Purpose: 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.
Data Sources: MEDLINE, the Cochrane Library, and trial registries through February 2, 2023; bibliographies from retrieved articles, outside experts, and surveillance of the literature through December 6, 2023.
Study Selection: 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 [ED], hospitalization) or harms.
Data Extraction: One reviewer extracted data and a second checked accuracy. Two reviewers independently rated methodological quality for all included studies using predefined criteria. When at least three similar studies were available, we conducted meta-analyses.
Data Synthesis: Twenty-five trials (N=14,355 participants) provided evidence on benefits of child maltreatment interventions. We found no evidence of differences in reports to child protective services (CPS) within 1 year of intervention completion (pooled odds ratio: 1.03 [95% confidence interval, 0.84 to 1.27]; 12.9% [intervention] vs. 12.2% [control]; 11 studies; 5,311 participants) or removal of the child from the home within 1 to 3 years of followup (pooled risk ratio: 1.06 [95% CI, 0.37 to 2.99]; 3.9% [intervention] vs. 3.5% [control]; 5 studies; 3,336 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 ED visits in the short-term (<2 years) and hospitalizations. The evidence was inconclusive for long-term outcomes for reports to CPS and ED 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, child development, school attendance, school performance, prevention of death, and other measures of abuse or neglect because of the limited number of trials reporting on each outcome and imprecise results. Among two trials reporting harms, neither reported statistically significant differences in harms. Contextual evidence indicated (1) widely varying reporting practices, including variations by race and ethnicity; (2) poor to good accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health (such as economic stability, education access and quality, healthcare access and quality, and social and community context).
Limitations: The scope of this review limited conclusions to primary care–relevant interventions for children who have not experienced maltreatment with evidence focused on direct or proxy measures of child maltreatment. Other limitations included the heterogeneity of outcome measures and the limited information on harms. We identified no gold standard instruments for identifying child maltreatment in our review of contextual evidence. Both parent-reported abuse and neglect measures and child welfare measures such as reporting to child protective services, or substantiated reports of abuse may reflect over- or underreporting of true child maltreatment occurrence.
Conclusions: The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggests no benefit for some outcomes (reports to CPS, removal of the child from the home, visits to the emergency department, hospitalization, child development) and is insufficient to demonstrate benefits for other direct or proxy measures of child maltreatment. Limited or no information was available about possible harms.