Safe Environment for Every Kid (SEEK) - Promising Futures

• Individual
• Dyadic

• In-Person
• Virtual
• Hybrid

• Licensed/Certified Professional Led

• Domestic Violence
• Child Abuse
• Neglect
• Substance Abusing Caregiver
• Verbal/Emotional Abuse

• Talk-based

• Primary Prevention
• Secondary Prevention

• Greater than 12 weeks

• Health Services
• Hospital-based

Type of services provided:

SEEK is an evidence-based prevention model to help primary healthcare professionals (PCPs) identify and address major risk factors for child maltreatment or Adverse Childhood Experiences (ACEs), including intimate partner violence (IPV). SEEK aims to support parents and parenting, strengthen families, promote children’s health, development, wellbeing and safety, and prevent child abuse and neglect. The model includes screening parents/caregivers for important and targeted social determinants of health, brief intervention, and facilitation of services.
The SEEK model includes several core components:

• Health Professional Training: SEEK provides online training, materials and support; Continuing Medical Education (CME) and Maintenance of Certification (MOC) 4 / Performance Improvement credits are available
• The SEEK Parent Questionnaire (PQ-R) is a brief, simple, screening tool (16 yes/no questions; 2 minutes to complete).
• Briefly assessing and initially helping address identified problems
• Motivational Interviewing: the SEEK model incorporates principles of Motivational Interviewing to help engage parents/caregivers and build upon their strengths.
• Behavioral Health Professional/Social Worker/Case Manager: It is optimal when PCPs have access to one of these colleagues to assist in approaching problems. The model is flexible, however, deferring to PCPs and parents to decide how to address problems. Of note, SEEK is being implemented without these resources, involving instead a practice’s clerical staff.
• SEEK Parent Handouts: User-friendly, one-page handouts to be customized with information on local resources for the targeted problems addressed by SEEK (parental depression, major stress, substance misuse, IPV, food insecurity and harsh punishment, as well as poison control, smoke alarms, tobacco use) – in English and Spanish. Practices may use alternative handouts if they prefer.

The SEEK model uses the REAP approach to help PCPs assess and address risk factors identified by the SEEK PQ-R. REAP refers to:

• Reflect – on what a parent has disclosed
• Empathize
• Assess – the nature of the issue, parent’s view, wishes
• Plan – with the parent, knowing community resources

Program setting:

Primary healthcare settings serving children

Length of program/number of sessions:

The SEEK PQ-R is given to parents/caregivers at selected check-ups, such as at visits at 2, 9, 15, 24, 36, 48 and 60 months. Practices choose which visits to target.

Type(s) of trauma/concerns addressed:

The SEEK model, designed to prevent child maltreatment, prioritizes these risk factors:

• Parental depression
• Parental substance misuse
• Major parental stress
• Intimate partner violence
• Food insecurity
• Harsh punishment

Education level of providers:

Primary care physicians, nurse practitioners, and physician assistants, as well as behavioral health colleagues, and those with expertise in human services

Unique/Innovative Characteristics:

The SEEK model makes the connection between IPV and child maltreatment by addressing IPV as a leading risk factor or ACE. Arguably, given children’s basic need for a safe, secure and loving home, IPV can also be construed as a form of child maltreatment. Rigorous evaluation has shown that brief PCP training and ongoing support, significantly increased screening for IPV (19%) and there were fewer instances of other manifestations of child maltreatment. The SEEK model provides free access to online training and many useful resources. There is a 3-page “Partner Violence Algorithm and Addressing Barriers” resource that suggests how to briefly discuss IPV with a parent and support them in accessing services and reviewing a safety plan. The SEEK Algorithm emphasizes the importance of supporting the parent’s choice.

The SEEK model incorporates the use of protective factors to effectively intervene with families, encouraging professionals to identify and utilize parents’ strengths and resources.

The SEEK PQ-R asks two screening questions re: IPV:

• “Have you and a partner fought a lot?” and “Has a partner threatened, shoved, hit or kicked you or hurt you physically in any way?”
• A “Yes” to either question = a positive screen.

Date Added/Updated:

07/21/22

• 0-5 (Early Childhood)

• English
• Spanish

• Asian
• Black or African American
• Hispanic or Latino
• Indigenous People – American Indian/Native American, Alaskan Native
• Native Hawaiian or other Pacific Islander
• White

• Child and Non-abusive Parent/Caregiver
• Child
• Family
• Parent who uses Violence
• Survivor parent
• Foster/Adoptive Parents
• Other Client/Audience (Primary Care Givers)

Age range of children served:

0-5 years old

Are parent/adult caregiver(s) included in intervention?

SEEK involves screening of and intervention with parents/caregivers

Ethnic/racial and other groups served:

The SEEK model was evaluated with mostly African American and white, low- and middle-income families. However, there has been much clinical experience with diverse populations including Latinos and Asians.

Specific cultural adaptations:

We work with interested practitioners to accommodate other priorities, such as adding a question or two to the SEEK PQ-R and adapting the model for other settings.

Languages that service/resource is available:

The SEEK PQ-R is available in English, Spanish, Swedish and Italian. The earlier SEEK PQ is available in Chinese and Vietnamese.

Goals of the program/services:

• Improve pediatric primary care, in order to better address prevalent psychosocial problems or ACEs that are also social determinants of health
• Prepare pediatric primary care professionals (e.g., pediatricians, family medicine physicians, nurse practitioners, and physician assistants) to identify, briefly assess, and help address major risk factors for child maltreatment
• Identify families with major risk factors for child maltreatment and facilitate help when indicated
• Strengthen families, support parents and parenting, and promote children’s health, development, and safety
• Primary prevention of child maltreatment with families with children aged 0-5 years old

Has there been any evaluation?

Yes

Key evaluation results:

Child Maltreatment

In the first federally-funded randomized controlled trial, the SEEK model was evaluated with 558 parents of children, ages 0-5 years, that were receiving care at a pediatric primary care resident continuity clinic serving a low income, predominantly African American community (Dubowitz, Feigelman, Lane & Kim, 2009). The model included: (1) SEEK training, (2) the Parent Screening Questionnaire, and (3) a social worker. The residents received two half-days of training, laminated pocket cards, a handbook with information on local resources, and user-friendly parent handouts. SEEK resulted in significantly lower rates of child maltreatment, including 31% fewer Child Protective Services (CPS) reports, less medical neglect (non-adherence, delayed immunizations), and fewer instances of severe physical punishment reported by parents. Of note, decreased IPV partially explained the fewer CPS reports in the SEEK group.

In the second randomized controlled trial, the SEEK model was evaluated in 18 private pediatric practices and 1,119 predominantly White, middle income, mothers of children 0-5 years of age (Dubowitz, Lane, Semiatin & Magder, 2012). Mothers seen in SEEK practices reported fewer instances of psychological aggression and minor physical assaults against their children compared to controls.

Impact on Health Care Professionals

In the first randomized controlled trial of pediatric residents in a primary care resident continuity clinic serving a predominantly African American, low-income, urban community, SEEK led to improved residents’ level of comfort, perceived competence, and response to the targeted psychosocial risk factors (Feigelman, Dubowitz, Lane, Grube & Kim, 2011).

In the second randomized controlled trial, private pediatric primary care practices were assigned to the SEEK or control group (Dubowitz, Lane, Semiatin, Magder, Venepally & Jans, 2011). Outcome measures included the SEEK Parent Screening Questionnaire, the SEEK Health Professional Questionnaire, review of children’s medical records and observation of PCPs at check-up visits. Primary care providers in the SEEK practices received 4 hours of training. Those implementing SEEK improved more in their thinking and behavior regarding addressing the targeted problems. SEEK increased screening for IPV from close to zero to 58% of eligible visits.
Importantly, PCPs’ improved thinking and practice behavior regarding addressing the targeted social determinants of health was sustained for up to 36 months of follow-up.

Other Publications:

Dubowitz H, Feigelman S, Lane W, & Kim J. (2009). Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) model. Pediatrics, 123(3), 858-864.

Dubowitz, H., Lane, W. G., Semiatin, J. N., Magder, L. S., Venepally, M., & Jans, M. (2011). The Safe Environment for Every Kid model: Impact on pediatric primary care professionals. Pediatrics, 127(4), 962-970.

Dubowitz H, Lane WG, Semiatin JN, & Magder, LS. (2012). The SEEK model of pediatric primary care: Can child maltreatment be prevented in a low-risk population? Academic Pediatrics, 12(4), 259-268.

Feigelman S, Dubowitz H, Lane W, Grube L, & Kim J. (2011). Training pediatric residents in a primary care clinic to help address psychosocial problems and prevent child maltreatment. Academic Pediatrics, 11(6), 474-480.

Dubowitz H. (2014). The Safe Environment for Every Kid model: Promotion of children’s health, development, and safety, and prevention of child neglect. Pediatric Annals, 43(11), e271-277. doi:10.3928/00904481-20141022-11

Dubowitz H. (2014). The Safe Environment for Every Kid (SEEK) model: Promoting children’s health, development and safety: SEEK offers a practical model for enhancing pediatric primary care. Child Abuse and Neglect, 38, 1725-1733. doi:10.1016/j.chiabu.2014.07.01.

Lane WG, Dubowitz H, Frick KD, Semiatin J, Magder L. (2021). Cost effectiveness of SEEK: A primary care-based child maltreatment prevention model. Child Abuse Negl. Jan;111:104809. doi: 10.1016/j.chiabu.2020.104809.

Eismann EA, Theuerling J, Maguire S, Hente EA, Shapiro RA. (2019). Integration of the Safe Environment for Every Kid (SEEK) Model Across Primary Care Settings. Clin Pediatrics, Feb;58(2):166-176. doi: 10.1177/0009922818809481.

Dubowitz H, Finkelhor D, Zolotor A, Kleven J, Davis N. (2022). Addressing Adverse Childhood Experiences in Primary Care: Challenges and Considerations. Pediatrics. Apr 1;149(4):e2021052641. doi: 10.1542/peds.2021-052641.

Letson MM, Brink FW, Daniels A, Thompson S, Wolf KG, Michaels NL. Implementation of SEEK in a Children’s Advocacy Center: A Process Improvement Initiative. Pediatr Qual Saf. 2022 Jun 23;7(4):e573. doi: 10.1097/pq9.0000000000000573.

Rated/Reviewed by Evidence Based Registries:

California Evidence-Based Clearinghouse for Child Welfare (CEBC)
Recognized as a promising practice to reduce child abuse and neglect by the U.S. Agency for Healthcare Research and Quality
Included in American Academy of Pediatrics’ Bright Futures

• English

• Yes

There are many free resources to help implement the SEEK model that can be downloaded (www.SEEKwellbeing.org) including algorithms to support PCPs in addressing the targeted problems.

Availability of Training:

Yes. The SEEK website provides online training. There are seven modules for the core training, with separate modules for each of the targeted risk factors.
There are two additional online modules and supplemental materials for PCPs and mental health professionals in primary health care settings, focused on:

• Relationship building
• Motivational interviewing
• Addressing barriers to engagement
• Probing suicidality

Training Costs:

Online training is free; there is a cost for Continuing Medical Education and MOC 2 credits (3 credits: $50). The Quality Improvement Activity approved by the Boards of Pediatrics and of Family Medicine (MOC 4 / PI): $100).

SEEK License Agreement: SEEK requires an Agreement with those implementing the model. There is a negotiable charge for large practices or systems involving over 25 PCPs.

Languages that training/resource is available:

Online training is in English; the website written information can be readily translated into most languages via Google Translate.

See training details.

Howard Dubowitz MD, MS, FAAP
410-706-6144
hdubowitz@som.umaryland.edu
www.SEEKwellbeing.org