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Abstract
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Many JAMA readers understand that child maltreatment is a pervasive public health and costly societal problem with devastating consequences to the long-term physical health, mental health, and well-being of surviors.1-3 But few have witnessed what we see on a regular basis: the lost futures of chronically neglected children who have never experienced the stability and safety of a nurturing family; the mental health challenges of adolescents who have been sexually abused and assaulted for years by their caregivers; the permanent neurologic injuries of infants who have survived abusive head trauma; and the battered bodies of murdered toddlers in our local morgues. As primary care pediatricians, hospitalists, and child abuse experts, these neglected, abused, beaten, and battered children are our patients, and it has been an uphill battle to stem the tide.
We were therefore disheartened, but not surprised, to read the conclusions from the US Preventive Services Task Force (USPSTF) commissioned systematic review of the evidence on primary care-feasible or referable behavioral counseling interventions to prevent child maltreatment: the evidence is largely insufficient to make a recommendation for or against, and where it exists, it is inconclusive.4,5 Every day we see our patients' caregivers doing their best with the resources available to them. We also see that those resources--food security, housing stability, accessible treatment for substance use and mental health disorders, effective and developmentally appropriate strategies to manage typical child behavior, and affordable childcare--too often fall short. We would like to think there is something we as pediatricians can do help our patients and their families to strengthen their resources and reduce the risk of maltreatment. So, what does this USPSTF recommendation mean? Is the only available response a referral to Child Protective Services (CPS)? Should we abandon the prevention strategies available to us as physicians?
The bottom line is no, prevention efforts should continue. We contextualize this clear bottom line with 3 considerations. First, complicated multifactorial societal problems such as child maltreatment require societal investment in strategic solutions that target multiple contributing factors. No single prevention intervention will tip the balance. Second, the inability to accurately measure the outcome of child maltreatment makes it challenging to determine prevention effectiveness; for this reason, proximal measures of maltreatment (which may be more accurate) should be embraced. And last, a lack of evidence to support the benefit of primary care-based child maltreatment prevention efforts does not mean that they are ineffective--only that the evidence is lacking, as it is for many pediatric primary prevention strategies.
The effectiveness of select pediatric prevention interventions such as vaccinations and fluoride varnish has been clearly demonstrated.6,7 And although these prevention breakthroughs took groundbreaking scientific discovery, the problems they addressed were primarily biological, with clearly defined and measurable outcomes. Child abuse and neglect, on the other hand, is a complex, multifactorial, widespread societal problem, which no single person, intervention, institution, policy, or program can solve. Multifactorial problems require multifactorial solutions; in the absence of societal investment in programs to support families and mitigate the risk factors that increase a child's vulnerability to maltreatment, a primary care-based intervention studied in isolation is unlikely to register on existing blunt and inadequate measurement tools. Large societal factors influencing child maltreatment include the health, economic, educational, and social policies that perpetuate economic and social inequalities in the US. Thus, prevention requires policy intervention at the societal level. For example, policies addressing Medicaid expansion, paid family leave, earned income tax credit, and lack of waitlists to access subsidized childcare have each been associated with a decrease in child maltreatment.8-15
To assess the effectiveness of primary care-based child maltreatment prevention programs, one must be able to measure maltreatment as an outcome. ...
Language: en |