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Preventive health care, 2000 update: prevention of child maltreatment

Dr. MacMillan is Associate Professor of Psychiatry and Behavioural Neurosciences, and of Pediatrics at the Canadian Centre for Studies of Children at Risk, McMaster University, Hamilton, Ont.Members of the Canadian Task Force on Preventive Health Care Chairman: Dr. John W. Feightner, Professor, Department of Family Medicine, University of Western Ontario, London, Ont.; Past Chairman: Dr. Richard Goldbloom, Professor, Department of Pediatrics, Dalhousie University, Halifax, NS. Members: Drs. R. Wayne Elford, Professor and Chair of Research, Department of Family Medicine, University of Calgary, Calgary, Alta.; Denice Feig, Assistant Professor, Department of Endocrinology, University of Toronto, Toronto, Ont.; Michel Labrecque, Professeur, Unité de médecine familiale, Université Laval, Rimouski, Qué.; Robin McLeod, Professor, Department of Surgery, Mount Sinai Hospital and University of Toronto, Toronto, Ont.; Harriet MacMillan, Associate Professor, Departments of Psychiatry and Behavioural Neurosciences and of Pediatrics, Canadian Centre for Studies of Children at Risk, McMaster University, Hamilton, Ont.; Jean-Marie Moutquin, Professeur titulaire et directeur, Département d'obstétrique-gynécologie, Université de Sherbrooke, Sherbrooke, Que.; Valerie Palda, Assistant Professor, Department of General Internal Medicine, University of Toronto, Toronto, Ont.; Christopher Patterson, Professor and Head, Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ont.; and Elaine E.L. Wang, Associate Professor, Departments of Pediatrics and Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, Ont. Resource people: Nadine Wathen, Coordinator, and Tim Pauley, Research Assistant, Canadian Task Force on Preventive Health Care, Department of Family Medicine, University of Western Ontario, London, Ont.

Objectives: To update the 1993 report from the Canadian Task Force on the Periodic Health Examination (now the Canadian Task Force on Preventive Health Care) by reviewing the evidence for the effectiveness of interventions aimed at preventing child maltreatment described in the scientific literature over the past 6 years.

Options: Screening: a variety of techniques including assessment of risk indicators. Prevention: programs including home visitation; comprehensive health care programs; parent education and support, combined services and programs aimed specifically at preventing sexual abuse.

Outcomes: Occurrence of one or more of the subcategories of physical abuse, sexual abuse, neglect and emotional abuse in childhood.

Evidence: MEDLINE, PSYCINFO, ERIC and several other databases were searched, experts were consulted, and published recommendations were reviewed. Original research articles and overviews that examined screening for or prevention of child maltreatment were included in the update. No meta-analysis was performed because the range of manoeuvres precluded comparability.

Benefits, harms and costs: Because of the high false-positive rates of screening tests for child maltreatment and the potential for mislabelling people as potential child abusers, the possible harms associated with these screening manoeuvres outweigh the benefits. Two randomized controlled trials showed a reduction in the incidence of childhood maltreatment or outcomes related to physical abuse and neglect among first-time disadvantaged mothers and their infants who received a program of home visitation by nurses in the perinatal period extending through infancy. It is expected that a reduction in incidence of child maltreatment and other outcomes will lead to substantial government savings. Evidence remains inconclusive on the effectiveness of a comprehensive health care program, a parent education and support program, or a combination of services in preventing child maltreatment. Education programs designed to teach children prevention strategies to avoid sexual abuse show increased knowledge and skills but not necessarily reduced abuse.

Values: The systematic review and critical appraisal of the evidence were conducted according to the evidence-based methodology of the Canadian Task Force on Preventive Health Care.

Recommendations: There is further evidence of fair quality to exclude screening procedures aimed at identifying individuals at risk of experiencing or committing child maltreatment (grade D recommendation). There is good evidence to continue recommending a program of home visitation for disadvantaged families during the perinatal period extending through infancy to prevent child abuse and neglect (grade A recommendation). The target group for this program is first-time mothers with one or more of the following characteristics: age less than 19 years, single parent status and low socioeconomic status. The strongest evidence is for an intensive program of home visitation delivered by nurses beginning prenatally and extending until the child's second birthday. There is insufficient evidence to recommend a comprehensive health care program (grade C recommendation), a parent education and support program (grade C recommendation) or a combination of home-based services (grade C recommendation) as a strategy for preventing child maltreatment, but these interventions may be recommended for other reasons. There is insufficient evidence to recommend education programs for the prevention of sexual abuse (grade C recommendation); whether such programs reduce the incidence of sexual abuse has not been established.

Validation: The members of the Canadian Task Force on Preventive Health Care reviewed the findings of this analysis through an iterative process. The task force sent the final review and recommendations to selected external expert reviewers, and their feedback was incorporated.

Sponsors: The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.

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