Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.
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. Children with signs or symptoms suggestive of maltreatment should be assessed or reported according to the applicable state laws.
Frequency of Service
No information available.
Risk Factor Information
No information available.
Patient Population Under Consideration
This recommendation applies to children and adolescents 18 years and younger in the United States who do not have signs or symptoms of maltreatment. The Centers for Disease Control and Prevention define child maltreatment as any act or series of acts of commission (abuse) or omission (neglect) by a parent or other caregiver (eg, clergy, coach, or teacher) that results in harm, potential for harm, or threat of harm to a child.2 Words or actions that are deliberate and cause harm, potential harm, or threat of harm are considered acts of commission (eg, physical, sexual, and psychological abuse).2 Failure to provide for a child’s basic physical, emotional, or educational needs or to protect a child from harm or potential harm constitutes an act of omission (neglect).2
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
Approximately 676,000 US children experienced abuse or neglect in 2016.1 Of those, 1700 died as a result of that maltreatment.1 Younger children appear to be the most vulnerable, with nearly 25 per 1000 children younger than 1 year identified as having experienced maltreatment.1 Abuse and neglect can result in long-term negative physical and emotional effects. Risk factors for maltreatment in children include young age (<4 years), having special health care needs, female sex, and past history of maltreatment. Children are also at increased risk based on factors related to their caregiver or environment, including having young, single, or nonbiological parents or parents with poor educational attainment, low income, history of maltreatment, and social isolation. Additionally, living in a community with high rates of violence, high rates of unemployment, or weak social networks are linked to child maltreatment.3
The USPSTF reviewed risk assessment instruments used to identify children for whom preventive interventions might be indicated and found limited and inconsistent evidence on the validity and reliability of these tools.3-5
The USPSTF found a lack of evidence on the harms associated with interventions to prevent child maltreatment. Potential harms of preventive interventions include social stigma and effects on family functioning and dynamics.
Because of the recommended schedule of periodic health assessments, primary care clinicians, including pediatricians, family clinicians, and others, are uniquely positioned to identify child maltreatment. The Federal Child Abuse Prevention and Treatment Act sets minimum standards for state laws overseeing the reporting of child abuse and neglect.4 Forty-eight states, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands mandate that professionals who have contact with children report suspected child maltreatment to Child Protective Services (CPS).6 An estimated 3.4 million children were referred to CPS in 20161; however, there is evidence that many cases of child abuse and neglect are not reported.7
Several factors may play a role in the underreporting of child maltreatment, including missed diagnosis of intentional child injury, fear of alienating caregivers, and stigma related to CPS involvement.8, 9 Signs and symptoms of child abuse include, but are not limited to, frequent injuries or unexplained/inconsistent explanation of injury cause, signs of poor hygiene, or lack of medical care; frequent absences from school; being excessively withdrawn or fearful; unexplained changes in behavior; trouble walking or sitting; and displaying knowledge of sexual acts inappropriate for age.8, 10 Preventive interventions initiated in primary care focus on preventing maltreatment before it occurs.
Although the USPSTF found insufficient evidence to recommend for or against preventive interventions in primary care settings, several strategies for preventing child abuse and neglect have been studied. Specific interventions include primary care programs designed to identify high-risk patients and refer them to community resources, parent education to improve nurturing and increase the use of positive discipline strategies, and psychotherapy to improve caregivers’ coping skills and strengthen the parent-child relationship.3, 4 These interventions are delivered in settings such as primary care clinics, schools, and the community.
Most available research included in the evidence review is from studies of home visitation programs.3, 4 These programs usually involve a professional or paraprofessional (eg, peer educator or community health worker) providing periodic counseling, educational services, or support in a family’s home. Families are identified and referred most often by health care professionals in the prenatal and immediate postpartum period. These services contain multiple components, including assessing family needs, providing information and referrals, providing clinical care, and enhancing family functioning and positive child-parent interactions.3 All states and the District of Columbia, as well as tribal and territorial entities, have home visitation programs to support families with young children. In 2017, 942,000 home visits were carried out in the United States,11 but eligibility criteria and services provided vary by location. The USPSTF reviewed evidence that included home visitation–based interventions. 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 home visitation programs for other outcomes (eg, improving child and maternal health, encouraging positive parenting, or promoting child development) or in other situations (eg, secondary prevention of abuse and neglect).
The USPSTF has issued a recommendation on screening for intimate partner violence, elder abuse, and abuse of vulnerable adults.12 The Centers for Disease Control and Prevention provides Web-based resources for the prevention of child abuse and neglect.13 The Administration for Children and Families offers resources on child maltreatment, including definitions, identification of signs and symptoms, and statistics.6 The Child Maternal Health Bureau and the Administration for Children and Families jointly offer resources and funding for home visitation programs.11
In 2016, approximately 676,000 children in the United States experienced maltreatment (abuse, neglect, or both), with 75% of these children experiencing neglect, 18% experiencing physical abuse, and 8% experiencing sexual abuse. Approximately 14% of abused children experienced multiple forms of maltreatment, and more than 1700 children died as a result of maltreatment.1
Benefits of Interventions
The USPSTF found inadequate evidence that interventions initiated in primary care can prevent maltreatment among children who do not already have signs or symptoms of such maltreatment. The USPSTF deemed the evidence inadequate because of a lack of studies on accurate methods to predict a child’s individual risk of maltreatment and the limited and inconsistent report of outcomes from studies of preventive interventions for maltreatment.
Harms of Interventions
The USPSTF found inadequate evidence to assess the harms of preventive interventions for child maltreatment.
Evidence on interventions to prevent child maltreatment is limited and inconsistent; therefore, the USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of interventions initiated in primary care to prevent child maltreatment in children and adolescents.
Research Gaps and Needs The USPSTF recognizes the importance of this serious health problem and calls for the prioritization of research to address gaps in numerous areas related to child maltreatment. There is limited evidence supporting the use of risk-assessment instruments to identify children at risk of maltreatment. Further research to determine effective methods for clinicians to identify children at increased risk should be a priority. Although most studies included home visitation, there was significant heterogeneity in study design and outcome measurements. Standardization of outcome measurement across trials would greatly strengthen the evidence base and improve the ability to pool data. Additionally, research on home visitation should base interventions on proven and well-designed theoretical models. Without this type of contextual information, it will be difficult to interpret whether inventions are successful and, if so, how those interventions worked. When investigating interventions and outcomes, the inclusion of diverse populations and settings would help improve the applicability of study findings. These would include families with known risk factors for child maltreatment (eg, history of substance abuse in the home) and settings with limited access to social services. In addition, future research is needed to determine whether there are unintended harms from risk assessment and preventive interventions. Recommendations of Others There are varying recommendations related to the primary prevention of child maltreatment. In 2013, the American Academy of Family Physicians concluded that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment.40 The American Academy of Pediatrics has no recommendations on preventive interventions but strongly recommends clinician involvement in preventing child maltreatment and provides guidance and information on risk factors, protective factors, and clinical management.8, 41 Update of Previous USPSTF Recommendation n 2013, the USPSTF found insufficient evidence to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The current recommendation reaffirms this position.