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Nelson HD, Selph S, Bougatsos C, et al. Behavioral Interventions and Counseling to Prevent Child Abuse and Neglect: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Jan. (Evidence Syntheses, No. 98.)

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Behavioral Interventions and Counseling to Prevent Child Abuse and Neglect: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation [Internet].

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1INTRODUCTION

Purpose of Review and Prior U.S. Preventive Services Task Force Recommendation

This systematic review is an update for the U.S. Preventive Services Task Force (USPSTF) that addresses the effectiveness and adverse effects of behavioral interventions and counseling to prevent child abuse and neglect for children at potentially increased risk. This review focuses on children without obvious signs or symptoms of abuse or neglect who are seen in health care settings. A separate review examines screening women for intimate partner violence and screening for elder abuse.1,2

In 2004, based on results of a previous review of screening for abuse and neglect,3,4 the USPSTF found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children (I statement).5,6 The USPSTF could not determine the balance between the benefits and harms of screening because of the lack of critical evidence. Limitations included the following:

  • Interventions were predominantly home visitation programs that utilized varied and often inadequately described components during the prenatal, postpartum, and early childhood periods. It is unknown whether these models would work in other populations or with older children.
  • There were no studies of screening for child abuse and neglect in health care settings that reported health outcomes, including premature death and disability.
  • There were no studies of the adverse effects of screening and interventions.
  • There was no demonstration of a gold standard screening instrument. Instruments designed to screen for child abuse and neglect had fairly high sensitivity in the few studies evaluating test performance, but they had low specificity. Instruments were primarily directed at pregnant women and lacked testing in other populations, particularly older children in the context of usual health care.
  • Studies were conducted in high-risk populations.
  • There were no studies of the feasibility of screening procedures and interventions in the primary care setting, including identification of barriers to screening.

Condition Definition

Child abuse and neglect has been defined from medical as well as legal perspectives. The Centers for Disease Control and Prevention (CDC) recognize four categories of violence, including physical violence, sexual violence, threat of physical or sexual violence, and psychological/emotional abuse.7 The CDC defines child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child from birth through age 17 years.8 Child abuse (acts of commission) includes harmful words or overt actions such as physical, sexual, and psychological abuse. Child neglect (acts of omission) includes the failure to provide for a child’s basic physical, emotional, or educational needs or to protect a child from harm or potential harm. This includes failure to provide, such as physical, emotional, medical/dental, or educational neglect, and failure to supervise, such as inadequate supervision or exposure to violent environments.

The 2003 Keeping Children and Families Safe Act amendment to the 1996 Federal Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. §5106g) defines child abuse and neglect as any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, or sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.911 Individual States are required to define child abuse and neglect using the minimum standards in the federal law according to CAPTA; however, State definitions vary.12

In 2009, the U.S. Department of Health and Human Services’ (DHHS’) Administration for Children and Families used the following definitions:

  • Physical abuse is any nonaccidental physical injury to the child and can include striking, kicking, burning, or biting or any action that results in a physical impairment of the child. In most States, the definition of abuse also includes acts or circumstances that threaten the child with harm or create a substantial risk of harm to the child’s health or welfare.
  • Neglect is the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision such that the child’s health, safety, and well-being are threatened. Several States also include failure to educate the child as required by law in their definition of neglect. Seven States specifically define medical neglect as failing to provide any special medical treatment or mental health care needed by the child. In addition, four States define medical neglect as the withholding of medical treatment or nutrition from disabled infants with life-threatening conditions.
  • Sexual abuse/exploitation. All States include sexual abuse in their definitions of child abuse. Some refer in general terms to sexual abuse, while others specify various acts. Sexual exploitation is an element of the definition of sexual abuse in most jurisdictions. Sexual exploitation includes allowing the child to engage in prostitution or in the production of child pornography.
  • Emotional/psychological abuse. Nearly all States include emotional/psychological maltreatment as part of their definitions of abuse or neglect. This is often defined as injury to the psychological capacity or emotional stability of the child, as evidenced by an observable or substantial change in behavior, emotional response, or cognition or as evidenced by anxiety, depression, withdrawal, or aggressive behavior.
  • Parental substance abuse is an element of the definition of child abuse or neglect in some States, including prenatal exposure from the mother’s use of an illegal drug or other substance; manufacture of a controlled substance in the presence of a child or on the premises occupied by a child; allowing a child to be present where the chemicals or equipment for the manufacture of controlled substances are used or stored; selling, distributing, or giving drugs or alcohol to a child; and use of a controlled substance by a caregiver that impairs the caregiver’s ability to adequately care for the child.
  • Abandonment. Several States include abandonment in their definition of abuse or neglect. This includes situations when the parent’s identity or whereabouts are unknown, the child has been left by the parent in circumstances in which the child suffers serious harm, or the parent has failed to maintain contact with the child or to provide reasonable support for a specified period of time.

Definitions used in child abuse and neglect research are highly variable.12 The absence of standard operational definitions limits communications, has led to a lack of consensus on the magnitude and distribution of child abuse and neglect, and creates difficulties in determining and collecting accurate measurements.9,13

Prevalence and Burden of Disease

Child Protective Services (CPS), part of the larger Department of Human Services (DHS) that specifically responds to child abuse reports, received 3.3 million referrals representing 6 million children nationally in 2009 (43 referrals per 1,000 children).11 Of children receiving a CPS investigation, one fifth were found to have been victims of abuse and neglect.11

According to the National Child Abuse and Neglect Data System, approximately 695,000 children were victims of child abuse and neglect in 2010, and 1,537 children died.14 Approximately 78 percent of victims suffered from neglect, 18 percent physical abuse, 9 percent sexual abuse, 8 percent emotional or psychological abuse, and 2 percent medical neglect. In addition, 10 percent of children experienced other types of abuse and neglect, such as abandonment, threats of harm, and congenital drug addiction.14 Rates of abuse were similar for boys and girls. The majority of deaths from abuse and neglect occurred in very young children (48% age <1 year, 14% age 1 year, 12% age 2 years, 6% age 3 years). An analysis of self-reported abuse and neglect from 15,197 participants in the National Longitudinal Study of Adolescent Health found that 28 percent experienced physical assault, 12 percent physical neglect, 5 percent contact sexual abuse, and 42 percent supervision neglect.15

Immediate health consequences of child abuse and neglect include injuries and death related to physical and sexual assault, as well as emotional and behavioral problems.16,17 Related long-term physical conditions include neurological and musculoskeletal disorders; gastrointestinal problems such as peptic ulcers; metabolic conditions including diabetes; autoimmune disorders;18,19 obesity;20,21 chronic pain;22,23 teen pregnancy and pregnancy complications such as premature contractions, cervical insufficiency, and premature birth;24 and several disabilities.25 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 disorders.20,2633

Risk Factors/Indicators

Risk factors for child abuse and neglect are wide-ranging, but nonspecific. According to the CDC34 and additional studies, risk factors include parents’ lack of understanding of child development and inadequate parenting skills; parental history of child abuse;35 substance abuse in the family;36 young, single,37 or nonbiological parents; parental thoughts and emotions supportive of maltreatment behaviors; and parental stress and distress, including depression36 or other mental health conditions. Family risk factors include social isolation;35 poverty15,38 and other socioeconomic disadvantage,35 such as unemployment or lack of education;15,36 family disorganization, dissolution, and violence, including intimate partner violence (IPV); and poor parent-child relationships. Risk factors for child victimization include age younger than 4 years; disabilities,11,35,37 developmental delay,36 or mental retardation; and other conditions that may increase caregiver burden, such as preterm birth, congenital addiction, or admission to the neonatal intensive care unit.39

Rationale for Screening/Screening Strategies

Screening children without obvious signs of abuse and neglect in health care settings could identify children who have experienced abuse and neglect as well as children at risk, and lead to interventions that reduce abuse and neglect and improve health outcomes. However, children, caretakers, perpetrators, or other family members may not self-disclose abuse because of the negative ramifications of doing so. These include involvement of CPS, dissolution of families, legal concerns for the perpetrators, and increased risk of abuse for the child or family, among other reasons. Young children usually are not capable of recognizing abuse or neglect, do not have the verbal skills to describe the abuse, and do not know a trusted individual with whom to confide. Children may want to protect their families or keep them intact, keep abuse secretive due to shame or other reasons, or fear speaking out due to fear of unknown consequences.

Interventions

Referral to the local CPS agency is the main intervention for responding to child abuse and neglect.11 CPS may provide preventive services to high-risk families to improve parents’ understanding of child development and parenting practices. Other services include family support, child daycare, education and training, information and referral, and assistance with employment and housing.11 Postinvestigation services for substantiated cases focus on the safety of the child and are based on family assessments. These include in-home family services when the child remains living at home, such as counseling, treatment for mental health problems and substance abuse, and other services, or foster care services when the child needs to be removed from the home and placed with either relatives or others. Court actions may also ensue, including legal actions for custody on behalf of the child.11

Most preventive services that target at-risk families are not provided by CPS, which deals with abuse reports. Preventive services include hospital-based maternity case management, community-based home visitation programs, and other models that focus on early childhood. In these programs, at-risk families are identified during pregnancy or postpartum and supportive services are provided over several months to years. Eligibility criteria for services, types of services, delivery, duration, and effectiveness vary widely.40 Many of these preventive services are now included in the Patient Protection and Affordable Care Act, which established a Maternal, Infant, and Early Childhood Home Visiting Program, providing $1.5 billion over 5 years to States to establish home visiting program models for at-risk pregnant women and children from birth to age 5 years.

Current Clinical Practice

In the United States, 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 CPS.41 In 2009, teachers (17%), law enforcement and legal personnel (16%), and social services staff (11%) reported three fifths of CPS reports, while anonymous sources (9%), other relatives (7%), parents (7%), and friends and neighbors (5%) reported the remaining.11 CAPTA specifies that children younger than age 3 years with substantiated cases of abuse or neglect must have access to rapid or immediate intervention10 and legal representation for custodial care.11

Identifying abuse or neglect and linking children to these services has been problematic. Pediatricians, family physicians, and other primary care providers are in a unique position to identify children experiencing abuse or neglect during well-child and other visits. However, while pediatricians believe screening for abuse and neglect is one of their important roles,42 they rarely screen in practice, or screen only in selected cases.43,44 Barriers to screening include lack of experience, training, and confidence in handling abuse cases.43,4547

Recommendations of Other Groups

Recommendations of other medical groups are summarized in Table 1. In 2010, the American Academy of Pediatrics published a clinical report advocating for the pediatrician’s prominent role in the prevention of child abuse and neglect and providing specific guidelines and information on specific risk factors and protective factors.42 The American Medical Association recommends routine inquiry about child abuse or neglect.48 Other organizations do not specifically recommend universal screening, but recommend that pediatricians and family practice clinicians remain alert for indications of abuse or neglect49,50 or recommend screening in pediatric offices for intimate partner and family violence.51,52 The Canadian Task Force on Preventive Health Care issued various recommendations in 2000 that do not support screening. However, it recommends home visitation for disadvantaged families from the prenatal period through infancy, but not other forms of interventions.53 Disadvantaged families are defined as first-time mothers with one or more of the following characteristics: younger than age 19 years, single parent status, and low socioeconomic status. The Community Preventive Services Task Force does not recommend for or against screening for child abuse and neglect, but recommends early childhood home visitation interventions.54

Table 1. Recommendations of Other Groups.

Table 1

Recommendations of Other Groups.

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