Training paediatricians to screen parents for risk factors correlated to child abuse slashed referrals to child protection services by 31% in the US. Safe Environments for Every Kid (SEEK) is a four-stage screening procedure that identifies at-risk families. By asking new parents to fill out a short questionnaire while they wait to see a doctor, paediatricians get a snapshot into the life of the parent and thus the safety of the child. Then, they can refer parents to social services or create plans of action to keep children safe.
Results & Impact
A randomised controlled trial among low-income residents of Baltimore demonstrated a 31% reduction in calls to child protection services where SEEK ran. Children’s medical charts also showed significantly fewer neglect-related health issues, and self-reports of severe physical assault by mothers fell. In another trial, conducted in a high-income suburb of Maryland, child health improved but less significantly.
Hospitals, University of Maryland
Paediatricians are trained to screen parents of young children for a range of psycho-social problems that correlate to child abuse. Parents fill out a questionnaire while they wait with a range of questions relating to four topics: maternal depression, alcohol and substance abuse, intimate partner violence, and parental stress. Their answers, if they contain any red flags, are discussed with the paediatrician. If appropriate, the doctor then refers them to social workers or works with the parent to overcome or manage their difficulties.
Cost & Value
The training materials for SEEK are available online, though the University of Maryland asks for a small and negotiable fee of a few hundred dollars to cover their running costs.
Running since 2001
Some practices have been resistant to implementing SEEK for fear of the time pressures it would add to their appointments. In fact, observational studies by medical students suggested that SEEK had a neutral effect on workload: the questionnaire saved time with patients who exhibited no risk factors, but slightly expanded workload for parents who were flagged as at risk.
SEEK has been extensively implemented across the United States. A state-wide replication in Dalarna, Sweden, is now underway.
Calls to child protection services in low-income neighbourhoods of Baltimore fell by 31% when paediatricians began screening parents as well as their children.
Safe Environments for Every Kid (SEEK) is a four-stage program that protects children by assessing their parents for risk factors that correlate to child abuse.
“SEEK is addressing something that has been lost in the medical profession,” argues Professor Howard Dubowitz, Head of Child Protection Services at the University of Maryland and founder of the SEEK protocol.
“It’s not enough to focus on just the child and ignore the critical environment that surrounds them. SEEK recognises that we have to think more broadly if we are serious about the health, development and safety of children.”
In the first stage, paediatricians are trained to recognise the importance of the psychosocial well-being of parents, and how this can impact children. Second, questionnaires are given to parents while waiting for appointments. By slotting into the usual trips to see a doctor—usually vaccinations and check-ups—the questionnaire is a non-intrusive fact-finding tool that can flag any immediate problems. Maternal depression, alcohol or substance abuse, intimate partner violence and parental stress are all covered.
SEEK’s third stage comprises the paediatrician’s response to the questionnaire’s findings. The training suggests a REAP approach: Reflect, Empathise, Assess, Plan. The latest iteration of SEEK encourages “motivational interviewing”—a collaborative approach where doctors and patients work together to create action plans.
Fourth comes the planning stage. Paediatricians are trained to refer parents to revelant social services where appropriate and organise return visits to monitor progress.
In taking a more holistic view of paediatric care, SEEK shifts the frame from treatment to prevention.
“We were doing a fairly good job at identifying kids who had already been abused and neglected, but we weren’t preventing abuse in the first instance,” he recalls. “SEEK tackles the psychosocial problems that lead to these kids being abused and neglected.”
Primary care, and paediatricians, in particular, provides a particularly valuable in-road to preventing child maltreatment, according to Dubowitz.
“The trust between doctor and patient is a powerful tool. It offers the entry point to knowing what’s going on and having the credibility to help.”
“But that credibility doesn’t mean people always listen to their doctors,” he cautions. “The typical hierarchical model of telling someone what to do doesn’t work: very often, patients don’t do what we tell them.”
“The approach must be collaborative: patients must feel as if we are working with them, as partners, to solve problems they are facing.”
The approach is gaining traction across the states, though Dubowitz admits he doesn’t know exactly how far SEEK has spread. Extensive networks of SEEK practitioners exist across South Carolina, Virginia, Arizona and Ohio. The most significant international replication is taking place in Sweden, where the County Council of Dalarna in collaboration with the University of Uppsala are rolling SEEK out to all primary care establishments in the county.
“With any project like this, working at scale is a problem. The National Institute of Health recognised 20 years ago that they spend an enormous amount of money on research and developing cures, but typically there’s a long lag before whatever it is gets adopted. The number often bandied around is 17 years after something beneficial has been established – that’s when it is adopted at scale.”
The success of SEEK depends on the initiative of health practitioners. It is not currently mandated by states, or standard practice—though Dubowitz hopes that it one day will be. “Some doctors have welcomed playing a broader role. Some less so.”
The deciding factor for many is time. Many fear that SEEK will add time pressures to their busy schedules, though observational studies by medical students suggest a relatively neutral effect.
“We had medical students observe doctors using the SEEK framework. We found that using it did not add significantly to workload. We think the reason is that, quite often, parents fill out these questionnaires while waiting for an appointment. Often, they don’t have these problems which obviates the need to cover that territory during the visit,” said Dubowitz.
“SEEK saves time when there aren’t problems, but it demands more when there are problems that warrant discussion.”
Another question around SEEK is its effectiveness across income brackets. While significant falls in reports to child protection services and self-reports of violence by mothers occurred in low-income communities in urban Baltimore, a randomised controlled trial found less significant improvements among higher-income suburban populations.
For now, SEEK’s future depends on individual initiative or government buy-in. “Perhaps it shouldn’t be the case, but money talks in modern medicine,” said Dubowitz. Reimbursing health practitioners for using SEEK might be one way of encouraging its replication nationwide.
(Picture credit: Howard Dubowitz)