1. September 28, 2018 Howard Dubowitz, MD, MS, FAAP
The Safe Environment for Every Kid (SEEK) Model: Promoting Children’s Health, Development and Safety Strengthening Society through Stronger Parenting University of Maryland School of Social Work
September 28, 2018
Howard Dubowitz, MD, MS, FAAP

2. How can we help prevent children from being abused and neglected?

3. SEEK Goals To help address prevalent psychosocial problems
To support parents and parenting
To strengthen families
To promote children’s health, development, safety
To prevent child abuse and neglect

4. Pediatric Primary Care: An Opportunity to Promote Children’s Health, Development and Safety
Well accepted, institutionalized
Multiple visits (1st few yrs.)
Goal of prevention
Concern with child, family
Special relationship with family
No stigma
An opportunity and a responsibility

5. Core Components of the SEEK Model
SEEK trained medical professionals
SEEK Parent Questionnaire - R
Brief assessment of identified problems
Motivational interviewing principles
Initially help address problems
Integrated medical and behavioral health - ideal
Knowledge of community resources
SEEK Parent Handouts

6. Targeted Psychosocial Problems
Depression
Major parental stress
Substance abuse
Intimate partner (domestic) violence
Harsh punishment
Food insecurity

7. SEEK Parent Questionnaire - R (PQ-R)
Evidence-based
Brief
Easy to read
Answer yes/no
Convenient
Confidential

8. SEEK PQ-R 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
Voluntary
Confidential

9. How SEEK Works At start of visit, parent given SEEK PQ-R
Parent completes PQ-R while waiting
Parent gives PQ-R to doctor or nurse
Identified problems addressed by medical professional or social worker
SEEK Parent Handout
Referral to community agencies
Follow up

10. The Evidence Supporting SEEK

11. Two Randomized Controlled Trials
SEEK I
Pediatric resident continuity clinic
Inner city, low income
558 African American families
SEEK II
18 private practices
Suburban, middle income
1119 mostly white families

12. Hypothesis The SEEK model of primary care will
help prevent maltreatment, measured by:
Parent self-report
Medical record data
Child protective services (CPS) reports
Dubowitz et al, Pediatrics, Dubowitz et al, Acad. Peds, 2012

13. Study Design SEEK (Intervention) Standard Care (Control) Initial
Trained PCPs, PQ, + social worker
Medical Chart & CPS Record Review
Subset of mothers recruited
Randomly assign
practices
Initial
Survey
6 Mo. Survey
12 Mo. Survey
Title to deep blue consistent with earlier titles.
This is a good slide.
Just fixed one of the arrows to make it meet Randomly assign practices in same spot as other arrow.
Finally, I would center text within figure boxes which you did in all but the first box. I did it in that box.
Standard Care (Control)

14. SEEK I: Conflict Tactics Scale – Parent Child
Control
(n = 250)
Mean (SD) P
Psychological Aggression
7.5 (14.9)
9.1 (16.4) ns
Physical Assault
- Minor
3.5 (8.3)
5.0 (12.4)
- Severe or Very Severe
0.11 (0.75)
0.33 (1.96)
0.04*
CTS-PC Subscale
Effect size =1.6/15
.22/1.3=
* One-tailed t-test

15. Psychological Aggression
SEEK II: CTS-PC
Psychological Aggression
Mean no. of incidents per family
* P < .05
** P < .01
B = -0.16**
B = -0.06
B = -0.12*
P values based on a mixed effects regression model, including random effects for family and practice, controlling for child’s race and age, family income, mother’s education and marital status. Std. Bs represent differences between SEEK and controls in SD units.

16. Minor Physical Assault
SEEK II: CTS-PC
Minor Physical Assault
* P < .05
B = -0.16*
B = -0.08
B = -0.14*
P values based on a mixed effects regression model, including random effects for family and practice, controlling for child’s race, age, family income, mother’s education and marital status. Std. Bs represent differences between SEEK and control in SD units.

17. Medical Neglect: Non-compliance1 from chart review (SEEK I)
1MD documented “non-compliance”
* P < 0.05

18. Medical Neglect: Delayed Immunizations1 from chart review (SEEK I)
1 MD documented
* P = 0.002

19. Child Protective Services (CPS) Reports for Abuse or Neglect (SEEK I)
* One-tailed t-test
* P = 0.04

20. “How can I do all this in 5 minutes?”

21. Time Spent on Psychosocial Issues
Average time during SEEK II 21

22. Cost Analysis SEEK: cost $210 per case prevented
Compare to $14,520 ($1,993 – $21,400) for medical & mental health for one physically abused or psychologically maltreated child
SEEK is cost saving
Lane WG, Frick K, Dubowitz H, et al American Public Health Association 139th Annual Meeting and Exposition. Washington, DC. Nov
I thought that cost-benefit may still be useful because it’s a far broader analysis?
WGL – we started to do the cost benefit analysis – but in discussions with Kevin, he indicated that it is not necessary given that we’ve demonstrated cost savings, and the cost-benefit results are difficult to interpret (e.g. cost per QALY is negative b/c it is cost saving).
My use of cost saving here wasn’t intended to be an economic term, just stating that the program saves money.

23. Bringing Back the Social History
SEEK Parent Questionnaire - R
Systematic
Structured (checklist)
Targeted

24. In Sum
Pediatric primary care offers a good opportunity to address prevalent psychosocial problems
SEEK offers a practical model to improve primary care
SEEK can prevent:
Harsh parenting
Child abuse and neglect
SEEK promotes children’s health, development, safety

25. Thank You!