Screening for parental substance abuse in pediatric primary care

Characterizing Referrals to Mental and Behavioral Health and Community Resources in Urban Pediatric Primary Care

OBJECTIVE

Examine patient characteristics and practice processes associated with referrals to social and behavioral health resources in an urban/inner-city primary care pediatric practice.

METHOD

Retrospective chart review was conducted on Safe Environment for Every Kid (SEEK) screening and immediate and later clinician responses to positive screens (documented by the practice's early relational health specialist) from well-child visits for children 6 months to 6 years. Bivariate and multivariate analyses were used to examine associations between demographics, screening results, and referral acceptance.

RESULTS

Of 1104 SEEK screens, 152 (13.8%) were excluded for incomplete screens and 25 (2.3%) for duplicate caregiver screens. Of 927 included, responses were discussed at the time of screening for 286 (30.9%, "immediate") and/or attempted to be discussed at a later time by phone for 397 (42.8%, "later," median 11 days [interquartile range 6-19] between screen and discussion); 14 (1.5%) had both forms of contact; and 230 (24.8%) had no documented discussion at any time. Demographics were similar across groups. Clinician discussion was more likely if caregivers reported harsh punishment (p = 0.036), caregiver stress (p < 0.001), or caregiver depression (p < 0.001) on screen. After clinician discussion, referral was offered and subsequently accepted by 225 of 697 caregivers (32.3%). Each additional stressor endorsed increased odds of accepting referral by 25% (95% confidence interval, 1.07-1.47). Referrals to parenting groups, social needs navigation support, and social work were completed by 33 of 68 (48.5%) referred families.

CONCLUSION

Safe Environment for Every Kid screening in urban pediatric primary care can be used to identify families' unmet social and behavioral health care needs to provide support.

Dual Psychosocial Screening of the Adolescent Patient by Implementing the Safe Environment for Every Kid Teen Questionnaire

OBJECTIVE

This study introduces the SEEK Teen Questionnaire, expanding the Safe Environment for Every Kid (SEEK) approach to include adolescent perspectives alongside caregiver responses for dual psychosocial screening. The objective of this study was to triangulate adolescent responses with those of their caregivers to demonstrate the benefits of dual psychosocial screening.

METHODS

The SEEK Teen Questionnaire was developed by integrating input from primary care and adolescent medicine professionals, national experts, and adolescent stakeholders. The resulting 32-item psychosocial screening tool was administered to adolescent patients aged 11-18 during well visits simultaneously with caregiver completion of the SEEK Parent Questionnaire from August to October, 2022 with interventions offered for identified problems. Responses were compared using McNemar's and Fisher's exact tests.

RESULTS

Four hundred and eighty caregivers and adolescents consented to the study. Participants were generally white (64%), non-Hispanic (81%), and privately insured (62%). Adolescents had a high completion rate (97%) with concordant responses among matched caregivers between 83% and 96%. Among discordant dyads, adolescents disclosed concerns for their caregivers more commonly than caregivers expressed for themselves: discipline (83% vs. 17%, P<0.001), food insecurity (71% vs. 29%, P=0.09), intimate partner violence (78% vs. 22%, P<0.018), stress (81% vs. 19%, P<0.001), depression (64% vs. 36%, P=0.12), and substance misuse (91% vs. 9%, P<0.001).

CONCLUSIONS

This study demonstrates adolescents' willingness to provide insights into their caregivers' well-being and their high awareness of stressors affecting them. Incorporating adolescent perspectives enhances the identification of issues that may otherwise go unnoticed, underscoring the importance of dual psychosocial screening during adolescence.

Caregivers' Perceptions of Child Trauma Symptomatology, Stress, and Child Abuse Disclosures

Caregivers consider child abuse disclosures stressful life events, but research has not investigated whether this stress affects caregiver ratings of child trauma symptomatology. Secondary data from a Child Advocacy Center in the Midwestern United States between the period of January 1, 2018, and April 31, 2019, stepwise logistic regression models, and change in estimate calculations were used to assess (1) the relationship between child abuse disclosure(s) and caregiver stress and (2) the association between caregiver stress disclosure and clinically significant ratings on the Trauma Symptom Checklist for Young Children (TSCYC). While a child's physical abuse disclosure was associated with caregiver stress and caregiver stress was significantly associated with clinically significant ratings for child depression and anger/aggression TSCYC scales, abuse disclosure did not affect the relationship between caregiver stress and TSCYC scale ratings. Moving forward, caregiver-reported stress should be considered when utilizing caregiver-completed child trauma symptom screens.

Validation of the Swedish version of the safe environment for every kid (SEEK) parent screening questionnaire

BACKGROUND

Psychosocial risk factors in the home may impair children's health and development and increase the risk of maltreatment. The Safe Environment for Every Kid (SEEK) model was developed to provide pediatric primary care professionals with a structured way to identify common psychosocial problems. The SEEK model includes use of the Parent Screening Questionnaire (SEEK-PSQ) at routine preventive child health visits, discussion with parents about their responses and, when indicated, referral to relevant services. The SEEK-PSQ has not previously been available in Swedish. The aim of the present study was to evaluate the psychometric properties of an adapted Swedish version of the SEEK-PSQ (PSQ-S).

METHODS

This study is part of a cluster-randomised controlled trial of SEEK in the Swedish child health services. To validate the PSQ-S, parents (n = 852) with children 0-18 months of age were invited to complete a survey including the PSQ-S as well as evidence-based standardized instruments for the targeted psychosocial risk factors: economic worries, depressive symptoms, parental stress, alcohol misuse and intimate partner violence (IPV). Baseline data from 611 (72%) parents were analysed regarding sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each risk factor.

RESULTS

As a whole, the PSQ-S had a sensitivity of 93%, specificity of 52%, PPV of 67% and NPV of 87%. For mothers and fathers combined, sensitivity was 80% for economic worries, 89% for depressive symptoms, 78% for parental stress, 47% for intimate partner violence (IPV) and 70% for alcohol misuse. Specificity was highest for IPV and alcohol misuse (91%) and lowest for depressive symptoms (64%). NPV values were high (81-99%) and PPV values were low to moderate (22-69%) for the targeted problems. Sensitivity was higher for mothers compared to fathers for economic worries, depressive symptoms and IPV. This difference was particularly evident for IPV (52% for mothers, 27% for fathers).

CONCLUSION

The SEEK-PSQ-S demonstrated good psychometric properties for identifying economic worries, depressive symptoms, parental stress and alcohol misuse but low sensitivity for IPV. The PSQ-S as a whole showed high sensitivity and NPV, indicating that most parents with or without the targeted psychosocial risk factors were correctly identified.

TRIAL REGISTRATION

ISRCTN registry, study record 14,429,952 ( https://doi.org/10.1186/ISRCTN14429952 ) Registration date 27/05/2020.

Addressing Adverse Childhood Experiences in Primary Care: Challenges and Considerations

This article draws attention to the overlapping literature on social determinants of health and adverse childhood experiences, and the growing clinical interest in addressing them to promote children's and parents' health and well-being. We address important considerations and suggest solutions for leaders and practitioners in primary care to address social determinants of health/adverse childhood experiences. Priorities include: begin with a few prevalent conditions for which there are helpful resources; focus on conditions that are current or recent and where parents may be more apt to engage in services; focus initially on families with children aged <6 given the frequency of well-child visits and the especially strong relationships between primary care professionals and parents during this period; ensure training of primary care professionals and staff to help them play this role competently and comfortably; and have good referral processes to facilitate additional evaluation or help.

Factors Related to Providers Screening Children for Behavioral Health Risks in Primary Care Settings

PURPOSE

To provide information from a large sample of pediatric and family medicine primary care providers on practices in screening children for behavioral health risks.

DESIGN AND METHODS

Participants were a sample of physicians (n=319) and nurse practitioners (n=292) from across the U.S. who completed a confidential online survey about screening practices through a computer-assisted self-interview.

RESULTS

Almost all respondents (89%) reported screening children for depression/anxiety and behavior problems. Child substance use (82%), family social support (74%), significant household changes (73%), bullying (72%), child abuse (62%) and domestic violence (52%) were also asked about regularly, although with high rates of informal screening methods. Caregiver mental health (49%), caregiver substance use (35%), family financial strain (33%) and transportation difficulties (27%) were screened less frequently. Screening was associated with higher rates of referral for risk-related problems, and was more likely when providers reported greater confidence providing support to clients, perceived community resource availability as higher, and worked in systems with integrated primary care and behavioral health.

CONCLUSIONS

Findings suggest a great amount of diversity in how providers screen for behavioral health risks. There is reluctance to screen when options for addressing the problems are seen as limited. Research is needed to better guide healthcare providers in determining the right context and methods for screening social risks.

PRACTICE IMPLICATIONS

Protocols for screening adverse childhood events (ACES) and other social risk factors should be accompanied by adequate training and efforts to improve community resource and support networks.

Toward Improved Identification of Parental Substance Misuse: An Examination of Current Practices and Gaps in One US State

INTRODUCTION

The use of illicit substances, including opioids, is a serious public health issue in the United States. While there are reports of the impact of the ongoing opioid crisis on adults, a new focus has emerged on how parental substance misuse (PSM) affects children. This study explored existing screening and assessment practices and services for children and families affected by PSM across different service sectors in one state. The purpose of the study was to identify opportunities for training, policy development, and practice improvement related to identifying PSM and linking children and parents to services.

METHODS

Interviews (n = 15) with professionals from five service sectors (mental health, primary care, schools, community programs, and law enforcement) were used to inform development of a state-wide survey of the same groups (n = 498) to assess current practices, attitudes, knowledge, and training needs related to child screening of PSM. The survey was piloted using cognitive interviewing (n = 9) before it was distributed.

RESULTS

Fewer than 20% of survey respondents reported using standardized tools specific to screening PSM. Informal assessment practices predominate, though 60% of respondents saw value in adopting more standardized PSM screening. Attitudes about PSM and screening varied among sectors but interest in training was high.

DISCUSSION

Results indicate a need for more systematic PSM screening, cross-sector training and practice discussions, and policies to support early identification of children affected by PSM. Ramifications of these findings and recommendations are discussed.

Identifying intervention strategies for preventing the mental health consequences of childhood adversity: A modified Delphi study

Exposure to childhood adversity is a powerful risk factor for psychopathology. Despite extensive efforts, we have not yet identified effective or scalable interventions that prevent the emergence of mental health problems in children who have experienced adversity. In this modified Delphi study, we identified intervention strategies for effectively targeting both the neurodevelopmental mechanisms linking childhood adversity and psychopathology - including heightened emotional reactivity, difficulties with emotion regulation, blunted reward processing, and social information processing biases, as well as a range of psychopathology symptoms. We iteratively synthesized information from experts in the field and relevant meta-analyses through three surveys, first with experts in intervention development, prevention, and childhood adversity (n = 32), and then within our study team (n = 8). The results produced increasing stability and good consensus on intervention strategy recommendations for specific neurodevelopmental mechanisms and symptom presentations and on strength of evidence ratings of intervention strategies targeting youth and parents. More broadly, our findings highlight how intervention decision making can be informed by meta-analyses, enhanced by aggregate group feedback, saturated before consensus, and persistently subjective or even contradictory. Ultimately, the results converged on several promising intervention strategies for prevention programming with adversity-exposed youth, which will be tested in an upcoming clinical trial.

The Mitigating Toxic Stress study design: approaches to developmental evaluation of pediatric health care innovations addressing social determinants of health and toxic stress

Background

Health care administrators must establish and promote effective partnerships with community agencies to address social determinants of health, including reducing exposure of infants and young children to chronic stress. Because infants’ experiences are inextricably tied to their caregivers, an important target for mitigating “toxic” stress exposure in early childhood is through reducing parents’ experiences of chronic stress in addition to protecting children from direct experiences of harm such as physical or sexual abuse. Conducting screening to identify when children are exposed to early life adversity is a first step; connecting families to needed support services is an essential component to addressing identified challenges. This paper presents the methodology of a three-year study of health care systems innovations designed to engage and support parents of infants to prevent and mitigate children’s toxic stress exposures.

Methods

Key study features included: 1) multi-component study in five U.S. communities and nine pediatric health care clinics and the families they serve, 2) a developmental evaluation approach to describe how innovations are experienced over time at three levels—community systems, pediatric providers, and families, and 3) rapid cycle feedback conducted with communities, clinics and families to co-interpret data and findings. Data sources included: 1) focus groups and interviews with community stakeholders, clinic staff, and families, 2) electronic health record and Medicaid services data extracted to assess health care quality, utilization, and financial impact, and 3) clinic-recruitment of 908 parents of infants in a longitudinal survey. Results. The sample is briefly characterized based on responses to the enrollment phase of the parent survey.

Conclusions

We discuss the study design elements’ contribution to generating evidence needed by innovators, communities, and clinics to modify and sustain investments in these innovations to prevent or mitigate the effects of exposure to toxic stress on young children.

Co-located Parent Coaching Services Within Pediatric Primary Care: Feasibility and Acceptability

INTRODUCTION

This project assessed the feasibility and acceptability of Parent Connext, a positive parenting program that integrates screening and co-located parent coaching within pediatric primary care.

METHOD

Eleven practices implemented Parent Connext in phases between November 1, 2016, and July 31, 2019. Screening and surveillance for parenting and family psychosocial concerns were performed during patient visits. Providers responded with brief motivational interviewing and referral. Parenting Specialists provided individualized parent coaching to referred caregivers.

RESULTS

Screens were completed at 13,346 (65%) targeted visits, with 26% positive for concerns. Parent coaching was provided to 1,301 of 2,711 (48%) referred families (average 2.2 sessions per family). Providers and staff felt significantly more supported, confident, and knowledgeable about addressing parenting and family psychosocial concerns after implementing Parent Connext and felt the program improved their relationships with families and quality of care.

DISCUSSION

Co-located parent coaching was found to be a feasible and worthwhile addition to pediatric primary care.

Social determinants of health, personalized medicine, and child maltreatment

This review begins with a brief summary of the importance of child maltreatment as a major public health problem, given its prevalence and the substantial human and economic costs involved. The focus then shifts to consideration of personalized medicine and child maltreatment, including genetic and genomics factors, as well as the role of social determinants of health. Research on epigenetics related to child abuse and neglect is presented, followed by that pertaining to a few specific social factors, such as poverty, parental depression and substance use, and domestic (or intimate partner) violence. The review ends with a discussion of interventions to help address social determinants of health with brief descriptions of several model programs, and thoughts concerning the role of personalized medicine in addressing child maltreatment in the foreseeable future. IMPACT: This paper synthesizes knowledge on social determinants of health and advances in genetics and genomics related to the prevention of child maltreatment. It provides examples of model approaches to addressing the prevention of child maltreatment in primary care practices.

Protocol for comparing two training approaches for primary care professionals implementing the Safe Environment for Every Kid (SEEK) model

BACKGROUND

Child maltreatment (CM) is a major public health problem, affecting many lives, in the short and long term, and costing individuals, families, and society dearly. There is a need for broad implementation of evidence-based preventive interventions, such as the Safe Environment for Every Kid (SEEK) model, developed for pediatric primary care. Primary care offers an excellent opportunity to help address prevalent psychosocial problems (e.g., parental depression) that are risk factors for CM. By addressing such problems, SEEK can strengthen families and support parents; promote children's health, development, and safety; help prevent CM; and benefit the health of the US population. This study will examine intervention strategies for optimizing SEEK's adoption, implementation, and sustainment, and its effectiveness in preventing CM.Despite strong evidence from two federally funded randomized controlled trials, SEEK has not been widely adopted. The goal of this study is to examine technology-driven implementation strategies to scale-up SEEK-in pediatric and family medicine primary care settings. The aims are to (1) evaluate the effectiveness of training strategies on SEEK's implementation in primary care practices, (2) evaluate barriers and facilitators to successful implementation and sustainment of SEEK, and (3) examine the model's effectiveness in preventing CM and the economic costs of implementing SEEK.

METHODS

This randomized type III hybrid mixed methods design will examine how advances in medical training can bolster SEEK's adoption and implementation in pediatric and family medicine practices in different regions of the USA. These are independent online training and in-depth structured training via a quality improvement project, approved by the American Boards of Pediatrics and of Family Medicine. We will also evaluate SEEKonline, software that assists primary care practitioners implement the model, and a "Traditional" paper and pencil strategy for their impact on implementation. The study uses the EPIS framework and the Universal Stages of Implementation Completion, quantitative measures, qualitative interviews, and data abstracted from electronic health records.

DISCUSSION

The knowledge gained should improve pediatric primary care to better address prevalent social determinants of health, benefiting many children and families. The outcomes should enhance the field of implementation science and guide future interventions in primary care.

TRIAL REGISTRATION

NCT03642327, Clinical Trials, registered August 21, 2018.

Screening for Unhealthy Drug Use: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Illicit drug use is among the most common causes of preventable morbidity and mortality in the US.

OBJECTIVE

To systematically review the literature on screening and interventions for drug use to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Central Register of Controlled Trials through September 18, 2018; literature surveillance through September 21, 2019.

STUDY SELECTION

Test accuracy studies to detect drug misuse and randomized clinical trials of screening and interventions to reduce drug use.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal and data abstraction by 2 reviewers and random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, drug use and other health, social, and legal outcomes.

RESULTS

Ninety-nine studies (N = 84 206) were included. Twenty-eight studies (n = 65 720) addressed drug screening accuracy. Among adults, sensitivity and specificity of screening tools for detecting unhealthy drug use ranged from 0.71 to 0.94 and 0.87 to 0.97, respectively. Interventions to reduce drug use were evaluated in 52 trials (n = 15 659) of psychosocial interventions, 7 trials (n = 1109) of opioid agonist therapy, and 13 trials (n = 1718) of naltrexone. Psychosocial interventions were associated with increased likelihood of drug use abstinence (15 trials, n = 3636; relative risk [RR], 1.60 [95% CI, 1.24 to 2.13]; absolute risk difference [ARD], 9% [95% CI, 5% to 15%]) and reduced number of drug use days (19 trials, n = 5085; mean difference, -0.49 day in the last 7 days [95% CI, -0.85 to -0.13]) vs no psychosocial intervention at 3- to 4-month follow-up. In treatment-seeking populations, opioid agonist therapy and naltrexone were associated with decreased risk of drug use relapse (4 trials, n = 567; RR, 0.75 [95% CI, 0.59 to 0.82]; ARD, -35% [95% CI, -67% to -3%] and 12 trials, n = 1599; RR, 0.73 [95% CI, 0.62 to 0.85]; ARD, -18% [95% CI, -26% to -10%], respectively) vs placebo or no medication. While evidence on harms was limited, it indicated no increased risk of serious adverse events.

CONCLUSIONS AND RELEVANCE

Several screening instruments with acceptable sensitivity and specificity are available to screen for drug use, although there is no direct evidence on the benefits or harms of screening. Pharmacotherapy and psychosocial interventions are effective at improving drug use outcomes, but evidence of effectiveness remains primarily derived from trials conducted in treatment-seeking populations.

Adverse childhood experiences and their relationship to complex health profiles among child welfare-involved children: A classification and regression tree analysis

OBJECTIVE

To identify the clustering of adverse childhood experiences (ACEs) that best characterize child welfare-involved children with known complex health concerns.

DATA SOURCE

Multi-informant data were obtained from Wave I of the National Survey of Child and Adolescent Well-Being (NSCAW II).

STUDY DESIGN

This study used a cross-sectional design and classification and regression tree (CART) analyses.

DATA COLLECTION

Data were collected from families with children, aged birth to 17, investigated for child maltreatment and their child protective services caseworkers, including demographic characteristics of the children, their histories of adversity, and a wide range of health concerns.

PRINCIPAL FINDINGS

Results indicate that for children between the ages of six and 17, experiences of physical abuse alone, as well as experiences of physical abuse combined with having a caregiver with mental illness, are most strongly associated with complex health concerns. For children aged 2-5 years, results suggest that caregiver mental illness is a key adverse experience associated with complex health concerns.

CONCLUSIONS

Identifying specific combinations of ACEs may be a critical next step for child- and youth-serving agencies to allow providers to better calculate risk of health problems among children exposed to adversity.

Psychosocial Factors Associated with Healthy and Unhealthy Interpregnancy Intervals

Purpose: To examine the influence of psychosocial factors, including anxiety, depression, social support, maternal substance abuse, and intimate partner violence (IPV) on interpregnancy intervals (IPIs).

Methods: B'more for Healthy Babies–Upton/Druid Heights is part of a citywide initiative to improve the health of at-risk pregnant women and their children. Participants with at least one prior birth completed baseline, postpartum, and 3-month follow-up surveys with questions about pregnancy, medical, and psychosocial history. Associations between IPI and the independent variables were assessed using chi-square analysis and analysis of variance. Multivariable multinomial logistic regression models examined significant associations while controlling for other independent variables and potential confounders.

Results: Participants with current IPV were more likely to have a short IPI (odds ratio [OR]=13.1; 95% confidence interval [CI]=1.07–158.9; p=0.04) than healthy IPI. Women with family social support were more likely to have a healthy IPI (OR=5.88, 95% CI=1.02–31.25, p=0.05) than those without family social support. Maternal anxiety and depression did not significantly influence IPI.

Conclusion: IPV increased the likelihood of having an unhealthy IPI among this population and family social support increased the likelihood of having a healthy IPI. Additional efforts to address IPV and enhance family social support may lead to improved pregnancy outcomes.

The influence of maternal life stressors on breastfeeding outcomes: a US population-based study

OBJECTIVE

The purpose of this study was to examine the contribution of maternal financial, emotional, traumatic, and partner-associated stressors on breastfeeding initiation and duration.

METHODS

Data (216,756 records) from the Pregnancy Risk Assessment Monitoring System surveys were used in the analysis. Logistic regressions were conducted to estimate the magnitude and direction of associations between maternal stressors occurring in the 12 months prior to infant birth and both breastfeeding initiation and duration up to 4 weeks infant age.

RESULTS

A substantial proportion of mothers (42%) reported having experienced one or two major stressors during the 12 months prior to the birth of their infant. Mothers who reported at least one major life stressor in the year before their baby was born were less likely to initiate breastfeeding and more likely to cease by 4 weeks infant age. Emotional and traumatic stressors were found to have the greatest impact on breastfeeding outcomes.

CONCLUSIONS

Findings support the design and implementation of screening protocols for major maternal life stressors during regularly scheduled prenatal and newborn visits. Screening for at-risk mothers may lead to more targeted anticipatory guidance and referral with positive effects on breastfeeding outcomes and overall well-being of the mothers and their families.

Parental Opioid Abuse: Barriers to Care, Policy, and Implications for Primary Care Pediatric Providers

Parental opioid use is affecting the physical, developmental, and mental health of the pediatric population nationwide and raises questions of safety when these children remain in the care of opioid-addicted parents. Pediatric providers face many barriers to identifying and caring for children beyond the neonatal period who have been affected by parental opioid abuse both in utero and in the home. These barriers include communication between providers and services, identification of intrauterine exposure, parental opioid abuse screening, and knowledge of child protective services involvement. In addition, understanding current state and national health policy regarding parental opioid abuse helps providers navigate these barriers. The purpose of this article is to identify barriers to care of children affected by parental opioid abuse both in utero and in the home, to discuss current health policy surrounding the issue, and to identify implications for the care of these children in the primary care pediatric setting.

Child Maltreatment Screening and Anticipatory Guidance: A Description of Pediatric Nurse Practitioner Practice Behaviors

INTRODUCTION

Given the number of children affected by child maltreatment and the dire consequences that can develop, prompt identification of child maltreatment is crucial. The purpose of this study was to describe pediatric nurse practitioner (PNP) practice behaviors related to screening and providing anticipatory guidance for child maltreatment and its psychosocial risk factors.

METHOD

The Risk Assessment Survey was developed for this study by 12 PNPs, all of whom were members of NAPNAP's Child Maltreatment Special Interest Group to ensure face validity; all 12 PNPs were content experts in child maltreatment. The content of the survey was derived from key characteristics from the evidence on child maltreatment. The survey was emailed to the more than 8500 NAPNAP members.

RESULTS

Two hundred forty-three PNPs responded to the survey, which represents a response rate of 3%. Approximately half of the participants (n = 121; 51%) stated that they never/rarely ask parents questions about domestic violence, more than one-fourth (n = 71; 30%) reported that they never/rarely ask parents questions about discipline, and half of the responding PNPs (n = 120; 50%) reported that they perform an ano-genital exam at well visits.

DISCUSSION

This study demonstrates that a significant number of PNPs do not routinely screen for child maltreatment and psychosocial risk factors. This is especially true in regards to sexual abuse screening and anticipatory guidance.

The Safe Environment for Every Kid model: promotion of children's health, development, and safety, and prevention of child neglect

Child neglect is by far the most prevalent form of child maltreatment. There is a need to try to prevent this problem, and pediatric primary care offers an excellent opportunity. This article describes one such approach, the Safe Environment for Every Kid (SEEK) model. SEEK enables practitioners to identify and help address psychosocial problems facing many families. These include parental depression, substance abuse, major stress, intimate partner violence, harsh punishment, and food insecurity--problems that have been associated with neglect. Two large randomized, controlled trials yielded promising findings. Materials are now available to help practitioners implement this evidence-based practical model, thereby enhancing the primary care provided to children and their families.

Prevention of child maltreatment

Pediatricians and other health care providers can play several important roles in the prevention of child maltreatment. This article aims to help pediatricians incorporate child abuse prevention into their practice. Resources for systematizing anticipatory guidance and screening for risk factors in child maltreatment are described. The modalities, strengths, and weaknesses of community-based prevention programs are discussed, and tools with which providers can identify the effectiveness of available community-based programs are offered. On a broader level, ways whereby pediatricians can advocate at the local, state, and national levels for policies and programs that support families and children are described.

The Effectiveness of Food Insecurity Screening in Pediatric Primary Care

BACKGROUND

Food insecure children are at increased risk for medical and developmental problems. Effective screening and intervention are needed.

METHODS

Our purpose was to (1) evaluate the validity and stability of a single item food insecurity (FI) screen. (2) Assess whether use may lead to decreased FI. Part of a larger cluster randomized controlled trial, pediatric residents were assigned to SEEK or control groups. A single FI question (part of a larger questionnaire) was used on SEEK days. SEEK residents learned to screen, assess, and address FI. A subset of SEEK and control clinic parents was recruited for the evaluation. Parents completed the USDA Food Security Scale ("gold standard"), upon recruitment and 6-months later. Validity, positive and negative predictive values (PPV, NPV) was calculated. The proportion of screened families with initial and subsequent FI was measured. Screening effectiveness was evaluated by comparing SEEK and control screening rates and receipt of Supplemental Nutrition Assistance Program (SNAP) benefits between initial and 6-month assessments.

RESULTS

FI screen stability indicated substantial agreement (Cohen's kappa =0.69). Sensitivity and specificity was 59% and 87%, respectively. The PPV was 70%; NPV was 81%. SEEK families had a larger increase in screening rates than control families (24% vs. 4.1%, p<0.01). SEEK families were more likely to maintain SNAP enrollment (97% vs. 81%, p=0.05). FI rates remained stable at approximately 30% for both groups.

CONCLUSIONS

A single question screen can identify many families with FI, and may help maintain food program enrollment. Screening may not be adequate to alleviate FI.

Crecemos juntos: understanding and alleviating parental stress among lowcountry migrant workers

The focus of this study was to determine challenges and needs faced by families of migrant farm workers served by Rural Mission Migrant Head Start in the South Carolina Lowcountry. Data on common problems was collected via surveys, and results were analyzed. The Crecemos Juntos (We Grow Together) program was developed with the support of a Helping Hands Grant from the American Psychiatric Foundation, which funds service initiatives by medical students. A multimedia library of materials was compiled, addressing frequently encountered issues in mental health and child development. A presentation on effective positive disciplinary techniques was provided to parents.

The SEEK model of pediatric primary care: can child maltreatment be prevented in a low-risk population?

OBJECTIVE

To examine the effectiveness of the Safe Environment for Every Kid (SEEK) model of enhanced pediatric primary care to help reduce child maltreatment in a relatively low-risk population.

METHODS

A total of 18 pediatric practices were assigned to intervention or control groups, and 1119 mothers of children ages 0 to 5 years were recruited to help evaluate SEEK by completing assessments initially and after 6 and 12 months. Children's medical records and Child Protective Services data were reviewed. The SEEK model included training health professionals to address targeted risk factors (eg, maternal depression), the Parent Screening Questionnaire, parent handouts, and a social worker. Maltreatment was assessed 3 ways: 1) maternal self-report, 2) children's medical records, and 3) Child Protective Services reports.

RESULTS

In the initial and 12-month assessments, SEEK mothers reported less Psychological Aggression than controls (initial effect size = -0.16, 95% confidence interval [95% CI] -0.27, -0.05, P = .006; 12-month effect size = -0.12, 95% CI -0.24, -0.002, P = .047). Similarly, SEEK mothers reported fewer Minor Physical Assaults than controls (initial effect size = -0.16, 95% CI -0.29, -0.03, P = .019; 12-month effect size = -0.14, 95% CI -0.28, -0.005, P = .043). There were trends in the same positive direction at 6 months, albeit not statistically significant. There were few instances of maltreatment documented in the medical records and few Child Protective Services reports.

CONCLUSIONS

The SEEK model was associated with reduced maternal Psychological Aggression and Minor Physical Assaults. Although such experiences may not be reported to protective services, ample evidence indicates their potential harm. SEEK offers a promising and practical enhancement of pediatric primary care.

Identifying children at high risk for a child maltreatment report

OBJECTIVE

To help professionals identify factors that place families at risk for future child maltreatment, to facilitate necessary services and to potentially help prevent abuse and neglect.

METHOD

The data are from a prospective, longitudinal study of 332 low-income families recruited from urban pediatric primary care clinics, followed for over 10 years, until the children were approximately 12 years old. Children with prior child protective services involvement (CPS) were excluded. The initial assessment included sociodemographic, child, parent and family level variables. Child maltreatment was assessed via CPS reports. Risk ratios (RRs) and their 95% confidence intervals (CIs) were estimated using Cox regression models.

RESULTS

Of the 224 children without a prior CPS report and with complete data who were followed for an average of 10 years, 97 (43%) later had a CPS report. In a multivariate survival analysis, 5 risk factors predicted CPS reports: child's low performance on a standardized developmental assessment (RR=1.23, 95% CI=1.01-1.49, p=.04), maternal education≤high school (RR=1.55, CI=1.01-2.38, p=.04), maternal drug use (RR=1.71, CI=1.01-2.90, p<.05), maternal depressive symptoms (RR per one standard deviation higher score=1.28, CI=1.09-1.51, p<.01), and more children in the family (RR per additional child=1.26, CI=1.07-1.47, p<.01).

CONCLUSIONS

Five risk factors were associated with an increased risk for later maltreatment. Child health care and other professionals can identify these risk factors and facilitate necessary services to strengthen families, support parents and potentially help prevent child maltreatment.

Training pediatric residents in a primary care clinic to help address psychosocial problems and prevent child maltreatment

OBJECTIVE

The objectives of this study were to determine whether 1) residents trained in the SEEK (A Safe Environment for Every Kid) model would report improved attitudes, knowledge, comfort, competence, and practice regarding screening for psychosocial risk factors (parental depression, parental substance abuse, intimate partner violence, stress, corporal punishment, and food insecurity); 2) intervention residents would be more likely to screen for and assess those risk factors; and 3) families seen by intervention residents would report improved satisfaction with their child's doctor compared to families receiving standard care from control residents.

METHODS

Pediatric residents in a university-based pediatrics continuity clinic were enrolled onto a randomized controlled trial of the SEEK model. The model included resident training about psychosocial risk factors, a Parent Screening Questionnaire, and a study social worker. Outcome measures included: 1) residents' baseline, 6-month, and 18-month posttraining surveys, 2) medical record review, and 3) parents' satisfaction regarding doctor-parent interaction.

RESULTS

Ninety-five residents participated. In 4 of 6 risk areas, intervention residents scored higher on the self-assessment compared to control subjects, with sustained improvement at 18 months. Intervention residents were more likely than control subjects to screen and assess parents for targeted risk factors. Parents seen by intervention residents responded favorably regarding interactions with their doctor.

CONCLUSIONS

The SEEK model helped residents become more comfortable and competent in screening for and addressing psychosocial risk factors. The benefits were sustained. Parents viewed the intervention doctors favorably. The model shows promise as a way of helping address major psychosocial problems in pediatric primary care.

Tackling child neglect: a role for pediatricians

Child neglect, the most prevalent form of maltreatment, poses challenges for pediatricians. There often is uncertainty regarding what constitutes neglect and how best to address it. The complexity is compounded by the many ways neglect can manifest. This article first discusses why neglect is so important a concern and then provides definitional considerations and a description of forms of neglect. Next presented are principles for assessing and addressing neglect and suggestions for prevention and advocacy.

Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model

CONTEXT

Effective strategies for preventing child maltreatment are needed. Few primary care-based programs have been developed, and most have not been well evaluated.

OBJECTIVE

Our goal was to evaluate the efficacy of the Safe Environment for Every Kid model of pediatric primary care in reducing the occurrence of child maltreatment.

METHODS

A randomized trial was conducted from June 2002 to November 2005 in a university-based resident continuity clinic in Baltimore, Maryland. The study population consisted of English-speaking parents of children (0-5 years) brought in for child health supervision. Of the 1118 participants approached, 729 agreed to participate, and 558 of them completed the study protocol. Resident continuity clinics were cluster randomized by day of the week to the model (intervention) or standard care (control) groups. Model care consisted of (1) residents who received special training, (2) the Parent Screening Questionnaire, and (3) a social worker. Risk factors for child maltreatment were identified and addressed by the resident physician and/or social worker. Standard care involved routine pediatric primary care. A subset of the clinic population was sampled for the evaluation. Child maltreatment was measured in 3 ways: (1) child protective services reports using state agency data; (2) medical chart documentation of possible abuse or neglect; and (3) parental report of harsh punishment via the Parent-Child Conflict Tactics scale.

RESULTS

Model care resulted in significantly lower rates of child maltreatment in all the outcome measures: fewer child protective services reports, fewer instances of possible medical neglect documented as treatment nonadherence, fewer children with delayed immunizations, and less harsh punishment reported by parents. One-tailed testing was conducted in accordance with the study hypothesis.

CONCLUSIONS

The Safe Environment for Every Kid (SEEK) model of pediatric primary care seems promising as a practical strategy for helping prevent child maltreatment. Replication and additional evaluation of the model are recommended.