The Prevention of Child Maltreatment:Two Strategies in the

Child Healthcare System

Haruv Institute Conference Jerusalem May 2010

Howard Dubowitz, MD, MS University of Maryland School of Medicine

The Field of Child Healthcare

“As physicians who assume a responsibility for children’s physical, mental & emotional progress, pediatricians must be concerned with social and environmental influences which have a major impact on the health & well-being of children & their families”

The Potential of Prevention

Effective prevention

should yield

many benefits, including

child abuse & neglect

of child maltreatment

Prevention

Promotionof children’s health, development and safety

SEEKa Safe Environment for

Every KidPediatric Primary Care

Dubowitz et al, Pediatrics, 2009;123:858

Pediatric Primary Care

• Routine checkups

• Periodic intervals

– 1 wk, 1, 2, 4, 6, 9, 12, 15 and 18 months

– 2, 3, 4, 5 years …………….

• Aims at prevention, early detection of problems

Pediatric Primary Care: An Opportunity for Preventing Child

Abuse & Neglect

• Well accepted, institutionalized• Goal of prevention• Concern with child, family• Special relationship with family• No stigma• Multiple visits (1st few yrs.)• An opportunity, responsibility

The SEEK Model• Specially trained health professionals (HPs)

• Parent Screening Questionnaire (PSQ)

• Brief assessment of identified problems

• Initial management

• HP/social worker team

• SEEK resources – Parent Handouts

• Collaboration with community agencies

Training Primary Care Professionals

• Why problem is important

– prevalence, impact

• How to briefly assess

– risk & protective factors

• What to do

– initial management, referrals

Targeted Psychosocial Problems

Parents who may be experiencing:

• Major stress

• Depression

• Substance abuse

• Intimate partner (domestic) violence

Parent Screening Questionnaire (PSQ)

• brief • easy to read• answer yes/no• convenient, time to complete• voluntary

PSQ

PSQ Intro

• Empathic: “Being a parent is not always easy”

• Universal: “We’re asking everyone …”

• Provide context: “We want to help families have a safe environment for kids.”

• Builds on what’s accepted: injury prevention

Examples of PSQ Questions

• Intimate partner violence: In the past year, have you been afraid of a partner?

• Substance abuse: In the past year, have you felt the need to cut back on drinking or drug use?

• Depression: Lately, do you often feel down, depressed, or hopeless?

When to screen?

• Regular checkups

• Not “sick visits”

Study Hypothesis

The SEEK model of primary care will reduce child maltreatment rate, measured by:

• Parent self-report• Medical chart data• Child protective services (CPS) reports

SEEK Study Design

Subset of mothers recruited

Model Care (Intervention)Trained pediatricians, Parent Screening Questionnaire,

+ social worker. All patients receive Model Care

InitialSurve

y

6 Mo. Surve

y

Medical Chart &

CPS Record Review

Standard Care (Control)All patients receive standard pediatric primary care

Randomly assign practices

12 Mo. Surve

y

Participants

• Mothers of children < 6 years

• English speaking

• Child not in foster care

• Bringing child for a checkup

SEEK Samples

Parent Demographic Characteristics SEEK I SEEK II

N 558 1119

Demographics low income, urban middle class, suburban

Race mostly African American mostly white

Mean age 25 years 33 years

Education 66% high school or more 90% college or more

Employed 37 % 55 %

Marital status - 88 % Married

Family income - 56% > $75,000

SEEK Samples

Child Demographic Characteristics

SEEK I SEEK IIN 558 1119

Mean age 0.5 years 1.6 years

Gender 52% male 52% male

Race 92% African American

81% white

Insurance 93 % Medicaid 91% private

Parental Self-Report

SEEK 1 SEEK II*

PsychologicalAggressionPhysical Assault - minorPhysical Assault - severe

* Initially and at 12 months

Medical Neglect: Non-compliance†

based on chart review (SEEK I)

0123456789

10

Before After*

%

InterventionControl

* P = 0.05† MD documented “non-compliance”

Medical Neglect: Delayed Immunizations†

based on chart review (SEEK I)

0123456789

10

Before After*

%

InterventionControl

† MD documented this * P = 0.002

Child Protective Services Reports for Abuse or Neglect (SEEK I)

0

5

10

15

20

25

Before After*

%

InterventionControl

* P = 0.03

SEEK - Strengths

• Positive findings in 2 RCTs

• Moderate size samples– High and low risk

• Fits well with an existing system of pediatric primary care

• Little additional time required

SEEK - Limitations

• Low prevalence of risk factors in low risk sample

• Cost of social worker

In Sum• Pediatric primary care offers a good opportunity

to address major psychosocial issues facing many children & families

• SEEK offers a practical model for improving pediatric primary care

– Sustained improvement in health professional practice

– PSQ a useful screening tool

• Evidence that SEEK can prevent maltreatmentDubowitz et al, Pediatrics, 2009;123:858

Programs for parents of newborns to prevent abusive head trauma

(AHT)

Known cases – tip of the iceberg

AHT IncidenceAHT Incidence

17

2600

0

1000

2000

3000

Rat

e pe

r 100

,000

Keenan* Theodore**

• Shaking of children < 2 yrs

• Keenan: ICU admissions

• Theodore: parent report

*Keenan et al. JAMA 2003;290:621-6 **Theodore et al. Pediatrics 2005;115:e331-7

The Dias ModelThe Dias Model• Components

– Infant crying and AHT info– Video: coping with crying– Commitment statement

• Results – 47% reduction in AHT cases – 42 22 cases per 100,000 – No such decrease in neighboring state

Limitations of Dias studyLimitations of Dias study

• Many parents not exposed

• Decrease due to other factors?

• Generalizable?

• Reproducible?

The Period of The Period of PURPLE CryingPURPLE Crying

ModelModel

Peak patternUnexpected onsetResistance to soothingPain-like grimaceLong crying boutsEvening clustering

PURPLE EvaluationPURPLE Evaluation• Randomized controlled trials

– PURPLE booklet & CD

• Recruitment prenatally and post-partum • Diary – 24 hr ruler

– Infant states (eg, crying)– Parent behavior (eg, holding baby)– Key events: pick up, put down & walk away

• Phone interview at 2 months

PURPLE EvaluationPURPLE Evaluation

Knowledge PURPLE Control

Crying 69% 63%

Shaking 85% 83%

PURPLE EvaluationPURPLE Evaluation• Behavioral response to crying

– PURPLE a little better than control– Not statistically significant

• Sharing information– PURPLE more Don’t Shake info– PURPLE more walk away info– PURPLE more cry info - Vancouver study

• More infant contact during distress – WA study

PURPLE Strengths

• Large evaluations

• Randomized trials

• Fidelity to model

PURPLE LimitationsPURPLE Limitations• Evaluation limited to mothers

• Small differences in knowledge, behavior - self report

• No SBS or AHT outcomes

Can/should these programs be applied in

Israel?

Toda Rabahdubowitz@peds.umaryland.edu