the prevention of child maltreatment: two strategies in the child healthcare system haruv institute...
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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 Kid
Pediatric 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*
Psychological
Aggression
Physical
Assault - minor
Physical
Assault - severe
* Initially and at 12 months
Medical Neglect: Non-compliance†
based on chart review (SEEK I)
0123456789
10
Before After*
%
Intervention
Control
* P = 0.05† MD documented “non-compliance”
Medical Neglect: Delayed Immunizations†
based on chart review (SEEK I)
0123456789
10
Before After*
%
Intervention
Control
† 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
Ra
te p
er
10
0,0
00
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 pattern
Unexpected onset
Resistance to soothing
Pain-like grimace
Long crying bouts
Evening 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?
