howard dubowitz, md, ms university of maryland school of medicine
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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. - PowerPoint PPT PresentationTRANSCRIPT
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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
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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”
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The Potential of Prevention
Effective prevention
should yield
many benefits, including
child abuse & neglect
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of child maltreatment
Prevention
Promotionof children’s health, development and safety
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SEEKa Safe Environment for
Every KidPediatric Primary Care
Dubowitz et al, Pediatrics, 2009;123:858
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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
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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
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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
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Training Primary Care Professionals
• Why problem is important
– prevalence, impact
• How to briefly assess
– risk & protective factors
• What to do
– initial management, referrals
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Targeted Psychosocial Problems
Parents who may be experiencing:
• Major stress
• Depression
• Substance abuse
• Intimate partner (domestic) violence
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Parent Screening Questionnaire (PSQ)
• brief • easy to read• answer yes/no• convenient, time to complete• voluntary
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PSQ
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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
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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?
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When to screen?
• Regular checkups
• Not “sick visits”
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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
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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
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Participants
• Mothers of children < 6 years
• English speaking
• Child not in foster care
• Bringing child for a checkup
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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
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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
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Parental Self-Report
SEEK 1 SEEK II*
PsychologicalAggressionPhysical Assault - minorPhysical Assault - severe
* Initially and at 12 months
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Medical Neglect: Non-compliance†
based on chart review (SEEK I)
0123456789
10
Before After*
%
InterventionControl
* P = 0.05† MD documented “non-compliance”
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Medical Neglect: Delayed Immunizations†
based on chart review (SEEK I)
0123456789
10
Before After*
%
InterventionControl
† MD documented this * P = 0.002
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Child Protective Services Reports for Abuse or Neglect (SEEK I)
0
5
10
15
20
25
Before After*
%
InterventionControl
* P = 0.03
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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
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SEEK - Limitations
• Low prevalence of risk factors in low risk sample
• Cost of social worker
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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
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Programs for parents of newborns to prevent abusive head trauma
(AHT)
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Known cases – tip of the iceberg
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AHT IncidenceAHT Incidence
17
2600
0
1000
2000
3000
Rat
e pe
r 100
,000
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
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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
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Limitations of Dias studyLimitations of Dias study
• Many parents not exposed
• Decrease due to other factors?
• Generalizable?
• Reproducible?
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The Period of The Period of PURPLE CryingPURPLE Crying
ModelModel
Peak patternUnexpected onsetResistance to soothingPain-like grimaceLong crying boutsEvening clustering
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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
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PURPLE EvaluationPURPLE Evaluation
Knowledge PURPLE Control
Crying 69% 63%
Shaking 85% 83%
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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
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PURPLE Strengths
• Large evaluations
• Randomized trials
• Fidelity to model
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PURPLE LimitationsPURPLE Limitations• Evaluation limited to mothers
• Small differences in knowledge, behavior - self report
• No SBS or AHT outcomes
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Can/should these programs be applied in
Israel?
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Toda [email protected]