent child maltreatment from 24 trials of more than 14,000 participants.1 Of the included randomized clinical trials, most studies (22) assessed interventions with a home visiting component.1 Generally, interventions enrolled participants during the prenatal period or soon after birth, included clinical professionals (e.g., nurses), and compared interventions with usual care.1 Outcomes were characterized as direct or intermediate (proxy) measures of child maltreatment.1 Direct measures include direct evidence of physical, sexual, or emotional abuse or neglect (e.g., reports to CPS or removal of the child from the home).1 Intermediate measures include injuries with a high specificity of abuse, visits to the emergency department (ED) or hospital, and failure to provide for the child’s medical needs.1 Interpretation of some outcomes was unclear; for example, rates of ED visits or hospitalizations could reflect changes in healthcare access associated with the interventions rather than rates of maltreatment.1 To keep the intended scope focused on evidence for making a recommendation on child maltreatment, all intervention studies were required to report direct or intermediate measures of abuse.1 If direct or intermediate measures of abuse were reported, other measures, including behavioral, developmental, emotional, mental, and physical health, as well as well-being and mortality, were also evaluated.1

Direct Outcomes

Fifteen trials (n=8,513) evaluated the effectiveness of interventions based on reports to CPS.1 In a pooled analysis of 11 trials (n=5,311) reporting the first followup within 1 year after intervention completion, there were no group differences in effectiveness between intervention and control populations (pooled odds ratio, 1.03 [95% CI, 0.84 to 1.27]; I2=10.2%).1 Four trials could not be pooled due to differences in reported outcomes measures.1 Some trials reported additional findings (after the initial followup) 6 months to 1 year later, and more than 1 year later.1 There were no group differences associated with the intervention in trials reporting supplementary findings 6 months to 1 year after the initial followup, and after 1-year followup results were mixed; two trials reported statistically significant group differences and two reported no differences.1

Six trials (n=3,657) evaluated the effectiveness of interventions based on removal of the child from the home.1 In the five trials (n=3,336) included in a pooled analysis of results ranging from 12 months to 3 years after intervention, there were no group differences between intervention and control groups (3.9% vs. 3.5%; relative risk, 1.06 [95% CI, 0.37 to 2.99]; I2=49.9%).1 A sixth trial was not included in the pooled analysis due to differences in outcome measures, but reported no group differences.1

Three trials (n=2,106) reported outcomes related to specific measures of maltreatment identified from review of public agency documents, results of the Framingham Safety Survey, or based on rates of safeguarding (e.g., initial assessment, being identified as a child in need, or child protection conference).1 Findings in these trials yielded inconsistent results.1 In one trial, there were no differences reported in physical abuse (relative risk, 1.45 [95% CI, 0.58 to 3.62]) or neglect (relative risk, 2.79 [95% CI, 0.98 to 7.91) between the intervention and control groups.1,23 A second trial reported statistically significant group differences in results from the Framingham Safety Survey on household hazards after the intervention; however, the clinical importance of these results is unclear.1 A third trial reported higher rates of safeguarding in the intervention group compared with the control group (adjusted odds ratio, 1.85 [95% CI, 1.02 to 2.85]).1,24

Intermediate Outcomes

Thirteen trials (n=7,850) reported outcomes related to ED visits; generally, fewer visits was interpreted as beneficial.1 Trials evaluating ED visits within 4 years of study enrollment inconsistently demonstrated fewer ED visits.1 Type of outcome measurement (mean difference in ED visits, mean number of all-cause ED visits, or mean number of ED visits for accidents, injuries, and ingestions) and timing of measurement (6 months to more than 4 years after study enrollment) varied substantially across trials, precluding pooling of evidence.1 One study reporting mean difference in ED visits at age 12 months found statistically significant differences in the intervention group; two studies found no statistically significant differences at age 6 months.1 Of seven studies reporting findings within 1 to 2 years after enrollment, three reported statistically significant reductions in the average number of all-cause ED visits, while four reported no group differences.1 Long-term results (>4 years of followup) noted statistically significant reductions in ED visits in one of three studies.1

Thirteen trials (n=7,475) reported outcomes related to hospitalizations.1 Varying outcome definitions and timing of outcome measurement prevented pooling of study results.1 Statistically significant reductions in number of children with all-cause hospitalizations, average number of hospital days, and rates of admission were demonstrated in a minority of trials.1 Most trials of hospital-related outcomes reported no difference between study groups.1 For several additional measures of child maltreatment (e.g., failure to thrive [1 trial; n=79] and nonaccidental injuries [1 trial; n=136]), the USPSTF found insufficient evidence to evaluate intervention effectiveness.1 

Behavioral, Developmental, Emotional, Mental, and Physical Health and Well-Being

Six trials (n=5,115) reporting internalizing (e.g., depression or anxiety) and externalizing (disruptive, aggressive, or delinquent) behavioral outcomes in children yielded mixed results.1 Three of the six trials reported statistically significant reductions in reported behaviors, while others reported no group differences.1 Of five trials (n=4,439) evaluating social, emotional, and developmental outcomes (e.g., sleep issues or dysregulation), none reported group differences.1 Of four trials (n=1,638) evaluating outcomes based on the Bayley Scales of Development, one reported higher scores in the intervention group, while three other trials reported no group differences.1 Three of five trials (n=4,542) evaluating other developmental outcomes reported some benefit in study-specific outcomes; however, study construction and outcomes varied substantially and results could not be compared across studies.1 Three trials (n=3,561) evaluating school performance reported no group differences in the percentage of children repeating a grade at age 7 years, grade point averages across reading and math at age 9 years, or special education placements in grades 1 through 3.1 Similarly, two trials (n=2,818) evaluating school attendance reported few group differences in school absences between intervention and control groups.1 

Death

In six trials (n=2,900), none of the mortality outcomes reported reached statistical significance.1 Five trials did report lower (statistically nonsignificant) mortality rates in the intervention group and one trial reported higher (statistically nonsignificant) mortality rates in the intervention group.1 Fortunately, events were rare, despite inclusion of children judged to be at increased risk for infant mortality.1

Overall, evidence on the effect of interventions did not demonstrate benefit, yielded mixed results, or information was insufficent.1 The USPSTF also considered intervention effectiveness in specific populations of interest defined by child or caregiver characteristics such as age, developmental age (child), sex, gender identity, race and ethnicity, sociodemographic characteristics (e.g., family income), or special healthcare needs.1 Generally, evidence in these populations was consistent with that of the general population or too limited to draw comparisons.1

Harms of Counseling Interventions

Most trials reported rare harms rather than broader potential harms, such as stigma, labeling, legal risks, risks of further harm to the child, dissolution of families, or worsening inequities.1 Two trials (n=1,784)24,25 reported miscarriages or terminations of pregnancies; however, these outcomes were unlikely to be related to the intervention in either study.1 One trial reported miscarriage or termination events prior to intervention participation.1 A second trial reported that 44% of mothers or children had a serious adverse event (mainly clinical events associated with pregnancy and infancy period) in the intervention group and 38% in the control group (miscarriages/terminations [24 vs. 27], stillbirth/neonatal/infant death [5 vs. 7], death of the mother/infant pair [1 vs. 0], and adoption of the child [7 vs. 7]).1,24

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See Table 2 for research needs and gaps related to primary care interventions to prevent child maltreatment.

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The American Academy of Family Physicians has concluded there is insufficient evidence regarding screening or interventions and offers a list of steps for preventing child maltreatment.26 The American Academy of Pediatrics strongly recommends pediatrician involvement in preventing child maltreatment “through promotion of safe, stable, nurturing relationships and communities.”27 Bright Futures, a national initiative led by the American Academy of Pediatrics and supported in part by the U.S. Department of Health and Human Services, Health Resources and Services Administration, and Maternal and Child Health Bureau recommends anticipatory guidance (preventive education and guidance) and screening for social determinants of health for risks (including family or neighborhood violence, food security, or family substance use), and protective factors (emotional security and self-esteem or connectedness with family) during childhood and adolescence.28 The Canadian Task Force on Preventive Health Care recommends home visitation programs to “disadvantaged families” to prevent child maltreatment and recommends against screening, citing the risks of false-positive results and mislabeling.29 The Community Preventive Services Task Force recommends home visitation to high-risk families to prevent child maltreatment.30

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1. Viswanathan M, Rains C, Hart L, et al. Primary Care Interventions to Prevent Child Maltreatment: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 235. Rockville, MD: Agency for Healthcare Research and Quality; 2023. AHRQ Publication No. 23-05307-EF-1.
2. World Health Organization. Child Maltreatment. Geneva, Switzerland: World Health Organization; 2022.
3. U.S. Department of Health and Human Services, Administration for Children & Families, Children’s Bureau. Child Maltreatment 2021.Published February 9, 2023. Accessed July 26, 2023. https://www.acf.hhs.gov/cb/report/child-maltreatment-2021
4. U.S. Preventive Services Task Force. Procedure Manual.Accessed July 26, 2023. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
5. Leeb RT, Paulozzi LJ, Melanson C, Simon TR, Arias I. Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements. Version 1.0. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.
6. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. Child Abuse and Neglect Prevention. Accessed July 26, 2023. https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html
7. Sedlak AJ, Mettenburg J, Basena M, et al. Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress. Washington, DC: US Department of Health and Human Services, Administration for Children and Families; 2010.
8. Centers for Disease Control and Prevention. Preventing Child Abuse & Neglect. 2022. Accessed July 26, 2023. https://www.cdc.gov/violenceprevention/pdf/can/CAN-factsheet_2022.pdf
9. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of childhood exposure to violence, crime, and abuse: results from the National Survey of Children’s Exposure to Violence. JAMA Pediatrics. 2015;169(8):746-754.
10. Cénat JM, McIntee SE, Mukunzi JN, Noorishad PG. Overrepresentation of Black children in the child welfare system: a systematic review to understand and better act. Child Youth Serv Rev. 2021;120:105714.
11. Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council. New Directions in Child Abuse and Neglect Research. Washington, DC: National Academies Press; 2014.
12. Palusci VJ, Botash AS. Race and bias in child maltreatment diagnosis and reporting. Pediatrics. 2021;148(1):e2020049625.
13. Najdowski CJ, Bernstein KM. Race, social class, and child abuse: content and strength of medical professionals’ stereotypes. Child Abuse Negl. 2018;86:217-222.
14. Hymel KP, Laskey AL, Crowell KR, et al. Racial and ethnic disparities and bias in the evaluation and reporting of abusive head trauma. J Pediatr. 2018;198:137-143.e1.
15. Lanier P, Maguire-Jack K, Walsh T, Drake B, Hubel G. Race and ethnic differences in early childhood maltreatment in the United States. J Dev Behav Pediatr. 2014;35(7):419-426.
16. Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-e1354.
17. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621-626.
18. Rangel EL, Cook BS, Bennett BL, Shebesta K, Ying J, Falcone RA. Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline. J Pediatr Surg. 2009;44(6):1229-1235.
19. US Preventive Services Task Force. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force final recommendation statement. JAMA. 2018;320(16):1678-1687.
20. US Preventive Services Task Force. Interventions to prevent child maltreatment: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(20):2122-2128.
21. U.S. Department of Health and Human Services, Administration for Children & Families. Child Fatalities Due to Abuse and Neglect Decreased in FY 2020, Report Finds. Published January 21, 2022. Accessed July 26, 2023. https://www.acf.hhs.gov/media/press/2022/child-fatalities-due-abuse-and-neglect-decreased-fy-2020-report-finds
22. Hunter AA, Flores G. Social determinants of health and child maltreatment: a systematic review. Pediatr Res. 2021;89(2):269-274.
23. Brayden RM, Altemeier WA, Dietrich MS, et al. A prospective study of secondary prevention of child maltreatment. J Pediatr. 1993;122(4):511-516.
24. Robling M, Bekkers MJ, Bell K, et al. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet. 2016;387(10014):146-155.
25. Barnes J, Stuart J, Allen E, et al. Randomized controlled trial and economic evaluation of nurse-led group support for young mothers during pregnancy and the first year postpartum versus usual care. Trials. 2017;18(1):508.
26. Kodner C, Wetherton A. Diagnosis and management of physical abuse in children. Am Fam Physician. 2013;88(10):669-675.
27. American Academy of Pediatrics. Prevention of Child Abuse and Neglect. Last Updated July 9, 2021. Accessed July 26, 2023. https://www.aap.org/en/patient-care/child-abuse-and-neglect/prevention-of-child-abuse-and-neglect/
28. Hagan JF, Shaw JS, Duncan PM. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed.Elk Grove Village, IL: American Academy of Pediatrics; 2017.
29. MacMillan HL; Canadian Task Force on Preventive Health Care. Preventive health care, 2000 update: prevention of child maltreatment. CMAJ. 2000;163(11):1451
30. The Community Guide. Violence Prevention: Early Childhood Home Visitation to Prevent – Child Maltreatment. Published February 2002. Accessed July 26, 2023. https://www.thecommunityguide.org/findings/violence-early-childhood-home-visitation-prevent-child-maltreatment.html

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Rationale Assessment
Benefits of Preventive Interventions The USPSTF found inadequate evidence on interventions that are feasible in or referrable from primary care and their effectiveness to prevent maltreatment among children and adolescents who do not already have signs or symptoms of such maltreatment. Evidence of benefit on child maltreatment outcomes is limited and inconsistent.
Harms of Preventive Interventions The USPSTF found inadequate evidence to assess the harms of interventions that are feasible in or referrable from primary care to prevent child maltreatment.
USPSTF Assessment Evidence on interventions to prevent child maltreatment is limited and results are inconsistent; therefore, the USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of primary care interventions to prevent child maltreatment in children and adolescents younger than age 18 years.

Abbreviation: USPSTF=U.S. Preventive Services Task Force.

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To fulfill its mission to improve health by making evidence-based recommendations for preventive services, the USPSTF routinely highlights the most critical evidence gaps for making actionable preventive services recommendations. The USPSTF often needs additional evidence to create the strongest recommendations for everyone and especially for persons with the greatest burden of disease.

In this table, the USPSTF summarize key bodies of evidence needed for it to make recommendations for primary care interventions to prevent child maltreatment. For each of the evidence gaps listed below, research trials should enroll diverse populations across diverse settings to improve the applicability of study findings. Diverse populations include children across races, ethnicities, and socioeconomic status as well as children from rural and urban settings and children with cognitive, psychological, and physical disabilities. As noted, the USPSTF recognizes that race, ethnicity, and gender are social constructs (rather than biological constructs) that may be important predictors of health risk. 

For the current analytic framework, evidence is needed linking validated risk assessment and primary care–feasible or referrable interventions to direct or intermediate measures of abuse and neglect. Notably, measures of abuse and neglect are prone to underreporting, disproportionality (e.g., overrepresentation of Black children and underrepresentation of White children), and bias (e.g., recall bias in patient-reported outcomes and surveillance bias in intervention group exposure to opportunities for reporting or diagnosing abuse). Reconceptualizing the linkages between primary care–relevant risk assessment, prevention-based interventions, and standardized, accurate, and unbiased maltreatment outcomes measures are needed.

Evidence Gaps on Primary Care Interventions to Prevent Child Maltreatment
Research is needed to help primary care clinicians accurately identify families who might benefit from supportive interventions that may prevent child maltreatment.
  • Research is needed to determine if accuracy of risk assessment tools differs by social factors and race and ethnicity.
  • Research is needed to understand the optimal frequency of risk assessment considering chronicity, duration, intermittency, and severity of maltreatment.
Studies are needed to evaluate the effectiveness of primary care–feasible or referable preventive interventions designed to reduce exposure to maltreatment, including neglect.
  • Research is needed to determine whether intervention effectiveness or child maltreatment reporting differs by social factors and race and ethnicity.
  • Studies evaluating the effectiveness of interventions using more accurate outcome measures that limit bias (e.g., surveillance) are needed. Outcome measures could also include those outside the child welfare system (e.g., composite measures).
  • In addition, consistency in outcome measure definitions, outcome types, and outcome timing across studies is needed.
  • Research is needed on the most effective ways to prevent child maltreatment (using more accurate outcome measures), including interventions that address the social determinants of health that can negatively affect families.
Research is needed to determine whether there are unintended harms from risk assessment (e.g., stigma or legal risks related to Child Protective Services) and to engagement in preventive interventions (e.g., risk of biased reporting for maltreatment)
  • Research is needed to understand whether potential harms differ in children by social factors and race and ethnicity.
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