Joanne Klevens

Primary prevention of child physical abuse and neglect: gaps and promising directions

Reviews on primary prevention have identified effective strategies to prevent child maltreatment but have ignored potentially promising interventions that have not yet been evaluated as well as gaps in the development of programs. The goal of this review was to identify these gaps and recommend future directions for developing interventions from a public health perspective. To this end, a systematic review of the literature for 1980-2004 utilizing existing databases and found 188 primary prevention interventions that addressed a broad range of risk factors was conducted. However, few had been rigorously evaluated, and only a handful demonstrated impact on child maltreatment or its risk factors. From a public health perspective, interventions that target prevalent and neglected risk factors such as poverty, partner violence, teenage pregnancy, and social norms tolerating violence toward children need to be developed and evaluated. In addition, more attention should be given to low cost interventions delivered to the public, by society, or that require minimal effort from recipients.

Effect of Screening for Partner Violence on Women's Quality of Life: A Randomized Controlled Trial

CONTEXT Although partner violence screening has been endorsed by many health organizations, there is insufficient evidence that it has beneficial health outcomes. OBJECTIVE To determine the effect of computerized screening for partner violence plus provision of a partner violence resource list vs provision of a partner violence list only on womens health in primary care settings, compared with a control group. DESIGN, SETTING, AND PARTICIPANTS A 3-group blinded randomized controlled trial at 10 primary health care centers in Cook County, Illinois. Participants were enrolled from May 2009-April 2010 and reinterviewed 1 year (range, 48-56 weeks) later. Participants were English- or Spanish-speaking women meeting specific inclusion criteria and seeking clinical services at study sites. Of 3537 women approached, 2727 were eligible, 2708 were randomized (99%), and 2364 (87%) were recontacted 1 year later. Mean age of participants was 39 years. Participants were predominantly non-Latina African American (55%) or Latina (37%), had a high school education or less (57%), and were uninsured (57%). INTERVENTION Randomization into 3 intervention groups: (1) partner violence screen (using the Partner Violence Screen instrument) plus a list of local partner violence resources if screening was positive (n = 909); (2) partner violence resource list only without screen (n = 893); and (3) no-screen, no-partner violence list control group (n=898). MAIN OUTCOME MEASURES Quality of life (QOL, physical and mental health components) was the primary outcome, measured on the 12-item Short Form (scale range 0-100, mean of 50 for US population). RESULTS At 1-year follow-up, there were no significant differences in the QOL physical health component between the screen plus partner violence resource list group (n = 801; mean score, 46.8; 95% CI, 46.1-47.4), the partner violence resource list only group (n = 772; mean score, 46.4; 95% CI, 45.8-47.1), and the control group (n = 791; mean score, 47.2; 95% CI, 46.5-47.8), or in the mental health component (screen plus partner violence resource list group [mean score, 48.3; 95% CI, 47.5-49.1], the partner violence resource list only group [mean score, 48.0; 95% CI, 47.2-48.9], and the control group [mean score, 47.8; 95% CI, 47.0-48.6]). There were also no differences between groups in days unable to work or complete housework; number of hospitalizations, emergency department, or ambulatory care visits; proportion who contacted a partner violence agency; or recurrence of partner violence. CONCLUSIONS Among women receiving care in primary care clinics, providing a partner violence resource list with or without screening did not result in improved health. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00526994.

Failure to Thrive as a Manifestation of Child Neglect

Failure to thrive is a common problem in infancy and childhood. It is most often multifactorial in origin. Inadequate nutrition and disturbed social interactions contribute to poor weight gain, delayed development, and abnormal behavior. The syndrome develops in a significant number of children as a consequence of child neglect. This clinical report is intended to focus the pediatrician on the consideration, evaluation, and management of failure to thrive when child neglect may be present. Child protective services agencies should be notified when the evaluation leads to a suspicion of abuse or neglect.

Violence in the United States: Status, Challenges, and Opportunities

IMPORTANCE Interpersonal violence, which includes child abuse and neglect, youth violence, intimate partner violence, sexual violence, and elder abuse, affects millions of US residents each year. However, surveillance systems, programs, and policies to address violence often lack broad, cross-sector collaboration, and there is limited awareness of effective strategies to prevent violence. OBJECTIVES To describe the burden of interpersonal violence in the United States, explore challenges to violence prevention efforts and to identify prevention opportunities. DATA SOURCES We reviewed data from health and law enforcement surveillance systems including the National Vital Statistics System, the Federal Bureau of Investigations Uniform Crime Reports, the US Justice Departments National Crime Victimization Survey, the National Survey of Childrens Exposure to Violence, the National Child Abuse and Neglect Data System, the National Intimate Partner and Sexual Violence Survey, the Youth Risk Behavior Surveillance System, and the National Electronic Injury Surveillance System-All Injury Program. RESULTS Homicide rates have decreased from a peak of 10.7 per 100,000 persons in 1980 to 5.1 per 100,000 in 2013. Aggravated assault rates have decreased from a peak of 442 per 100,000 in 1992 to 242 per 100,000 in 2012. Nevertheless, annually, there are more than 16,000 homicides and 1.6 million nonfatal assault injuries requiring treatment in emergency departments. More than 12 million adults experience intimate partner violence annually and more than 10 million children younger than 18 years experience some form of maltreatment from a caregiver, ranging from neglect to sexual abuse, but only a small percentage of these violent incidents are reported to law enforcement, health care clinicians, or child protective agencies. Moreover, exposure to violence increases vulnerability to a broad range of mental and physical health problems over the life course; for example, meta-analyses indicate that exposure to physical abuse in childhood is associated with a 54% increased odds of depressive disorder, a 78% increased odds of sexually transmitted illness or risky sexual behavior, and a 32% increased odds of obesity. Rates of violence vary by age, geographic location, sex, and race/ethnicity, and significant disparities exist. Homicide is the leading cause of death for non-Hispanic blacks from age 1 through 44 years, whereas it is the fifth most common cause of death among non-Hispanic whites in this age range. Additionally, efforts to understand, prevent, and respond to interpersonal violence have often neglected the degree to which many forms of violence are interconnected at the individual level, across relationships and communities, and even intergenerationally. The most effective violence prevention strategies include parent and family-focused programs, early childhood education, school-based programs, therapeutic or counseling interventions, and public policy. For example, a systematic review of early childhood home visitation programs found a 38.9% reduction in episodes of child maltreatment in intervention participants compared with control participants. CONCLUSIONS AND RELEVANCE Progress has been made in reducing US rates of interpersonal violence even though a significant burden remains. Multiple strategies exist to improve violence prevention efforts, and health care providers are an important part of this solution.

Child maltreatment fatalities in children under 5: Findings from the National Violence Death Reporting System ☆

OBJECTIVE To describe the distribution of child maltreatment fatalities of children under 5 by age, sex, race/ethnicity, type of maltreatment, and relationship to alleged perpetrator using data from the National Violent Death Reporting System (NVDRS). STUDY DESIGN Two independent coders reviewed information from death certificates, medical examiner and police reports corresponding to all deaths in children less than 5 years of age reported to NVDRS in 16 states. RESULTS Of the 1,374 deaths for children under 5 reported to NVDRS, 600 were considered attributable to child maltreatment. Over a half of the 600 victims of child maltreatment in this age group were under 1 year old, 59% were male, 42% non-Hispanic Whites, and 38% were non-Hispanic Blacks. Two thirds of child maltreatment fatalities in children under 5 were classified as being due to abusive head trauma (AHT), 27.5% as other types of physical abuse, and 10% as neglect. Based on these data, fathers or their substitutes were significantly more likely than mothers to be identified as alleged perpetrators for AHT and other types of physical abuse, while mothers were more likely to be assigned responsibility for neglect. CONCLUSIONS Among children under 5 years, children under 1 are the main age group contributing to child maltreatment fatalities in the NVDRS. AHT is the main cause of death in these data. These findings are limited by underascertainment of cases and fair inter-rater reliability of coding. PRACTICE IMPLICATIONS The findings suggest the need to develop and evaluate interventions targeting AHT to reduce the overall number of child maltreatment deaths in young children. These interventions should make special efforts to include fathers and their substitutes.

The Victim-Perpetrator Overlap and Routine Activities Results From a Cross-Sectional Study in Bogotá, Colombia

The overlap between the populations of victims and perpetrators, as well as the differences between victims who are perpetrators and those who are not, are explored using data from a cross-sectional survey of violence among a random sample (n = 3,007) of the general population in Bogotá, Colombia. The findings show that about a third of the population have been both a victim and perpetrator of violence, whereas another third have been only victims. Victims who have not been perpetrators differ in their demographic profile and routine activities from those who have but tend to be similar to the general population. Given the large overlap between victims and perpetrators, interventions used to reduce aggression and offending might also have an impact on victimization in this population. Risk factors different from those hypothesized in the routine activities theory among victims who are not perpetrators of violence need to be explored.

Effect of Screening for Partner Violence on Women's Quality of Life

CONTEXT Although partner violence screening has been endorsed by many health organizations, there is insufficient evidence that it has beneficial health outcomes. OBJECTIVE To determine the effect of computerized screening for partner violence plus provision of a partner violence resource list vs provision of a partner violence list only on womens health in primary care settings, compared with a control group. DESIGN, SETTING, AND PARTICIPANTS A 3-group blinded randomized controlled trial at 10 primary health care centers in Cook County, Illinois. Participants were enrolled from May 2009-April 2010 and reinterviewed 1 year (range, 48-56 weeks) later. Participants were English- or Spanish-speaking women meeting specific inclusion criteria and seeking clinical services at study sites. Of 3537 women approached, 2727 were eligible, 2708 were randomized (99%), and 2364 (87%) were recontacted 1 year later. Mean age of participants was 39 years. Participants were predominantly non-Latina African American (55%) or Latina (37%), had a high school education or less (57%), and were uninsured (57%). INTERVENTION Randomization into 3 intervention groups: (1) partner violence screen (using the Partner Violence Screen instrument) plus a list of local partner violence resources if screening was positive (n = 909); (2) partner violence resource list only without screen (n = 893); and (3) no-screen, no-partner violence list control group (n=898). MAIN OUTCOME MEASURES Quality of life (QOL, physical and mental health components) was the primary outcome, measured on the 12-item Short Form (scale range 0-100, mean of 50 for US population). RESULTS At 1-year follow-up, there were no significant differences in the QOL physical health component between the screen plus partner violence resource list group (n = 801; mean score, 46.8; 95% CI, 46.1-47.4), the partner violence resource list only group (n = 772; mean score, 46.4; 95% CI, 45.8-47.1), and the control group (n = 791; mean score, 47.2; 95% CI, 46.5-47.8), or in the mental health component (screen plus partner violence resource list group [mean score, 48.3; 95% CI, 47.5-49.1], the partner violence resource list only group [mean score, 48.0; 95% CI, 47.2-48.9], and the control group [mean score, 47.8; 95% CI, 47.0-48.6]). There were also no differences between groups in days unable to work or complete housework; number of hospitalizations, emergency department, or ambulatory care visits; proportion who contacted a partner violence agency; or recurrence of partner violence. CONCLUSIONS Among women receiving care in primary care clinics, providing a partner violence resource list with or without screening did not result in improved health. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00526994.

Latinos’ Perspectives and Experiences With Intimate Partner Violence

This qualitative study, utilizing focus group interviews with community members and in-depth interviews with victims and perpetrators, explored Latinos’ beliefs and perceptions of IPV in Oklahoma City, Oklahoma, as a basis for developing culturally appropriate intimate partner violence (IPV) services for this population. The findings from these interviews suggest that this community recognizes IPV as a problem and is aware of the multiple dimensions, potential causes, and negative consequences of IPV. In general, participants perceived family and neighbors as preferring to not get involved in situations of IPV. However, family was also expected to, and often did, provide tangible support to victims. Directions for developing prevention programs for this population and future research are suggested.

Exploring the Links Between Components of Coordinated Community Responses and Their Impact on Contact With Intimate Partner Violence Services

In the 1990s, concerns with response fragmentation for intimate partner violence (IPV) led to the promotion of coordinated community responses (CCRs) to prevent and control IPV. Evaluation of CCRs has been limited. A previous evaluation of 10 CCRs funded by the Centers for Disease Control and Prevention showed no overall impact on rates of IPV when compared to matched communities. However, there was great variability in the quality and quantity of CCR efforts between sites and thus potentially different levels of impact. This article establishes the impact of each of the 10 CCRs on womens past-year exposure to IPV and contact with IPV services and explores the associations between specific CCR components and contact with IPV services.

Comparison of Screening and Referral Strategies for Exposure to Partner Violence

BACKGROUND Although under debate, routine screening for intimate partner violence (IPV) is recommended in health care settings. This study explored the utility of different screening and referral strategies for women exposed to IPV in primary health care. METHODS Using a randomized controlled trial design we compared two screening strategies (health care providers [HCP] versus audio computer-assisted self-interviews [A-CASI]) and three referral strategies (HCP alone, A-CASI referral with HCP endorsement, and A-CASI alone). English-speaking women who were 18 years and older and were attending womens health clinics at a public hospital were eligible to participate. Participants were randomly assigned to one of three study groups (HCP screen and referral, A-CASI screen and referral with HCP referral endorsement, and A-CASI screen and referral). Women were reinterviewed by telephone 1 week later. The primary outcome was rate of IPV disclosure; secondary outcomes were screening mode preference, reactions to IPV screening, and use of referral resources. RESULTS Of the 129 eligible women, 126 women were enrolled (98%); 102 women (81% of those enrolled) completed the follow-up telephone interview. Disclosure rates were higher for women screened with A-CASI compared with HCP-screened women (21% vs. 9%; p = .07). Screening mode preference, impact of screening (positive and negative reactions), and rates of use of referral resources were similar between study groups. CONCLUSION A-CASI tended to yield higher rates of IPV disclosure and similar rates of use of referral resources. A-CASI technology may be a practical way to screen for IPV.