Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made.  (Formerly, these situations were captured under a "C Recommendation".)  This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade.  For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Preventive Health Care, 2000 Update: Prevention of Child Maltreatment

Structured Abstract


Prepared  by Harriet L. MacMillan, MD, FRCPC, Departments of Pediatrics and Psychiatry, McMaster University, and Canadian Centre for Studies of Children at Risk.

These recommendations were finalized by the Task Force in June 1999

Objective
The objective of this review was to make recommendations for programs for primary prevention of child maltreatment (physical abuse, neglect, sexual abuse, and emotional abuse) in the periodic health examination of Canadian children and adults. This is an update of the 1993 Canadian Task Force guidelines. This update includes a review of any intervention focused on preventing child maltreatment, whether directed at the general population or at high-risk individuals or groups. It does not include programs aimed at "tertiary prevention", also referred to as clinical services, for cases in which the child or family has experienced abuse and the emphasis is on preventing recurrence or progression.

Burden of Suffering
The term maltreatment includes all types of child victimization but is commonly divided into the subcategories of physical abuse, neglect, sexual abuse and emotional abuse. Although many episodes of child maltreatment go unreported, an estimated 45 reports of suspected child maltreatment per thousand children were received in 1992 in the U.S. A 1993 study showed that the incidence of child maltreatment investigations was 21 per 1000 children in Ontario, and rates of child sexual abuse in Ontario and Quebec were 1.57 and 0.87 per 1000 children, respectively. The dissimilarity between the two provinces is attributed to differences in institutional response rather than differences in rates of child sexual abuse. One prevalence survey has been conducted in Canada since the 1993 review. In the Mental Health Supplement to the Ontario Health Survey, a self-administered questionnaire, 31.2% of males and 21.1% of females reported a history of child physical abuse, and 4.3% of males and 12.8% of females reported a history of child sexual abuse.

Children who are maltreated may suffer from cognitive, emotional and social impairment in addition to physical disabilities; and may also be susceptible to many types of psychiatric impairment including depression, personality disorders, anxiety, substance abuse, suicidal behaviour, conduct disorder and criminal behaviour. Risk indicators for physical abuse are low socio-economic status, young maternal age, large family, single-parent family, parental history of physical maltreatment, spousal violence, lack of social support, unplanned pregnancy, negative attitude toward pregnancy, substance abuse, male sex, recent life stressors, maternal psychiatric impairment, low maternal education level, lack of attendance at prenatal classes, substance abuse and low religious attendance. Risk indicators for sexual abuse are living in a family without a natural parent, growing up in a family with poor marital relationships between parents, presence of a step-father, poor parent-child relationship, unhappy family life, low maternal age and parental death. Risk indicators for neglect include parental sociopathic behaviour and substance abuse.

Options
Screening methods include staff-administered checklists (Family Stress Checklist and Dunedin Family Services Indicator), self-administered questionnaires (Child Abuse Potential Inventory, Michigan Screening Profile of Parenting, Adult Adolescent Parenting Inventory, and Parent Opinion Questionnaire), and standardized interviews. Screening can include the use of risk indicators for physical and sexual abuse and neglect. Preventive measures include perinatal and early childhood programs, such as hospital support, home visitations, comprehensive health care programs, parental training programs, and educational programs for children, parents, and teachers.

Outcomes
The occurrence of one or more of the subcategories of physical abuse, sexual abuse, neglect or emotional abuse was evaluated. Other outcomes included the sensitivity and specificity of tests and adverse events of testing. For screening and preventive manoeuvres, outcomes such as identification of individuals at risk of experiencing or committing child maltreatment, decreased incidences of injuries and ingestions, improved knowledge and prevention skills for parents and children, reduced number of out-of-home placements, and increased incidences of disclosure of victimization were measured.

Evidence
MEDLINE, HealthStar, PSYCINFO, ERIC, and Current Contents were searched from 1993 to February 1999 using the terms child abuse, child neglect, incest, and battered child syndrome. The type of publication was limited to original research articles, reviews, meta-analyses, practice guidelines, and literature reviews.

Recommendations were graded as:
 
A 
 Good evidence to support the recommendation that the condition be specifically considered in a PHE. 
B 
 Fair evidence to support the recommendation that the condition be specifically considered in a PHE. 
C 
 Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D 
 Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE. 
E 
 Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE. 

Quality of evidence was rated according to 5 levels:
 
I 
 Evidence from at least 1 properly randomized controlled trial (RCT). 
II-1 
 Evidence from well-designed controlled trials without randomization. 
II-2 
 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group. 
II-3 
 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here. 
III 
 Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees. 

Values
The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year in 1998. Consensus was reached on final recommendations.

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 of preventive programs showed a significant 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. 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.

It is expected that a reduction in incidence of child maltreatment and other outcomes will lead to substantial government savings.

Recommendations
Recommendation grade [A, B, C, D, E]  and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

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 two selected external expert reviewers, and their feedback was incorporated. It was then peer-reviewed as part of the journal publication process.

Sponsors
The Canadian Task Force on Preventive Health Care developed this guideline with funding from the Provincial and Territorial Ministries of Health and Health Canada.

Selected References

Source Document:

MacMillan H.L. with the Canadian Task Force on Preventive Health Care. Preventive health care, 2000 update: prevention of child maltreatment. CMAJ 2000; 163(11):1451-58.