Evidence From the USPSTF and New Approaches to Evaluate Interventions to Prevent Child Maltreatment.

Importance: The United States Preventive Services Task Force (USPSTF) has considered the topic of prevention of child maltreatment multiple times over its nearly 40-year history, each time reaching the conclusion that the evidence is insufficient to recommend for or against interventions aimed at preventing this important health problem with significant negative sequelae before it occurs. In the most recent evidence review, which was conducted from August 2021 to November 2023 and published in March 2024, the USPSTF considered contextual questions on the evidence for bias in reporting and diagnosis of maltreatment in addition to key questions regarding effectiveness of interventions to prevent child maltreatment. Observations: A comprehensive literature review found evidence of inaccuracies in risk assessment and racial and ethnic bias in the reporting of child maltreatment and in the evaluation of injuries concerning for maltreatment, such as skull fractures. When children are incorrectly identified as being maltreated, harms, such as unnecessary family separation, may occur. Conversely, when children who are being maltreated are missed, harms, such as ongoing injury to the child, continue. Interventions focusing primarily on preventing child maltreatment did not demonstrate consistent benefit or information was insufficient. Additionally, the interventions may expose children to the risk of harm as a result of these inaccuracies and biases in reporting and evaluation. These inaccuracies and biases also complicate assessment of the evidence for making clinical prevention guidelines. Conclusions and Relevance: There are several potential strategies for consideration in future efforts to evaluate interventions aimed at the prevention of child maltreatment while minimizing the risk of exposing children to known biases in reporting and diagnosis. Promising strategies to explore might include a broader array of outcome measures for addressing child well-being, using population-level metrics for child maltreatment, and assessments of policy-level interventions aimed at improving child and family well-being. These future considerations for research in addressing child maltreatment complement the USPSTF's research considerations on this topic. Both can serve as guides to researchers seeking to study the ways in which we can help all children thrive.

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences. Objective: To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023. Study Selection: English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment. Data Extraction and Synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures: Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms. Results: Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health. Conclusion and Relevance: The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

A System for Health, Not a Health Care System.

Clinical care makes a modest contribution to well-being, but adequate access to high-quality care is a necessary, if insufficient, condition for health. This issue of the North Carolina Medical Journal focuses on the Healthy North Carolina 2030 clinical indicators, the impact of health disparities, and the COVID-19 pandemic.

Primary Care Clinicians in Low-Access Counties.

Advanced practice providers comprise an increasing percentage of the health care and primary care workforce. This paper evaluates the weighted contribution of advanced practice providers to the primary care workforce in well-served and underserved counties across North Carolina using age- and sex-adjusted population measures of access.

Intention to Engage in Maternal and Child Health Home Visiting.

Home visiting (HV) programs have the potential to improve maternal and child health. As federal and state initiatives expand the reach of these programs, understanding what factors enhance uptake and retention of the services becomes increasingly important. This qualitative study used a Reasoned Action Model (RAM) and a cultural lens to explore factors influencing the engagement of women with low-income in HV programs. We conducted 21 semi-structured interviews in both English and Spanish in a prenatal clinic in an urban public health department. The constructs most salient for participants were emotions and affect, behavioral beliefs, and self-efficacy. In the context of an urban public health prenatal clinic, HV marketing and outreach should highlight convenience and social support, as well as clearly communicate program content and intent. In practice, HV programs must be flexible to work around work and home schedules; marketing and outreach should emphasize that flexibility.

Patterns of Risk and Protective Factors Among Alaska Children: Association With Maternal and Child Well-Being.

This study used population-representative data to examine associations of risk and protective factor patterns among Alaska Native/American Indian (AN/AI; N = 592) and non-Native (N = 1,018) children with maternal and child outcomes at age 3 years. Among AN/AI children, a high risk/moderate protection class was associated with child developmental risk and mothers being less likely to feel comfortable asking for help or knowing where to go for parenting information compared to a low socioeconomic status/high protection class. Among non-Native children, a moderate risk/high protection class was associated with child developmental risk and mothers being less likely to feel comfortable asking for help compared to a low risk/high protection class. Results provide insight on the intersection of risk and protective factors among Alaska families.

Preconception and Prenatal Predictors of Early Experiences of Risk and Protection Among Alaska Children.

OBJECTIVES: Our objective was to identify preconception and prenatal predictors of early experiences of co-occurring risk and protective factors to help target prevention efforts to the highest-need families prior to the birth of the child. METHODS: Data were from the Alaska Longitudinal Child Abuse and Neglect Linkage project and the 2012-2014 Alaska Child Understanding Behaviors Survey. We used latent class analysis and Vermunt's three-step approach to examine predictors of latent classes of risk and protective factors among Alaska children. RESULTS: Among children of Alaska Native/American Indian mothers, financial (OR 2.02, 95% CI 1.04, 3.90) and partner stress (OR 2.06, 95% CI 1.02, 4.10) prior to childbirth, maternal education < 12 years (OR 2.29, 95% CI 1.05, 4.96), and maternal substance use (OR 2.52, 95% CI 1.30, 4.89) were associated with a higher likelihood of membership in a high risk/moderate protection class as compared to a low socioeconomic status/high protection class. Among children of non-Native mothers, partner stress prior to childbirth (OR 3.92, 95% CI 1.08, 14.19), maternal education < 12 years (OR 2.69, 95% CI 1.24, 5.81), maternal substance use (OR 2.69, 95% CI 1.24, 5.81), younger maternal age (OR 0.87, 95% CI 0.80, 0.95), and a greater number of children (OR 1.62, 95% CI 1.09, 2.41) were associated with a higher likelihood of membership in a moderate risk/high protection class as compared to a low risk/moderate protection class. CONCLUSIONS: Results can inform eligibility criteria for prenatal home visiting programs and prenatal screening in Alaska to ensure prevention programming and referrals are directed to families most in need of additional support.

Child-Adult Relationship Enhancement in Primary Care: A Randomized Trial of a Skill-Based Parent Training with Parent Mentor Adaptation.

INTRODUCTION: Child-Adult Relationship Enhancement in Primary Care (PriCARE) is a 6-session group training designed to teach positive parenting skills. Parent engagement in such programs is a common implementation barrier. Our objectives were to (1) examine the impact of a peer mentor on attendance and stigma and (2) replicate a previous study by measuring PriCARE's impact on child behavior and parenting practices. METHOD: Parents of 2- to -6-year-old children without specific behavior problems were randomized to mentored PriCARE (n = 50), PriCARE (n = 50), or control (n = 50). Stigma was measured at 10 weeks. Child behavior and parenting practices were measured at baseline and 10 weeks using the Eyberg Child Behavior Inventory (ECBI) and Parenting Scale (PS). Analysis of variance models were used to examine differences across groups. RESULTS: There was no significant difference in attendance between mentored PriCARE and PriCARE arms (mean 3.80 vs 3.36 sessions, p = 0.35). Parents randomized to the mentor reported lower stigma (3.75 vs 5.04, p = 0.02). Decreases in the mean ECBI scores between 0 and 10 weeks were greater in the PriCARE arms (n = 100) compared with the control arm (n = 50), reflecting larger improvements in behavior [intensity: -7 (-2 to -13) vs 4 (-3 to 12) to p = 0.014; problem: -3 (-1 to -4) vs 1 (-1 to 3) to p = 0.007]. Scores on all PS subscales reflected greater improvements in parenting behaviors in PriCARE arms compared with control (all p < 0.04). CONCLUSION: Adapting PriCARE with a peer mentor may decrease stigma but does not improve program attendance. PriCARE shows promise in improving behavior in preschool-aged children and increasing positive parenting practices.

Heterogeneity in Risk and Protection Among Alaska Native/American Indian and Non-Native Children.

Currently, little is known about patterns of co-occurring risk and protective factors among young children. Understanding variations in co-occurring risk and protective factors among children in Alaska is important as experiences of collective trauma may contribute to differences in the intersection of risk and protective factors between Alaska Native/American Indian (AN/AI) and non-Native children. Using data from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a linkage of the 2009-2011 Alaska Pregnancy Risk Assessment Monitoring System survey and administrative data sources, and the 2012-2014 Childhood Understanding Behaviors Survey, we conducted latent class analysis to identify classes of AN/AI (N = 593) and non-Native (N = 1018) children in terms of seven risk factors (poverty, maternal depression, maternal binge drinking, parental incarceration, intimate partner violence exposure, other violence exposure, child maltreatment) and four protective factors (father figure involvement, reading by adults, family meals, peer interactions) experienced prior to age 3 years. We identified two classes among AN/AI children: (1) high risk-moderate protection (29.1%) and (2) low socioeconomic status-high protection (70.9%). We identified two classes among non-Native children: (1) moderate risk-high protection (32.9%) and (2) low risk-high protection (67.1%). A test of invariance revealed that risk and protective factor probabilities differed significantly for corresponding classes of AN/AI and non-Native children. Overall, results demonstrate heterogeneity within and between AN/AI and non-Native children in early experiences of risk and protection and suggest that interventions will be more effective if tailored to the experiences and developmental needs of specific groups of Alaska children.

Public Policy Approaches to Population Health.

The United States spends more per capita on health care than any other country and has worse health outcomes. Public policy can influence almost all aspects of health. Publicly funded insurance pays for health care for more than half of Americans. For individuals and employers that purchase insurance, the regulatory environment influences which insurance products can be purchased as well as by whom and for how much. Health policy levers at federal, state, and local levels can exert financial and regulatory influence over care. This influence determines what is health care, with increasing federal and state efforts to encourage nontraditional services.

Trajectories of child protective services contact among Alaska Native/American Indian and non-Native children.

BACKGROUND: Contact with child protective services (CPS) functions as an independent marker of child vulnerability. Alaska children are an important population for understanding patterns of CPS contact given high rates of contact overall and among specific demographic groups. OBJECTIVE: We aimed to identify longitudinal trajectory classes of CPS contact among Alaska Native/American Indian (AN/AI) and non-Native children and examine preconception and prenatal risk factors associated with identified classes. PARTICIPANTS AND SETTING: We used data from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a linkage of 2009-2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) births with administrative data including CPS records. METHODS: We conducted growth mixture modeling to identify trajectory classes of CPS contact from birth to age five years. We used Vermunt's three-step approach to examine associations with preconception and prenatal risk factors. RESULTS: Among AN/AI children, we identified three classes: 1) no/low CPS contact (75.4%); 2) continuous CPS contact (19.6%), and 3) early, decreasing CPS contact (5.0%). Among non-Native children, we identified four classes: 1) no CPS contact (81.3%); 2) low, increasing CPS contact (9.5%); 3) early, rapid decline CPS contact (5.8%); and 4) high, decreasing CPS contact (3.3%). Maternal substance use had the largest impact on probabilities of class membership, increasing the probability of membership in classes characterized by CPS contact, among both AN/AI and non-Native children. CONCLUSIONS: Results reveal heterogeneity in longitudinal patterns CPS contact across early childhood among Alaska children and identify maternal substance use as an important target for primary prevention.

Primary Care Interventions to Prevent Child Maltreatment: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Child maltreatment, also referred to as child abuse and neglect, can result in lifelong negative consequences. Objective: To update the evidence on interventions provided in or referable from primary care to prevent child maltreatment for the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, EMBASE, and trial registries through December 18, 2017; references; experts; literature surveillance through July 17, 2018. Study Selection: English-language fair- and good-quality randomized clinical trials that (1) included children with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment, (2) evaluated interventions feasible in a primary care setting or that could result from a referral from primary care, and (3) reported abuse or neglect outcomes or proxies for abuse or neglect (eg, injury with a specificity for abuse, visits to the emergency department, hospitalization). Data Extraction and Synthesis: Two reviewers independently assessed titles/abstracts, full-text articles, and study quality; a third resolved conflicts when needed. When at least 3 similar trials were available, random-effects meta-analyses were conducted. Main Outcomes and Measures: Direct measures (including reports to child protective services and removal of the child from the home) or proxy measures of abuse or neglect; behavioral, emotional, mental, or physical well-being; and harms. Results: Twenty-two trials (33 publications) were included (N = 11 132). No significant association was found between interventions and reports to child protective services within 1 year of intervention completion (10.6% vs 11.9%; pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]; 10 trials [n = 2444]) or removal of the child from the home within 1 to 3 years of follow-up (3.5% vs 3.7%; pooled OR, 1.09 [95% CI, 0.16-7.28]; 4 trials [n = 609]). No statistically significant associations were observed between interventions and outcomes for emergency department visits in the short term (<2 years), hospitalizations, child development, school performance, and prevention of death. Nonsignificant results from single trials led to a conclusion of insufficient evidence for injuries, failure to thrive, failure to immunize, school attendance, and other measures of abuse or neglect. Inconsistent results led to a conclusion of insufficient evidence for long-term (≥2 years) outcomes for reports to child protective services (ORs range from 0.48 to 1.13; 3 trials [n = 1690]), emergency department visits (1 of 2 trials reported significant differences) and internalizing and externalizing behavior symptoms (3 of 6 trials reported reductions in behavior difficulties). No eligible trials on harms of interventions were identified. Conclusions and Relevance: Interventions provided in or referable from primary care did not consistently prevent child maltreatment. No evidence on harms is available.

Intracranial Pressure Monitoring in Infants and Young Children With Traumatic Brain Injury.

OBJECTIVE: To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001. DESIGN: Prospective, observational cohort study. SETTING: Twelve PICUs in North Carolina. PATIENTS: All children 24 months old or younger with traumatic brain injury, admitted to an included PICU. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies. CONCLUSION: Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old or younger with traumatic brain injury and a need for better evidence to support treatment recommendations for this group of children.

Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina.

IMPORTANCE: Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100,000 person-years in the first year of life. OBJECTIVE: To assess the effectiveness of a statewide universal AHT prevention program. DESIGN, SETTING, AND PARTICIPANTS: In total, 88.29% of parents of newborns (n = 405 060) in North Carolina received the intervention (June 1, 2009, to September 30, 2012). A comparison of preintervention and postintervention was performed using nurse advice line telephone calls regarding infant crying (January 1, 2005, to December 31, 2010). A difference-in-difference analysis compared AHT rates in the prevention program state with those of other states before and after the implementation of the program (January 1, 2000, to December 31, 2011). INTERVENTION: The Period of PURPLE Crying intervention, developed by the National Center on Shaken Baby Syndrome, was delivered by nurse-provided education, a DVD, and a booklet, with reinforcement by primary care practices and a media campaign. MAIN OUTCOMES AND MEASURES: Changes in proportions of telephone calls for crying concerns to a nurse advice line and in AHT rates per 100,000 infants after the intervention (June 1, 2009, to September 30, 2011) in the first year of life using hospital discharge data for January 1, 2000, to December 31, 2011. RESULTS: In the 2 years after implementation of the intervention, parental telephone calls to the nurse advice line for crying declined by 20% for children younger than 3 months (rate ratio, 0.80; 95% CI, 0.73-0.87; P < .001) and by 12% for children 3 to 12 months old (rate ratio, 0.88; 95% CI, 0.78-0.99; P = .03). No reduction in state-level AHT rates was observed, with mean rates of 34.01 person-years before the intervention and 36.04 person-years after the intervention. A difference-in-difference analysis from January 1, 2000, to December 31, 2011, controlling for economic indicators, indicated that the intervention did not have a statistically significant effect on AHT rates (ß coefficient, -1.42; 95% CI, -13.31 to 10.45). CONCLUSIONS AND RELEVANCE: The Period of PURPLE Crying intervention was associated with a reduction in telephone calls to a nurse advice line. The study found no reduction in AHT rates over time in North Carolina relative to other states. Consequently, while this observational study was feasible and supported the program effectiveness in part, further programmatic efforts and evaluation are needed to demonstrate an effect on AHT rates.

Corporal punishment.

Corporal punishment is used for discipline in most homes in the United States. It is also associated with a long list of adverse developmental, behavioral, and health-related consequences. Primary care providers, as trusted sources for parenting information, have an opportunity to engage parents in discussions about discipline as early as infancy. These discussions should focus on building parents' skills in the use of other behavioral techniques, limiting (or eliminating) the use of corporal punishment and identifying additional resources as needed.

Update on prenatal care.

Many elements of routine prenatal care are based on tradition and lack a firm evidence base; however, some elements are supported by more rigorous studies. Correct dating of the pregnancy is critical to prevent unnecessary inductions and to allow for accurate treatment of preterm labor. Physicians should recommend folic acid supplementation to all women as early as possible, preferably before conception, to reduce the risk of neural tube defects. Administration of Rho(D) immune globulin markedly decreases the risk of alloimmunization in an RhD-negative woman carrying an RhD-positive fetus. Screening and treatment for iron deficiency anemia can reduce the risks of preterm labor, intrauterine growth retardation, and perinatal depression. Testing for aneuploidy and neural tube defects should be offered to all pregnant women with a discussion of the risks and benefits. Specific genetic testing should be based on the family histories of the patient and her partner. Physicians should recommend that pregnant women receive a vaccination for influenza, be screened for asymptomatic bacteriuria, and be tested for sexually transmitted infections. Testing for group B streptococcus should be performed between 35 and 37 weeks' gestation. If test results are positive or the patient has a history of group B streptococcus bacteriuria during pregnancy, intrapartum antibiotic prophylaxis should be administered to reduce the risk of infection in the infant. Intramuscular or vaginal progesterone should be considered in women with a history of spontaneous preterm labor, preterm premature rupture of membranes, or shortened cervical length (less than 2.5 cm). Screening for diabetes should be offered using a universal or a risk-based approach. Women at risk of preeclampsia should be offered low-dose aspirin prophylaxis, as well as calcium supplementation if dietary calcium intake is low. Induction of labor may be considered between 41 and 42 weeks' gestation.