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

1. The Prevention of Child Maltreatment:Two Strategies in the Child Healthcare SystemHaruv Institute Conference Jerusalem May 2010 Howard Dubowitz, MD, MS University of Maryland School of Medicine

2. 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”

3. The Potential of Prevention Effective prevention should yield many benefits, including child abuse & neglect

4. Prevention of child maltreatment Promotion of children’s health, development and safety

5. SEEKa Safe Environment for Every Kid Pediatric Primary Care Dubowitz et al, Pediatrics, 2009;123:858

6. 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

7. 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

8. 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

9. Training Primary Care Professionals • Whyproblem is important • prevalence, impact • How to briefly assess • risk & protective factors • What to do • initialmanagement, referrals

10. Targeted Psychosocial Problems Parents who may be experiencing: • Major stress • Depression • Substance abuse • Intimate partner(domestic) violence

11. Parent Screening Questionnaire (PSQ) • brief • easy to read • answer yes/no • convenient, time to complete • voluntary

12. PSQ

13. 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

14. 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?

15. When to screen? • Regular checkups • Not “sick visits”

16. 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

17. 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

18. Participants • Mothers of children < 6 years • English speaking • Child not in foster care • Bringing child for a checkup

19. SEEK SamplesParent Demographic Characteristics 56% > $75,000

20. SEEK SamplesChild Demographic Characteristics

21. Parental Self-Report * Initially and at 12 months

22. Medical Neglect: Non-compliance†based on chart review (SEEK I) * P = 0.05 † MD documented “non-compliance”

23. Medical Neglect: Delayed Immunizations† based on chart review (SEEK I) * P = 0.002 † MD documented this

24. Child Protective Services Reports for Abuse or Neglect (SEEK I) * P = 0.03

25. 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

26. SEEK - Limitations • Low prevalence of risk factors in low risk sample • Cost of social worker

27. 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 maltreatment Dubowitz et al, Pediatrics, 2009;123:858

28. Programs for parents of newborns to prevent abusive head trauma (AHT)

29. Known cases – tip of the iceberg

30. AHT Incidence • 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

31. The 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

32. Limitations of Dias study • Many parents not exposed • Decrease due to other factors? • Generalizable? • Reproducible?

33. The Period of PURPLE CryingModel Peak pattern Unexpected onset Resistance to soothing Pain-like grimace Long crying bouts Evening clustering

35. PURPLE 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

36. PURPLE Evaluation

37. PURPLE 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

38. PURPLE Strengths • Large evaluations • Randomized trials • Fidelity to model

39. PURPLE Limitations • Evaluation limited to mothers • Small differences in knowledge, behavior - self report • No SBS or AHT outcomes

40. Can/should these programs be applied in Israel?

41. Toda Raba hdubowitz@peds.umaryland.edu