Overview of the Safe Environment for Every Kid (SEEK) Project
Child maltreatment (CM) continues to be a major problem – over 3.3 million reports are made to Child
Protective Services (CPS) in the U.S. annually involving about 6 million children. Maltreated children are
at risk for many short- and long-term negative consequences, including medical, developmental/learning,
social and mental health problems. The effects of CM may persist long into adulthood, manifesting in an
array of problems in these areas. In addition to the human costs, there are enormous financial costs; a
recent estimate is that nationally we spend over 124 billion dollars a year on medical, mental health, child
welfare, and criminal and juvenile justice costs related to CM.
Since Haggerty et al’s description of the “new morbidity” in 1975, pediatricians have been aiming to
integrate the screening and management of psychosocial issues into the delivery of well child health care.
The American Academy of Pediatrics’ Bright Futures project developed practice recommendations for
pediatricians, urging consideration of the child’s family and environment. When surveyed, however,
many pediatricians feel that they have neither the knowledge nor competency to deal with several of these
issues, such as parental 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 U.S. Centers for Disease Control and Prevention (CDC),
and the Doris Duke Charitable Foundation (DDCF), offers a practical, evidence-based approach to the
identification and management of targeted risk factors for CM, for families with children aged 0-5 years.
It is designed to be 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 several agencies and organizations.
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 are adequately prepared to address the targeted
problems, such as parental depression, for which they may not have been trained.
 Principles of motivational interviewing are incorporated to help engage parents in developing
a plan.
 Professionals are encouraged to also identify and utilize families’ strengths and resources.
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2. The SEEK Parent Questionnaire (PQ, formerly the Parent Screening Questionnaire or PSQ)
screens for the targeted problems.
 The PQ screens for 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) major parental stress, and, 6) food insecurity.
 The SEEK PQ is based on findings from two randomized controlled trials. Sensitivity for the
targeted problems was low to moderate, but specificity was very high. See references.
 It was developed for parents to complete, voluntarily, before selected well-child visits.
Parents can do so while waiting and then hand the PQ to the health professional at the start of
the visit. It takes about 2 minutes to complete.
 The PQ has 15 items on one side of one page. It has a yes/no format that is easy to use by
both parents and professionals.
 The PQ is completed at selected checkups, such as at the 2, 9 and 15-month, and the 2, 3, 4,
and 5-year visits. ( Do you recommend this at any specific ones?)
 The SEEK PQ is available in English, Spanish, Chinese and Vietnamese.
3. Ideally, a behavioral or mental health specialist is available to help initially assess and briefly
address problems and facilitate referrals to community resources.
 In the two trials, medical professionals and parents had discretion about whether to involve a
social worker who was available to health professionals and parents during the regular work
week. 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 trial was by phone.
 This role could alternatively be played by a medical professional, such as a physician, nurse
practitioner, or physician assistant, with office staff facilitating referrals.
4. SEEK Parent Handouts were developed as adjuncts to clinician advice.
 Relatively simple and brief SEEK 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, and to include information on local resources.
5. An optional web-based decision support system (CHADIS) delivers the SEEK PQ online to
parents via tablet, phone, or computer.
 Provides health professionals with electronic responses to the PQ and decision support.
The Evidence Supporting SEEK
There is increasing recognition of the need to implement strategies that have been evaluated and found to
be effective. Two large randomized controlled trials of SEEK were conducted – the first in pediatric
resident clinics serving a very low income Baltimore population, the second in 18 suburban private
pediatric practices serving a relatively low risk, mostly middle income population in central Maryland.
The key findings were:
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In both studies, health professionals significantly improved in their level of comfort, perceived
competence and practice behavior regarding the targeted risk factors.1,2 Some of these improvements
were sustained 18-36 months beyond the initial training.
©2012, University of Maryland School of Medicine
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In the 1st study, there was significantly less child abuse and neglect in SEEK families, measured three
ways: 1) fewer parents reported physical assaults and psychological aggression, 2) children’s medical
records showed fewer instances of neglect (non-adherence to medical care, delayed immunizations),
and 3) fewer reports to child protective services (CPS).3 For example, there were 30% fewer CPS
reports in the SEEK group compared to controls; for every 17 families receiving the SEEK model,
one reported instance of CM was prevented.
In the 2nd study involving relatively low risk families, fewer SEEK mothers reported minor physical
assaults and psychological aggression toward their children.4 While such experiences may not meet
legal definitions of CM, 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 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.2
SEEK did not require additional time, on average, for medical professionals to address psychosocial
problems.4
The SEEK Parent Questionnaire is based on findings from the two trials.5-10
Given the importance of cost-related assessments in determining how to best allocate prevention
dollars, we analyzed cost data from the 2nd SEEK study.11 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.
Recognition of SEEK
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The SEEK model was selected by the U.S. Agency for Healthcare Research and Quality to include in
their Health Care Innovations Exchange offering health professionals information on evidence-based
innovations and tools. http://www.innovations.ahrq.gov/content.aspx?id=3205
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The SEEK PSQ is one of the screening tools suggested by the American Academy of Pediatrics’
Bright Futures project for pediatricians to utilize during health supervision visits. It’s included in the
Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents.
http://brightfutures.aap.org/tool_and_resource_kit.html
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The SEEK PSQ is on the Maryland Department of Health and Human Services website regarding
recommended measures for Early Periodic Screening, Diagnosis and Treatment (EPSDT)
professionals. http://dhmh.maryland.gov/innovations/SitePages/evidencebased-clinicalpractice.aspx,
http://dhmh.maryland.gov/innovations/1.SitePages/seekprogram.aspx
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A presentation on SEEK by Drs. Dubowitz and Lane received the award for Best Long Presentation
at the Annual Meeting of the Helfer Society in April, 2013 in Sonoma, CA. This is an international
honorary society of physicians working in the child abuse field.
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SEEK received a rating of 2 (out of 5, with 1 indicating the strongest evidence) by the California
Evidence-Based Clearinghouse for Child Welfare (CEBC). CEBC provides professionals with
©2012, University of Maryland School of Medicine
information on selected child welfare related programs, with a rating of the quality of the supportive
evidence. http://www.cebc4cw.org/program/safe-environment-for-every-kid-seek-model/detailed
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SEEK is listed on the Public Health Agency of Canada’s Canadian Best Practices Portal. http://cbpppcpe.phac-aspc.gc.ca/interventions/the-safe-environment-kid-seek-model/
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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Health professional interest in enhancing 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.
A commitment to completing the SEEK online training. The SEEK training aims to help prepare
health professionals address problems for which they may not have been trained. Guidance is
provided on how to briefly assess and initially help address identified problems.
Signing the Terms of Use agreement with the University of Maryland, Baltimore.
Paying the one-time fee for implementing SEEK.
What Resources and Assistance are Available?
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More detailed descriptions of SEEK are available.12-15
The SEEK website (http://theinstitute.umaryland.edu/seek) provides free online training materials (9
videos and supplemental materials), practical tools, and technical assistance.
SEEK is approved by the University of Maryland School of Medicine to provide Continuing
Medical Education (CME) AMA PRA Category 1 Credits (2-3 hours) to physicians. Nurses and
physician assistants who complete the training receive documentation of their participation.
The SEEK training is approved for Maintenance of Certification (MOC) Part 2 and Part 4 credit
by the American Board of Pediatrics. SEEK has also been approved for MOC Part 4 credit by the
American Board of Family Medicine. We plan to obtain approval also from the American Board of
Preventive Medicine and the National Commission on Certification of Physician Assistants.
We offer technical assistance to those interested in implementing the SEEK model in a clinical
setting, as well as help evaluating the project.
Contact Us
For more information, please contact:
Howard Dubowitz, MD, MS, FAAP – hdubowitz@peds.umaryland.edu or 410.706.6144
Emily Redding, BA – eredding@peds.umaryland.edu or 410.706.1703
©2012, University of Maryland School of Medicine
References
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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, 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.
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.
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. Ambulatory Pediatrics. 2008;8(4):255-60.
Feigelman S, Dubowitz H, Lane W, Kim J. Screening for Harsh Punishment in a Pediatric Primary Care
Clinic. Child Abuse and Neglect. 2009;33(5):269-77.
Lane W, Dubowitz H, Feigelman S, Poole G. The Effectiveness of Food Insecurity Screening in Pediatric
Primary Care. International Journal of Child Health and Nutrition. 2014;3:130-138.
Lane W, Dubowitz H, Frick K, Semiatin J, Magder L. The Safe Environment For Every Kid (SEEK)
Program: A Cost-Effectiveness Analysis. 139th Annual Meeting of the American Public Health Association.
Washington, D.C., November, 2011.
Dubowitz H. The Safe Environment for Every Kid Model: Promotion of Children's Health, Development,
and Safety, and Prevention of Child Neglect. Pediatric Annals. 2014; Nov 1;43(11):e271-7.
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.
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©2012, University of Maryland School of Medicine