初级保健干预以预防儿童虐待

Patient Population Under Consideration

This recommendation applies to children in the general U.S. population from newborn to age 18 years who do not have signs or symptoms of maltreatment. “Child maltreatment” is defined by the Centers for Disease Control and Prevention 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 (2). "Child abuse” (acts of commission) includes physical, sexual, and psychological abuse. “Child neglect” (acts of omission) includes the failure to provide for a child's basic physical, emotional, health care, or educational needs or to protect a child from harm or potential harm (3).

Assessment of Risk

Numerous risk factors are associated with child maltreatment, including but not limited to young, single, or nonbiological parents; parental lack of understanding of children's needs, child development, or parenting skills; poor parent–child relationships or negative interactions; parental thoughts or emotions that support maltreatment behaviors; family dysfunction or violence; parental history of abuse or neglect in the family of origin; substance abuse within the family; social isolation, poverty, or other socioeconomic disadvantages; and parental stress and distress.

Interventions

Although the evidence is insufficient to recommend specific preventive interventions in a clinical setting, most programs for prevention of child maltreatment studied and recommended by others focus on home visitation, which is generally considered to be a community-based service. Home visitation programs usually comprise a combination of services provided by a nurse or paraprofessional in a family's home on a regularly scheduled basis. Most home visitation programs are targeted to families with young children and often begin in the pre- or postnatal period.

The services provided in home visitation programs often include parent education on normal child development, counseling, problem solving, free transportation to health clinic appointments, enhancement of informal support systems, linkage to community services, promotion of positive parent–child interactions, ensuring a source for regular health care, promotion of environmental safety, and classes for preparing for motherhood. The one trial reviewed by the USPSTF that was not a home visitation program used a multistep approach in a primary care clinic, with a social worker available to help parents who self-reported psychosocial problems, such as substance abuse.

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Child maltreatment is a serious problem that affected more than 680,000 children and resulted in 1,570 deaths in 2011. It can result in lifelong negative consequences for victims. Most child maltreatment is in the form of neglect (approximately 78%), and most deaths occur in children younger than 4 years (approximately 80%) (1).

Potential Harms

There is limited evidence on harms of interventions to prevent child maltreatment. Reported potential harms include dissolution of families, legal concerns, and an increased risk for further harm to the child.

Current Practice

All states and the District of Columbia have laws that mandate that all professionals who have contact with children, including all health care workers, report suspected maltreatment to Child Protective Services (CPS) (4). Pediatricians, family physicians, and other primary care providers are in a unique position to identify children at risk of maltreatment through well-child and other visits. However, although pediatricians state that preventing maltreatment is one of their primary roles (5), they rarely explicitly screen for family violence in practice or screen only in selected cases (6, 7). All states have home visiting programs to support families with young children, but the services provided in these programs and the eligibility criteria vary by state.

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