The researchers at OHSU analyzed 11 studies that evaluated the effectiveness of child abuse and neglect prevention programs or interventions that took place in clinics — such as meetings with a social worker, for example. They gave parents questionnaires that assessed such risk factors as substance abuse, depression, stress and attitudes toward physical punishment — as well as noting whether parents were concerned that their child may have been physically or sexually abused. Doctors discussed the risk factors with parents and referred them to social workers if needed. After three years, researchers found that parents who took part in risk assessments and received social work referrals, if necessary, had decreased incidences of abuse, fewer reports to Child Protective Services (CPS) and better adherence to immunization schedules.
But the studies’ results were not persuasive enough to warrant new recommendations for physicians, says Dr. Heidi Nelson, senior author of the study analysis published in Annals of Internal Medicine and a research professor in medical informatics, clinical epidemiology and medicine at OHSU. “This is not about identifying kids who are being abused,” says Nelson. “This is about determining if a family in front of me is at risk for abuse in the future.”
A major challenge with determining who is at risk for child abuse is how — and to whom — to pose questions. If the parents who bring a child to a check-up are mistreating that child, says Grossman, it’s not likely they will volunteer that information. “You are potentially asking the perpetrators if there is a problem,” he says.
While evidence underpinning the effectiveness of screening questions is scanty, home visits seem to have had more success. Last year, a study in the Journal of the American Medical Association (JAMA) found that home visits can cut child maltreatment cases by up to half. States determine eligibility for home visits in different ways, but poor moms, single moms, homeless moms, teen moms and those with a history of domestic violence typically top the list. Home visitors serve as a sounding board and support system, educating moms about normal infant behavior, cautioning them against shaking crying babies and offering suggestions for stress relief and interacting with their babies. Parenting can be overwhelming even for educated, well-to-do women, but those who are less fortunate stand to benefit even more from having someone help them navigate the challenges of child-rearing. In fact, when researchers evaluated the effect of home visitations, they found that those babies whose families were visited by nurses were less likely to die of all causes by age 9 than other children. Some studies showed that children who benefited from home visits had less contact with CPS and fewer trips to the hospital.
But other studies on home visits have shown mixed results, leading the task force to stop short of issuing a blanket recommendation for primary-care clinics across the U.S to adopt the program for families they perceive to be at risk. “It’s one thing to say that it’s a good idea, but it’s another to say that we have definite proof,” says Nelson.
The task force last took up this issue in 2004; it will take another look at any new studies that have emerged five years from now to see if things have changed. In the meantime, for the next 30 days the public is welcome to submit comments on the task force’s preliminary recommendations. “We are looking to see if we missed any key pieces of evidence,” says Grossman.
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