Viswanathan M, Fraser JG, Pan H, Morgenlander M, McKeeman JL, Forman-Hoffman VL, Hart LC, Zolotor AJ, Lohr KN, Patel SV, Jonas DE. Primary Care Interventions to Prevent Child Maltreatment: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 170. AHRQ Publication No. 18-05241-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2018.
To systematically review evidence on the benefits and harms of interventions provided in or referable from primary care to prevent child maltreatment for the U.S. Preventive Services Task Force (USPSTF).
MEDLINE®, the Cochrane Library, EMBASE, and trial registries, through December 18, 2017; reference lists of retrieved articles; outside experts; reviewers; and surveillance of literature through July 17, 2018.
Two investigators independently selected studies using a priori criteria. Eligible trials (1) enrolled children (from birth through age 18 years with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment) or their caregivers; (2) evaluated interventions feasible in a primary care setting or that could result from a referral by a primary care provider; and (3) reported abuse or neglect outcomes, or proxies for abuse or neglect (injury, visits to the emergency department, hospitalization).
One investigator extracted data and a second checked accuracy. Two reviewers independently rated quality for included studies using predefined criteria.
Twenty-two trials provided evidence on benefits. We found no evidence of differences in reports to child protective services within 1 year of intervention completion (pooled odds ratio [OR], 0.94, 95% CI, 0.72 to 1.23; 10.6% vs. 11.9%; 10 studies, 2444 participants) or removal of the child from the home within 1 to 3 years of followup (pooled (OR: 1.09,95% CI, 0.16 to 7.28; 3.51% vs. 3.71%; 4 studies, 609 participants). Owing to heterogeneity of outcome measures, we could not pool other results, but the evidence either demonstrates no benefit or was inconclusive for abuse, neglect, or their sequelae. The evidence suggested no benefit for emergency department visits in the short-term (<2 years), hospitalizations, child development, school performance, and prevention of death. The evidence was inconclusive for long-term outcomes for reports to child protective services and emergency department visits (≥2 years) because results were inconsistent and imprecise. The evidence was also inconclusive for injuries, failure to thrive, failure to immunize, internalizing and externalizing behavior symptoms, school attendance, and other measures of abuse or neglect because of the limited number of trials reporting on each outcome and imprecise results. We found no results on harms.
The scope of this review limits conclusions to children who have not experienced maltreatment and to primary-care relevant interventions. Other limitations include the heterogeneity of the interventions and outcome measures and the lack of information on harms.
Overall, the evidence on interventions provided in or referable from primary care to prevent child maltreatment does not consistently demonstrate benefit. We found no evidence on possible harms of these interventions. New studies that address a comprehensive array of risk factors and evaluate outcomes over the long term may help identify effective, generalizable, and acceptable interventions.