Overview
Child maltreatment (CM) continues to be a major problem – over 3.3 million reports are made to Child
Protective Services in the United States annually involving about 6 million children. Maltreated children
are at risk of many short- and long-term negative consequences, including medical,
developmental/learning and mental health problems. The effects of CM may also persist into adulthood,
manifesting in an array of physical, social and mental health problems. In addition to the human costs,
there are enormous fiscal costs involved; a recent estimate is that nationally we spend over 124 billion
dollars a year on medical, mental health, child welfare, criminal and juvenile justice costs related to CM.
Since Haggerty et al’s description of the “new morbidity” in 1975, pediatricians have been trying to
integrate the screening and management of psychosocial issues into the delivery of well child health care.
The American Academy of Pediatrics participated in a national effort, “Bright Futures,” to develop
practice recommendations for pediatricians, urging consideration of the child’s critical environment in the
family and in the community. When surveyed, however, many pediatricians feel that they have neither the
knowledge nor competency to deal with several of these issues, including maternal depression and
intimate partner (or domestic) violence.
The SEEK project, funded by the Maryland Department of Human Resources, the US DHHS
Administration on Children and Families, the US Centers for Disease Prevention (CDC), and the Doris
Duke Charitable Foundation (DDCF), offers a practical approach to the identification and management of
targeted risk factors for CM for families with children aged 0-5 years. It was designed to be well
integrated into pediatric primary care, and relatively easy to implement. By building upon the good
relationships that usually exists between child health professionals and parents and helping address these
problems, SEEK aims to strengthen families, support parents, and thereby promote children’s health,
development and safety – and help prevent CM.
Two randomized controlled trials have been conducted – the first in pediatric resident continuity/training
clinics serving a very low income urban population, the second in 18 suburban private pediatric practices
serving a relatively low risk population. The findings have been promising. Several papers have been
published on SEEK (see references). Accordingly, the DDCF has provided funds to disseminate the
SEEK model. The SEEK model has been recognized by the Agency for Healthcare Research and Quality
(AHRQ) and Bright Futures™ as a promising practice to reduce child abuse and neglect.
The SEEK Model
The main components of the SEEK model include:
1. Training child health primary care professionals to briefly assess and initially help address
prevalent psychosocial problems.
 It is important that primary care professionals feel adequately prepared to address the
targeted problems, such as parental depression, for which they may not have been trained.
 The principles of motivational interviewing are incorporated to help parents engage in
efforts and services to improve their situation.
 Professionals are encouraged to also identify and utilize families’ strengths and resources.
©2012, University of Maryland School of Medicine
2. The SEEK Parent Screening Questionnaire (PSQ) screens for the targeted problems.
 We developed the SEEK PSQ for parents to complete, voluntarily, before selected wellchild visits. Parents can do so while waiting and then give the PSQ to the health
professional at the start of the visit. The entire PSQ is contained on one side of one page.
It has a format that is easy to use by both parents and professionals.
 The PSQ is designed to screen - not diagnose - several common problems that are risk
factors for child maltreatment: 1) maternal depression, 2) alcohol and substance abuse, 3)
intimate partner (or domestic) violence, 4) harsh parenting, 5) parenting stress, and, 6)
food insecurity.
 The PSQ is completed at selected checkups, such as at the 2, 9 and 15 month, and the 2,
3, 4, and 5 year visits, and takes about 2 minutes to complete.
 The SEEK PSQ is available in English, Chinese and Spanish.
3. Ideally, a mental health professional is available to initially assess and briefly address problems
and facilitate referrals to community resources.
 In the two trials, health professionals and parents had discretion about whether to involve
a social worker. The social worker tailored her approach to meet the needs of individual
parents, occasionally provided crisis intervention, but did not engage in extended therapy.
Much of the work in the 2nd study was by phone.
 This role could be largely played by someone else in the practice, such as a physician or
nurse practitioner, with office staff facilitating referrals.
4. SEEK Parent Handouts were developed as adjuncts to clinician advice.
 Relatively simple and brief Parent Handouts address the targeted problems. These
Handouts provide basic information in a user-friendly way, and list national hotlines and
websites for organizations with good parent resources. There is space to customize these
for one’s practice/location, and to include information on local resources.
5. An optional web-based decision support model (CHADIS) to deliver the SEEK PSQ online to
parents via tablet, phone, or computer.
 Provides findings and decision support electronically to medical professionals.
Major Findings from Two Large Trials of SEEK
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In both studies, health professionals demonstrated significant improvement in their level of
comfort, perceived competence and practice behavior regarding the targeted risk factors.7,8 Some
of these improvements were sustained 18-36 months beyond the initial training.
In the 1st study, there were significant reductions in the rate of child maltreatment in SEEK
families, measured in three ways: 1) fewer self-reported parental physical assaults and less
psychological aggression, 2) children’s medical records showed fewer instances of neglect (nonadherence to medical care, delayed immunizations), and 3) fewer reports to Child Protective
Services (CPS).5
In the 2nd study involving relatively low risk families, there were fewer maternal reports of minor
physical assaults (mostly “corporal punishment”) and psychological aggression toward their
children.9 While such experiences may not meet legal definitions of maltreatment, there is ample
evidence that they jeopardize children’s health, development and safety. Some may refer to this
as “harsh parenting,” although it can reasonably be considered as maltreatment. In this 2nd study
©2012, University of Maryland School of Medicine
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there were relatively few instances of maltreatment in the medical records and few reports to
CPS.
Parents were generally quite satisfied with their child’s doctor or nurse. In the 1st study, parents in
the SEEK group were more positive about their child’s doctor than were controls.5
SEEK did not require additional time on average for health professionals to address psychosocial
problems.
Given the importance of cost-related assessments in determining how to best allocate prevention
dollars, we analyzed cost data from the 2nd SEEK study.10 SEEK cost $5.12 per family and $122
per case of psychological aggression or physical assault averted. Providing the SEEK model to
100,000 families would prevent maltreatment in 4,200 children and would save about $37
million. Expansion of the SEEK model of pediatric primary care has the potential to decrease
medical, mental health, and social service costs associated with child maltreatment.
What’s Needed to Implement SEEK
There are a few core ingredients for successfully implementing the SEEK model in a primary care setting
serving children. These include:
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Provider interest to enhance the quality of child healthcare, particularly by helping address
prevalent psychosocial problems facing many families.
At least one physician in the practice to “champion” the project and lead the implementation.
At least one staff member such as the office/clinic manager to help lead the effort and liaise with
the SEEK office.
A commitment to completing the SEEK online training. This will provide a good sense of what
SEEK involves. The SEEK online training materials are intended to help health professionals feel
adequately prepared to address issues for which they may not have been trained. Each module
addresses why a specific parental or family risk factor is important, its prevalence, and its impact
on the child and family. Guidance is provided on how to briefly assess and initially help address
identified problems.
The Near Future
The new SEEK website (www.theinstitute.umaryland.edu/SEEK) will provide free online training
materials including videos, practical tools, and technical assistance.
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We plan to incorporate SEEK into residency training programs in Maryland and elsewhere
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SEEK is approved by the University of Maryland School of Medicine to provide Continuing
Medical Education credit to pediatricians and family medicine practitioners. Physicians (MD,
DOs and equivalent medical degrees from another country) are eligible to receive AMA PRA
Category 1 Credits. Nurses and Physician Assistants who complete the CME will receive
documentation of their participation.
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The SEEK training is currently approved for MOC Part 2 and MOC Part 4 credit by the American
Board of Pediatrics. Approval for MOC Part 4 credit is being sought from the American Board of
Family Medicine (ABFM), the American Board of Preventive Medicine (ABPM) and the
National Commission on Certification of Physician Assistants (NCCPA).
©2012, University of Maryland School of Medicine
Contact Us
For more information, please contact one of us:
Howard Dubowitz, MD, MS, FAAP – hdubowitz@peds.umaryland.edu or (410) 706 6144
Kathleen Graham, MHS, MSW – kgraham1@peds.umaryland.edu or (410) 706-1703
References
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Dubowitz H, Prescott L, Feigelman S, Lane W, Kim J. Screening for Intimate Partner Violence in an Urban
Pediatric Primary Care Clinic. Pediatrics. 2008:121(1):e85-91.
Lane W, Dubowitz H, Feigelman S, Kim J, Prescott L, Meyer W, Tracy JK. Screening for Parental
Substance Abuse in an Urban Pediatric Primary Care Clinic. Ambulatory Pediatrics. 2007;7:458–462.
Dubowitz H, Feigelman S, Lane W, Prescott L, Blackman K, Grube L, Meyer W, Tracy JK. Screening for
depression in an urban pediatric primary care clinic. Pediatrics. 2007;119(3):435-43.
Kim J, Dubowitz H, Hudson-Martin E, Lane W. Comparison of 3 data collection methods for gathering
sensitive and less sensitive information. Ambul Pediatr. 2008;8(4):255-60.
Dubowitz H, Feigelman S, Lane W, Kim JW. Pediatric Primary Care to Help Prevent Child Maltreatment:
The Safe Environment for Every Kid (SEEK) Model. Pediatrics. 2009;123:858-864.
Feigelman S, Dubowitz H, Lane W, Kim J. Screening for Harsh Punishment in a Pediatric Primary Care
Clinic. Child Abuse Neglect. 2009;33(5):269-77.
Dubowitz H, Lane W, Semiatin J, Magder L, Venepally M, Jans M. The Safe Environment for Every Kid
(SEEK) Model: Impact on Pediatric Primary Care Professionals. Pediatrics. 2011;127(4):e962-70.
Feigelman S, Dubowitz H, Lane W, Grube L, Kim J. Training Pediatric Residents in a Primary Care Clinic
to Help Address Psychosocial Problems and Prevent Child Maltreatment. Academic Pediatrics.
2011;11(6):474-80.
Dubowitz H, Lane W, Semiatin J, Magder L. The SEEK model of Pediatric Primary Care: Can Child
Maltreatment Be Prevented In A Low-risk Population? Academic Pediatrics.2012;12(4):259-68.
Lane W, Dubowitz H, Frick K, Semiatin J, Magder L. (2011, November) The Safe Environment For Every
Kid (SEEK) Program: A Cost-Effectiveness Analysis. 139th Annual Meeting of the American Public Health
Association. Washington, D.C.
Selph S, Bougatsos C, Blazina I, Nelson H. Behavioral Interventions and Counseling to Prevent Child
Abuse and Neglect: A Systematic Review to Update the U.S. Preventive Services Task Force
Recommendation. Annals of Internal Medicine. 2013;158 (3):179-190.
Dubowitz H. The Safe Environment for Every Kid (SEEK) Model: Promoting Children’s Health,
Development and Safety. Zero to Three. September, 2013.
Dubowitz H. The Safe Environment for Every Kid (SEEK) Model: Promoting Children’s Health,
Development and Safety. Child Abuse and Neglect. In press.
©2012, University of Maryland School of Medicine