Behavioral Interventions and Counseling to Prevent Child Abuse and Neglect

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 Abstract

Background: In 2004, the U.S. Preventive Services Task Force determined that evidence was insufficient to recommend behavioral interventions and counseling to prevent child abuse and neglect.
Purpose: To review new evidence on the effectiveness of behavioral interventions and counseling in health care settings for reducing child abuse and neglect and related health outcomes, as well as adverse effects of interventions.
Data Sources: MEDLINE and PsycINFO (January 2002 to June 2012), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the second quarter of 2012), Scopus, and reference lists.
Study Selection: English-language trials of the effectiveness of behavioral interventions and counseling and studies of any design about adverse effects.
Data Extraction: Investigators extracted data about study populations, designs, and outcomes and rated study quality using established criteria.
Data Synthesis: Eleven fair-quality randomized trials of interventions and no studies of adverse effects met inclusion criteria. A trial of risk assessment and interventions for abuse and neglect in pediatric clinics for families with children aged 5 years or younger indicated reduced physical assault, Child Protective Services (CPS) reports, nonadherence to medical care, and immunization delay among screened children. Ten trials of early childhood home visitation reported reduced CPS reports, emergency department visits, hospitalizations, and self-reports of abuse and improved adherence to immunizations and well-child care, although results were inconsistent.
Limitations: Trials were limited by heterogeneity, low adherence, high loss to follow-up, and lack of standardized measures.
Conclusion: Risk assessment and behavioral interventions in pediatric clinics reduced abuse and neglect outcomes for young children. Early childhood home visitation also reduced abuse and neglect, but results were inconsistent. Additional research on interventions to prevent child abuse and neglect is needed.
Primary Funding Source: Agency for Healthcare Research and Quality.

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Introduction

In 2004, the U.S. Preventive Services Task Force (USPSTF) found, on the basis of the results of a previous review (1, 2), insufficient evidence to recommend for or against routine screening of parents or caregivers for abuse or neglect of children (3, 4). This systematic review is an update for the USPSTF that focuses on studies published since the previous recommendation and addresses the effectiveness and adverse effects of behavioral interventions and counseling to prevent child abuse and neglect for children at potentially increased risk. Separate reviews examine screening women for intimate partner violence (5, 6) and elderly and vulnerable adults for abuse (6).
Approximately 695,000 children in the United States were victims of child abuse and neglect in 2010, and 1537 died (7). Most of these deaths were in infants and toddlers (7). Additional immediate health consequences of abuse and neglect include injuries and emotional and behavioral problems (8, 9). Associated long-term physical conditions include neurologic and musculoskeletal disorders; gastrointestinal problems; metabolic conditions, including diabetes; autoimmune disorders (10, 11); obesity (12, 13); chronic pain (14, 15); teen pregnancy and pregnancy complications (16); and others (17). 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 (12, 18–25).
In the United States, child abuse and neglect have legal as well as medical implications. Federal legislation defines child abuse and neglect as any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk for serious harm (26–28). Although laws vary, states are required to include the minimum standards of the federal law (29). 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 Child Protective Services (CPS) (30), part of the larger U.S. Department of Health and Human Services that specifically responds to child abuse reports (28).
Physicians and other health care providers who care for children and families are uniquely situated to identify children at risk for abuse and neglect during well-child and other visits and to initiate interventions to prevent harm. Although pediatricians consider screening for abuse and neglect one of their important roles (31), it is rarely done in practice (32, 33). Barriers to screening include lack of experience, training, and confidence in handling abuse cases (32, 34–36).