Primary Care Interventions to Prevent Child Maltreatment
Authors: Meera Viswanathan, Jenifer Goldman Fraser, Huiling Pan, Marcia Morgenlander, Joni L. McKeeman, Valerie L. Forman-Hoffman, Laura C. Hart, Adam J. Zolotor, Kathleen N. Lohr, Sheila Patel, Daniel E. Jonas
Journal: JAMA (2018)

<h3>Importance</h3> Child maltreatment, also referred to as child abuse and neglect, can result in lifelong negative consequences. <h3>Objective</h3> To update the evidence on interventions provided in or referable from primary care to prevent child maltreatment for the US Preventive Services Task Force. <h3>Data Sources</h3> PubMed, Cochrane Library, EMBASE, and trial registries through December 18, 2017; references; experts; literature surveillance through July 17, 2018. <h3>Study Selection</h3> English-language fair- and good-quality randomized clinical trials that (1) included children with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment, (2) evaluated interventions feasible in a primary care setting or that could result from a referral from primary care, and (3) reported abuse or neglect outcomes or proxies for abuse or neglect (eg, injury with a specificity for abuse, visits to the emergency department, hospitalization). <h3>Data Extraction and Synthesis</h3> Two reviewers independently assessed titles/abstracts, full-text articles, and study quality; a third resolved conflicts when needed. When at least 3 similar trials were available, random-effects meta-analyses were conducted. <h3>Main Outcomes and Measures</h3> Direct measures (including reports to child protective services and removal of the child from the home) or proxy measures of abuse or neglect; behavioral, emotional, mental, or physical well-being; and harms. <h3>Results</h3> Twenty-two trials (33 publications) were included (N = 11 132). No significant association was found between interventions and reports to child protective services within 1 year of intervention completion (10.6% vs 11.9%; pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]; 10 trials [n = 2444]) or removal of the child from the home within 1 to 3 years of follow-up (3.5% vs 3.7%; pooled OR, 1.09 [95% CI, 0.16-7.28]; 4 trials [n = 609]). No statistically significant associations were observed between interventions and outcomes for emergency department visits in the short term (&lt;2 years), hospitalizations, child development, school performance, and prevention of death. Nonsignificant results from single trials led to a conclusion of insufficient evidence for injuries, failure to thrive, failure to immunize, school attendance, and other measures of abuse or neglect. Inconsistent results led to a conclusion of insufficient evidence for long-term (≥2 years) outcomes for reports to child protective services (ORs range from 0.48 to 1.13; 3 trials [n = 1690]), emergency department visits (1 of 2 trials reported significant differences) and internalizing and externalizing behavior symptoms (3 of 6 trials reported reductions in behavior difficulties). No eligible trials on harms of interventions were identified. <h3>Conclusions and Relevance</h3> Interventions provided in or referable from primary care did not consistently prevent child maltreatment. No evidence on harms is available.