Sparse Evidence for Abuse Interventions in Asymptomatic Kids

— USPSTF: Interventions did not consistently reduce exposure to maltreatment


There is insufficient evidence to assess whether primary care interventions can prevent child maltreatment in asymptomatic children, ages ≤18, according to the U.S. Preventive Services Task Force (USPSTF).

Due to "limited and inconsistent" evidence about the benefits, and no trials reporting on the harms of interventions that could prevent child maltreatment, the task force found insufficient evidence to assess the balance between the two (I statement), according to a draft recommendation available on the USPSTF website.

The evidence review and ensuring recommendation, which remains unchanged from the previous 2013 statement, is are available for public comment through June 18, 2018.

Research from the Department of HHS Administration for Children and Families identified 676,000 children subjected to abuse or neglect in 2016, 1,700 of whom died as a result. Moreover, the report identified a rate of nearly 25 per 1,000 children age >1 year as victims of such abuse.

The task force acknowledged that because children are recommended to be routinely seen by their primary care clinicians, including well-child visits, these clinicians are "uniquely positioned to identify child maltreatment." But evidence for such interventions are limited, they cautioned.

They cited research from the evidence review mostly on home visitation programs, comprised of a professional or paraprofessional that provides "periodic counseling, educational services, or support in a family's home." These services have multiple components, such as "assessing family needs, providing information and referrals, providing clinical care and enhancing family functioning and positive child-parent interactions." Healthcare providers identify and refer these families who may benefit from this care, most often in the pre-natal or immediate post-partum period, the task force said.

But these interventions did not consistently reduce exposure to maltreatment, improve child well-being or reduce mortality. Of the 22 randomized, controlled, good or fair quality trials, the authors found no significant difference about the effect of the intervention between intervention and control groups (pooled OR 0.94, 95% CI 0.72 to 1.23) in the 10 studies included in the pooled analysis.

Pooled analyses of four of five trials on the removal of the child from the home found no significant difference between groups (pooled OR 1.09, 95% CI 0.16 to 7.28), despite a wide confidence interval.

The task force stated that pooled analyses were not performed on outcomes in 11 trials related to emergency department (ED) visits and 12 trials related to hospitalizations, due to variations in outcome definitions and time periods. They added that most trials showed no significant difference between groups in reductions in all-cause hospitalization, average number of hospital days, and rates of admission. There was also inconsistent evidence on the effects of ED visits.

Four trials reporting on child mortality did not allow for pooled analysis either because of variations on timing and outcome specifications.

Moreover, the authors stated there were no trials that examined harms of these interventions, such as "stigma, unnecessary involvement with Child Protective Services (CPS) or the legal system and dissolution of the family."

Research gaps suggested by the authors included "significant heterogeneity in study design and outcome measurements," and suggested the potential inclusion of diverse populations and settings.

"Standardization of outcome measurement across trials would greatly strengthen the evidence base and improve the ability to pool data," they wrote. "Without this type of contextual information, it will be difficult to interpret whether interventions are successful, and, if so, how those interventions worked."

Primary Source

U.S. Preventive Services Task Force

Source Reference: USPTF "Draft recommendation statement: Child maltreatment primary care interventions" 2018.