1. 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

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

5. SEEK a 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 Why problem is important – prevalence, impact How to briefly assess – risk & protective factors What to do – initial management, 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 Subset of mothers recruited Model Care (Intervention) Trained pediatricians, Parent Screening Questionnaire, + social worker. All patients receive Model Care Initial Survey 6 Mo. Survey Medical Chart & CPS Record Review Standard Care (Control) All patients receive standard pediatric primary care Randomly assign practices 12 Mo. Survey

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

19. SEEK Samples Parent Demographic Characteristics SEEK I SEEK II N 558 1119 Demographicslow income, urbanmiddle class, suburban Racemostly African Americanmostly white Mean age25 years33 years Education66% high school or more90% college or more Employed37 %55 % Marital status-88 % Married Family income- 56% > $75,000

20. SEEK Samples Child Demographic Characteristics SEEK I SEEK II N5581119 Mean age0.5 years1.6 years Gender52% male Race92% African American 81% white Insurance93 % Medicaid91% private

21. Parental Self-Report SEEK 1 SEEK II* Psychological Aggression Physical Assault - minor Physical Assault - severe * 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) † MD documented this * P = 0.002

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 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 Crying Model 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 KnowledgePURPLE Control Crying 69% 63% Shaking 85% 83%

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