Getting Pediatric Practices to Prevent Child Abuse and Neglect

1
Getting Pediatric Practices to Prevent Child
Abuse and Neglect

• Steve Kairys, MD, MPH, FAAP, PI
• Tammy Piazza Hurley, Project Director

2
Session Objectives

• At the end of this session, participants will be
  able to
• 1. To detail the epidemiology and long term
  effects of child abuse and neglect
• 2. To review the role of pediatrics in the
  primary prevention of child abuse and neglect
• 3. To learn specific office based strategies for
  the primary prevention of child abuse and neglect

3
The Importance of Prevention

• 10-15 of young children are victims of serious
• physical trauma (Finkelhor and Straus)
• Neglect is the leading cause of substantiated
  cases
• of abuse
• Survey data demonstrate that 25 of females and
• 10 of males will be sexually abused by age
  18
• Estimates of treatment costs are 24 billion
  dollars a year
• Long term sequelae are enormous in terms of
  psychological and functional damage, substance
  abuse, delinquency, learned aggressiveness and
  abuse potential when a parent

4
The Adverse Childhood Experiences (ACE) Study

• The largest study of its kind ever done to
  examine the health and social effects of adverse
  childhood experiences over the lifespan (18,000
  participants)

5
Adverse Childhood Experiences Are Very Common
Percent reporting types of ACEs
Household exposures Alcohol abuse
23.5 Mental illness 18.8 Battered
mother 12.5 Drug abuse 4.9
Criminal behavior 3.4
Childhood Abuse Psychological
11.0 Physical 30.1 Sexual
19.9
6
ACES

• determine the likelihood of the ten most common
  causes of death in the United States.
• Top 10 Risk Factors Are

Smoking Severe Obesity
Physical inactivity Depression
Suicide attempt Alcoholism
Illicit drug use Injected drug use
50 sexual partners h/o STDs
7
With an ACE Score of 0, the majority of adults
have few, if any, risk factors for these
diseases. However, with an ACE Score of 4 or
more, the majority of adults have multiple risk
factors for these diseases or the diseases
themselves.
8
Many chronic diseasesin adults are
determineddecades earlier in childhood.
9

• The Role Primary Care Practice in Preventing
  Child Abuse and Neglect

10
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

11
Percent Of Children Who Saw A Pediatric Clinician
In Past Year
12
Pediatrician Perspectives on Content of Health
Supervision

• Most pediatricians say they discuss traditional
  topics with less than 75 of parents of patients
  0-9 months
• Immunizations (94), nutrition (93),
  sleeping positions (82), breastfeeding (70)
• Less frequently discussed are topics related to
  cognitive development
• Reading to child (48) how child communicates
  (42)
• Least discussed are topics related to family
  community needs
• Social support (28), financial needs (16),
  violence in the community (13)

13
Parents Misconceptions

• Parents of young children
• 57 believe a baby younger than 6 months can be
  spoiled
• Almost 40 believe a 12-month-olds behavior can
  be based on revenge
• 51 expect a 15-month-old to share

What Grown-Ups Understand About Child
Development, Civitas, 2000
14
Missed Opportunities

• Parents concerns are often not elicited or
  addressed
• 44-79 of parents report not discussing important
  child development topics with their pediatricians
• About 57 of parents report receiving a
  developmental assessment of any kind
• Only half of exemplary practices refer children
  to developmental programs

15
Dissemination Strategies

• Continuing medical education
• Evidence-based guidelines
• Opinion leaders
• Audit and feedback
• Incentives disincentives
• Academic detailing
• Patient and/or consumer activation
• Office system innovations
• Continuous quality improvement

16

• A national health care promotion and disease
  prevention initiative that uses a developmentally
  based approach to address childrens health needs
  in the context of family and community.

17
Goals

• Bright Futures has four goals that will allow it
  to carry out its mission of improving the health
  of our nations children, families, and
  communities. These goals are to
• Work with states to make the Bright Futures
  approach the standard of care for infants,
  children, and adolescents
• Help health care providers shift their thinking
  to a prevention-based, family-focused, and
  developmentally-oriented direction
• Foster partnerships between families, providers,
  and communities and
• Empower families with the skills and knowledge to
  be active participants in their childrens
  healthy development.

18
Guidelines

• Comprehensive health supervision guidelines
• Developed by multidisciplinary child health
  expertsproviders, researchers, parents, child
  advocates
• Provide framework for well-child care from birth
  to age 21
• Present single standard of care based on health
  promotion and disease prevention model
• Include recommendations on immunizations, routine
  health screening, and anticipatory guidance
• Replace the former AAP Guidelines for Health
  Supervision

19
Features of 3rd Edition Ten Themes

• Child development
• Family support
• Mental health and emotional well-being
• Nutritional health
• Physical activity

• Healthy weight
• Oral health
• Safety and injury prevention
• Healthy sexuality
• Community resources and relationships

20
Core Concepts

• Prevention Works
• Families Matter
• Health Is Everyones
• Business

21
Official AAP Policy on Prevention

• The Pediatricians Role in Child Maltreatment
  Prevention published October 2010 Pediatrics
  (http//pediatrics.aappublications.org/cgi/reprint
  /126/4/8330)
• Factors and characteristics placing child at risk
• Protective Factors
• Review of Prevention and Intervention programs
• Guidance for Pediatrician

22
Schmidts 7 Deadly Sins of Childhood

• Normal developmental phases of childhood that may
  cause difficulty for some
• Colic
• Awakening at night
• Separation anxiety
• Normal exploratory behavior
• Normal negativism
• Normal poor appetite
• Toilet training resistance
• Schmitt BA. Child Abuse and Neglect, 1987.

23
Guidance for Pediatrics

• Obtain a thorough social history, initially and
  periodically, throughout a patients childhood.
• Acknowledge the frustration and anger that often
  accompany parenting.
• Talk with parents about their infants crying and
  how they are coping with it.
• When caring for children with disabilities, be
  cognizant of their increased vulnerability and
  watch for signs of maltreatment.

24
Guidance

• Be alert to signs and symptoms of parental
  intimate partner violence and postpartum
  depression.
• Guide parents in providing effective discipline.
• Talk to parents about normal sexual development
  and counsel them about how to prevent sexual
  abuse.
• Encourage caregivers to use the pediatric office
  as a conduit to needed expertise. Become
  knowledgeable about resources in the community,
  and, when appropriate, refer families, especially
  stressed parents, to these resources.

25
Advocacy

• Advocate for community programs and resources
  that will provide effective prevention,
  intervention, research, and treatment for child
  maltreatment and for programs that address the
  underlying problems that contribute to child
  maltreatment (eg, poverty, substance abuse,
  mental health issues, and poor parenting skills).
• Advocate for positive behavioral interventions
  and supports in schools.

26
Practicing Safety An Intervention to Prevent
Child Abuse and Neglect Funded by the Doris
Duke Charitable Foundation
27
Practicing Safety

• Overall Goal
• Decrease child abuse and neglect by increasing
  screening and improving anticipatory guidance
  provided by pediatric practices to parents of
  children ages 0-3.
• Funded by DDCF from 2003-3007
• 9 practices in NJ and PA
• Used Complex Adaptive Theory
• Toolkit consisting of 7 bundles

28
Toolkit Components

• Toolkit included 7 modules with
• Color coded Practice Guides
• Red Coping with Crying/SBS Prevention
• Purple Parenting
• Pink Safety in Others Care
• Blue Family The Environment
• Orange Effective Discipline
• Green Sleeping/Eating Issues
• Aqua Toilet Training
• Parent Educational Materials
• Office Marketing Tools
• Staff tools
• Moderate Interactives/Tangibles
• Issues Management

29
Evaluation

• Pre-Post staff survey
• Pre-Post parent survey
• Chart review
• Toolkit evaluation
• Physician interviews
• Staff focus group interviews

30
Data Analysis

• Staff and physician report of raised awareness
  about child abuse and neglect.
• Staff and parent reports of a significant
  increase in maternal depression screening.
• Toolkit data identified use of Infant crying,
  discipline and toilet training tools with
  families.
• Staff report that maternal drug and alcohol
  issues were generally difficult for practices to
  address although those with established referral
  systems to social workers fared better.
• Most practices noted that the intervention
  program contained too much information.

31
Lessons Learned

• Some type of facilitation is needed to help the
  practices make change.
• Efforts need to be made to spread intervention
  throughout practice.
• 3. AAP brochures, posters and screening tools
  were of most use to practices.
• Need to get the materials into an electronic
  format as well culturally diverse for ease of
  building the materials into the core of the
  practice style.
• Strong need for better connection to community
  resources.

32
Changes in practice

• Raised awareness about child abuse and neglect.
• Maternal depression screening was adopted by 4
  of the 5 pediatric practices. .
• Infant crying, discipline and toilet training
  modules were also implemented by the practices.
• Maternal drug and alcohol issues were generally
  difficult for practices to address although those
  with established referral systems to social
  workers fared better.
• Most practices noted that the intervention
  program contained too much information.

33
Weaknesses

• Focus Groups
• Too much information (and cost of materials)
• Lack of feedback loop from docs back to staff
  and from parents back to staff staff discontent
  with not knowing impact of PS materials/efforts
• No change in roles staff wanted to play a bigger
  role
• Physician Interviews
• Too many meetings
• Materials too wordy, language barriers

34
Practicing Safety Phase II
35
Revised Toolkit

• 3 Bundles
• Infant coping with crying
• Mother/Caregiver maternal depression,
  bonding/attachment
• Toddler effective discipline, toilet training
• Each bundle includes a practice guide as well as
  tools for each topic

36
Infant Bundle
Infant Bundle Coping with Crying Infant Bundle Coping with Crying Infant Bundle Coping with Crying
Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance. Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance. Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance.
Green light Assessment/Screening Anticipatory Guidance -Example How often does your baby cry and how do you handle it? -Provide anticipatory guidance -Welcome to the World of Parenting brochure -Guide for parents Swaddling 101 -Crying poster
Yellow light Parent concerns -Example Who can you call to help when you need a break? -Provide anticipatory guidance -Refer to family strengthening organization
Red light Possible safety concerns for infant Referral to Child Protective Services for evaluation and care management
Introduce at 2 weeks to 4 weeks Reinforce at 2
months Tools are identified by purple font
37
Mother/Caregiver Bundle
Mother/Caregiver Bundle Maternal Depression/Bonding/Attachment Mother/Caregiver Bundle Maternal Depression/Bonding/Attachment Mother/Caregiver Bundle Maternal Depression/Bonding/Attachment
Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance. Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance. Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance.
Green light Assessment/Screening Anticipatory Guidance -Edinburgh Postnatal Depression Scale (EPDS) -Example Is the moms partner available for support? -Example What do you enjoy doing with your baby? -Provide anticipatory guidance -Postpartum Depression Brochure -Refresh. Renew. Recharge Poster -Have you Read to Your Baby today button
Yellow light At risk for depression/lt9 but have concerns/early signs Referral to support system, including PCP, OB, Behavioral health agency, home visiting program
Red light Depression/9 or 1 on Q10/potential risk to self and/or infant Referral to Child Protective Services and/or Behavioral Health agency
Refers to the EPDS Introduce at 2 weeks to 4
weeks Reinforce at 2 and 3 months Tools are
identified by purple font
38
Toddler Bundle Discipline
Toddler Bundle Discipline Toddler Bundle Discipline Toddler Bundle Discipline
Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance. Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance. Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance.
Green light Assessment/ Screening Anticipatory Guidance -Example What makes you lose it with your baby/child? How do you handle it? -How were you disciplined as a child? -Provide anticipatory guidance -Teaching Good Behavior-Tips on Discipline -Play is How Toddlers Learn -Reading. Routine. Relationships. Rewards poster
Yellow light Evidence help is needed/parental frustration/unrealistic expectations -Example How do you handle temper tantrums? -Provide anticipatory guidance -Temper Tantrum brochure -Refer to family strengthening organization
Red light Possible safety concerns for child Referral to Child Protective Services for evaluation and care management
Introduce at 6 months Reinforce at 12, 15, 18,
24, 36 months Tools are identified by purple
font
39
Toddler Bundle Toilet Training
Toddler Bundle Toilet Training Toddler Bundle Toilet Training Toddler Bundle Toilet Training
Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance. Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance. Practice Guide includes care management plan, assessment/screening questions, anticipatory guidance.
Green light Assessment/ Screening Anticipatory Guidance -Example Have you thouhgt about or started toilet training? How is it going? -Provide anticipatory guidance -AAP Toilet Training brochure
Yellow light Evidence help is needed/parental frustration/unrealistic expectations -Provide anticipatory guidance -Potty Chart -Bedwetting Brochure -Refer to family strengthening organization
Red light Possible safety concerns for child Referral to Child Protective Services for evaluation and care management
Introduce at 18 months Reinforce at 2 and 3
years Tools are identified by purple font
40
Practicing Safety Project Aims

• Improve assessment/screening and anticipatory
  guidance by pediatric physicians and staff with
  parents/caregivers on topics of crying, maternal
  depression, toilet training, and discipline (to
  100 by November 2009).
• Test use of the Practicing Safety tools for
  education by pediatric physicians and staff with
  parents/caregivers on topics of crying, maternal
  depression, toilet training, and discipline.
• Test the usefulness of the Practicing Safety
  tools and ease of use of the tools and determine
  strategies for use of the tools.

41
Practicing Safety Project Methods

• Modified Learning Collaborative with 14 teams
  (lead physician plus 2 others from practice)
• Model for Improvement Plan, Do, Study, Act
  small tests of change
• Prework period (April 2009)
• Baseline chart review
• Pre-Inventory Survey
• Learning Session 1(May 2009)
• Action Period (June-November 2009)
• Monthly Chart Review/Chart Documentation Forms
• 10 charts of patients at the 2-month visit
  (infant and mother/caregiver bundles)
• 10 charts of patients at the 18-month visit
  (toddler bundle)
• Monthly Progress Reports
• Monthly Team Calls
• Review of Run Charts to guide improvements
  (posted to a Project Workspace Web site)
• Follow-up (November 2009)
• Post-Inventory Survey
• Post Toolkit Evaluation Survey
• Post-Telephone Interviews

42
Thank you to the 14 Practicing Safety Teams!
Brooklyn, NY Maimonides Infants and Childrens
Hospital-Newkirk Family Health Center Flushing,
NY Flushing Hospital Medical Center
Grand Rapids, MI Helen DeVos Childrens Hospital
General Pediatrics
Longview, WA Child and Adolescent Clinic
Dayton, OH Childrens Health Clinic
New Haven, CT Hospital of Saint Raphael Pediatric
Primary Care Center
Midlothian, VA Pediatric Adolescent Health
Partners
West Reading, PA All About Children Pediatric
Partners PC
Charlotte, NC CMC-Myers Park Pediatrics
Tuscaloosa, AL University Medical Center
Greenville, SC Center for Pediatric Medicine
Bluefield, WV Dr Frazers Office
Houston, TX Lyndon B. Johnson Pediatric Clinic
Brewton, AL Lower Alabama Pediatrics
43

• Practicing Safety Results Assessment/Screening
  and Anticipatory Guidance

44
Infant
45
Mother/Caregiver
46
Toddler Discipline
47
Toddler Toilet Training
48

• Practicing Safety Results Usefulness of Tools

49
Average Respondent Ratings of Practicing Safety
Tool Evaluation Infant Bundle
    Swaddling 101 World of Parenting Coping with Crying Hug, Hold, Comfort, Cuddle
Information/ Content Appropriate Information 3.9 4.6 4.3 4.2
Information/ Content Adequately Comprehensive/ Thorough 4.0 4.4 4.3 4.1
Information/ Content Aids in Patient Care 3.9 4.5 4.3 4.2
Cultural Sensitivity Literacy Level is Appropriate 3.5 3.9 4.5 4.4
Cultural Sensitivity Culturally Appropriate 3.8 4.2 4.4 4.4
Cultural Sensitivity Free of Bias 4.5 4.5 4.6 4.6
Usefulness Readability 3.5 4.1 4.6 4.5
Usefulness Relevant Information 3.9 4.2 4.4 4.4
Usefulness Purpose is Clear 3.9 4.3 4.4 4.4
Usefulness Effective 3.9 4.2 4.3 4.3
  Total (average) 3.9 4.3 4.4 4.3
Key 1 Poor 5 Excellent
50
Average Respondent Ratings of Practicing Safety
Tool Evaluation Mother/Caregiver Bundle
    Post Partum Depression Refresh, Renew, Recharge Edinburgh Postnatal Scale Read to Baby Button
Information/ Content Appropriate Information 4.5 4.1 4.4 3.4
Information/ Content Adequately Comprehensive/ Thorough 4.3 4.1 4.2 3.4
Information/ Content Aids in Patient Care 4.5 4.1 4.5 3.4
Cultural Sensitivity Literacy Level is Appropriate 3.7 4.2 3.6 4.3
Cultural Sensitivity Culturally Appropriate 4.1 4.4 4.1 4.2
Cultural Sensitivity Free of Bias 4.5 4.6 4.3 4.6
Usefulness Readability 4.1 4.2 3.9 4.1
Usefulness Relevant Information 4.2 4.2 4.2 4.2
Usefulness Purpose is Clear 4.6 4.2 4.4 4.3
Usefulness Effective 4.1 4.1 4.4 3.9
  Total (average) 4.3 4.2 4.2 4.0
Key 1 Poor 5 Excellent
51
Average Respondent Ratings of Practicing Safety
Tool Evaluation Toddler Bundle
    Toilet Training Potty Chart Bed-Wetting Teaching Good Behavior Temper Tantrum Playing is Learning Reading, Routine, etc.
Information/ Content Appropriate Information 4.7 4.6 4.2 4.8 4.9 4.7 4.5
Information/ Content Adequately Comprehen-sive/ Thorough 4.6 4.3 4.2 4.7 4.7 4.6 4.5
Information/ Content Aids in Patient Care 4.7 4.5 4.1 4.7 4.8 4.5 4.4
Cultural Sensitivity Literacy Level Appropriate 4.1 4.6 4.3 4.3 4.2 4.4 4.3
Cultural Sensitivity Culturally Appropriate 4.4 4.5 4.4 4.5 4.6 4.6 4.3
Cultural Sensitivity Free of Bias 4.7 4.7 4.6 4.8 4.8 4.7 4.5
Usefulness Readability 4.5 4.7 4.1 4.6 4.6 4.6 4.5
Usefulness Relevant Information 4.7 4.5 4.1 4.7 4.8 4.8 4.4
Usefulness Purpose is Clear 4.8 4.8 4.3 4.8 4.8 4.8 4.6
Usefulness Effective 4.5 4.6 4.0 4.6 4.7 4.6 4.2
  Total (average) 4.6 4.6 4.2 4.6 4.7 4.6 4.4
Key 1 Poor 5 Excellent
52

• Practicing Safety Results Office Systems
  Inventory

53
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54
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55
Average Time spent at 2- and 18-month well child
visits from pre to post intervention
Pre-test Average (n13 practices) Post-test Average (n13 practices) Change in minutes (average)
On average, how much time is spent at a 2-month well child visit (in minutes) 19.2 minutes 20.6 minutes 1.4 minutes
On average, how much time is spent at a 18-month well child visit (in minutes) 21.7 minutes 22.3 minutes 0.6 minutes
56

• Practicing Safety Results Qualitative Themes

57
Qualitative Themes

• Consistent use of PS toolkit
• Systemization of risk
• Changes to chart documentation
• Community resource linkages
• Initiation of meetings
• Improved medical education
• Implementation of QI methodology
• Increased awareness
• Challenges
• Unanticipated positive outcomes

58
Practicing Safety Lessons Learned

• Practices need guidance in order to incorporate
  practice-based protocols that address child abuse
  and neglect prevention as part of well-child care
• Pediatricians, once supported and mentored, are
  excited to offer families more concrete and
  systematic guidance in these areas
• Practicing Safety can inform more successful
  implementation of enhanced care and assists
  practices in establishing a medical home
• Parents are receptive to guidance on these topics
  and believe these issues are of significant
  concern
• Practicing Safety provided an opportunity for
  enhanced clinical education for physicians,
  nurses, residents, etc

59
Practicing Safety Lessons Learned (cont.)

• Practices tailored tools to fit their patient
  population.
• Some practices incorporated tools for more than
  the project prescribed well-child visit based on
  age.
• Some practices collapsed the suggested green
  and yellow assessment questions and
  anticipatory guidance and used both levels
  routinely as primary prevention topics at
  well-visits for all of their families with
  children in the targeted age ranges
• Some practices found a need for multi-lingual,
  low literacy and more graphic materials for
  parents
• Just participating in PS raised awareness of
  child abuse and neglect issues for all roles in
  the pediatric office
• Chart documentation is key to determining
  improvements in care

60
Practicing Safety Lessons Learned (cont.)

• It is important to have an engaged practice
  champion to succeed leadership support, teams
  enhance practice change
• Some practices found it challenging to promote
  the bigger picture of their work to the rest of
  the practice physicians and staff the
  importance of testing and measuring prior to
  full-on implementation
• Administrative and clinical priorities compete
  with making change (H1N1, EMR implementation,
  staff turnover)
• Coding and reimbursement remain a challenge
• The project motivated practices to link with
  community.
• Lastly, practices would like more info on
  diffision.

61
Additional Resources

• Practicing Safety QuIIN Web Page
  http//www.aap.org/qualityimprovement/quiin/Practi
  cingSafety.html
• Project Staff
• Jill Healy, QuIIN Project Manager jhealy_at_aap.org
• Tammy Hurley, Manager, Child Abuse and Neglect
  Prevention Activities thurley_at_aap.org

62
The Safe Environment for Every Kid (SEEK) Model
Pediatricians Preventing Child
Maltreatment Howard Dubowitz, MD, MS Wendy Lane,
MD, MPH Cindy Weisbart, PsyD University of
Maryland School of Medicine
63
The SEEK Model

• Specially trained physicians
• Parent Screening Questionnaire (PSQ)
• Brief assessment of problems
• Initial management
• Physician - social worker team
• Referral to community agencies

64
Introduction to the PSQ

• Provides context We want to help families
  have a safe environment for kids
• Builds on whats accepted injury prevention
• Universal Were asking everyone
• Empathic Being a parent is not easy

65
Parent Screening Questionnaire (PSQ)

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

66
PSQ
67
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?

68
If screen

• PSQ 1-2 questions per problem
• Brief assessment
• Initial management, refer
• A positive screen is not a diagnosis

69
SEEK Study Design
Model Care (Intervention) Trained pediatricians,
Parent Screening Questionnaire, social worker.
All patients receive Model Care
Medical Chart CPS Record Review
Subset of mothers recruited
Randomly assign practices
Initial Survey
6 Mo. Survey
12 Mo. Survey
Standard Care (Control) All patients receive
standard pediatric primary care
70
SEEK HPs

• SEEK I Residents continuity clinics
• SEEK II Private practices in central Maryland
• Agreed for practice to be randomized to
  intervention or control group
• If in intervention group, agreed to attend
  training and implement SEEK

71
SEEK Study Samples

• SEEK I
• 558 families
• Low income, urban
• Mostly African American
• Pediatric resident clinic
• 92 residents

• SEEK II
• 1121 families
• Middle class, mostly suburban
• Mostly white
• 18 pediatric private practices
• 101 pediatricians pediatric nurse
  practitioners

72
Hypothesis 1

• Training physicians to address risk factors
  for CM will significantly improve their
• Attitudes
• Knowledge
• Comfort level
• Perceived competence
• Practice

73
SEEK I Practice BehaviorIntervention vs.
Control Residents
Range 0 - 5
p .03 (pretest - 18 months)
a .72
74
SEEK I Rates that Problems were Screened for
During Regular Checkupsbased on chart review

Depression
Partner Violence
75
SEEK I II PSQ Conclusions

• Very good test - retest reliability
• High sensitivity depression, stress
• Low sensitivity acceptable?
• High specificity - all risk factors
  except food insecurity

76
In Summary

• Improved physician sense of competence and
  screening for risk factors, based on
• Self-report
• Medical chart review
• Direct observation
• In SEEK I and II
• Sustained 18 months after initial training

77

Hypothesis 2

• The SEEK model will help prevent child
  maltreatment

78
Parent-Child Conflict Tactics Scale (CTS PC)

• Parents report of psychological and physical
  aggression in disciplining a child
• Starts with positive approaches, escalates with
  increasingly violent behaviors
• Adequate reliability, validity
• Straus et al, Child Abuse Neglect.
  199822249-70

79
Medical Neglect Non-compliancebased on chart
review (SEEK I)
P 0.05
MD documented non-compliance
80
Medical Neglect Delayed Immunizations based on
chart review (SEEK I)
P 0.002
MD documented
81
Child Protective Services Reports for Abuse or
Neglect (SEEK I)
P 0.03
82
SEEK II CPS Results
Group No CPS Reports Pre-SEEK CPS Reports Only During SEEK CPS Reports Only Pre and During SEEK CPS Reports
n (row ) n (row ) n (row ) n (row )

Interven-tion 579 (95) 15 (3) 8 (1) 7 (1)

Control 519 (98) 6 (1) 3 (0.6) 2 (0.4)
P 1.0 using Fishers exact test
83
Closing thoughts

• Practices can incorporate screening and guidance
  into their practices
• Focused engagement in child abuse prevention
  shows promise
• Reimbursement issues need to be addressed
• It appears that more than one model on practice
  improvement can be effective

84
The Road Ahead .

• Further replication, evaluation, refinement
• Prioritize resident continuity clinics
• Begin pre-natally
• SEEKING SAFETY- combine the elements of the two
  models
• Broad outcomes based study of at least 100
  practices

85
Thank you!

• Questions