Multifaceted Program That Screens for Maternal Depression, Infant Crying, and Toilet Training Enhances Ability of Pediatricians to Identify and Address Cases of Potential Child Abuse

Problem Addressed

Pediatricians are in a prime position to identify and prevent child abuse and neglect. However, attempts to implement psychosocial interventions that target child abuse and neglect in pediatric practices have been disappointingly slow, marginally effective, and/or have involved increased practice costs.¹

• Young children at risk of abuse: An estimated 10 million children are exposed to domestic violence each year²; children age 3 years and younger account for nearly 30 percent of victims of physical, emotional, and sexual abuse.³ Children of battered women are more likely to be abused.³
• Failure to screen among pediatricians: Active screening, including having mothers fill out a questionnaire asking about their exposure to domestic violence, increases the odds of identifying families experiencing domestic violence, but this is rarely done in pediatric practices.⁴ A national survey of more than 1,600 pediatricians revealed that, although 85 percent of pediatricians agree on the importance of addressing abuse, neglect, and other psychosocial issues, fewer than 60 percent reported having consistent discussions with parents about developmental concerns.⁵ Part of the problem is that pediatricians feel inadequately equipped to handle the complexity of abuse and psychosocial problems in their clinical practice; most practices have insufficient communication systems, capacity, and financial resources to introduce new programs, methods, or processes into their established routines.⁴
• Ineffectiveness of traditional interventions: Continuing medical education, performance review and feedback, practice guidelines, enhanced financial incentives, continuous quality improvement, and physician profiling do not make pediatricians more effective at addressing psychosocial issues.⁴ Although primary care residency programs now include more psychiatric and behavioral pediatric and developmental training, no associations have been found between enhanced training and better identification of psychosocial problems.⁴ More effective approaches at the practice level are needed to alter how pediatricians provide preventive services.⁴

Description of the Innovative Activity

Five pediatric practices participated in a study to rethink patient care processes, based on complex adaptive systems theory, to more effectively screen for and address child abuse and neglect. The practices incorporated several American Academy of Pediatrics (AAP) Practicing Safety education and screening tools that help raise awareness and give providers and office staff the capacity to comfortably address these complex psychosocial issues with parents and make referrals when necessary. The practices implemented the following strategies:

• Screening for postnatal maternal depression: The pediatricians screen new mothers, using a postnatal depression scale, during the 2-week, 1- and 2-month well-child visits. The screening provides the opportunity for providers to routinely discuss maternal depression and other psychosocial issues. Providers make referrals to either onsite social workers or other community services when appropriate and available. One practice has modified its existing psychosocial assessment forms to include components from the AAP Practicing Safety initiative.
• Probing how parents cope with crying: Because chronic crying can trigger abuse, pediatricians ask parents to describe the baby’s personality, if crying is a problem, if they think the child is misbehaving, and whether they have someone they trust to turn to when they are feeling overwhelmed. The clinicians provide “anticipatory guidance” about crying through discussions and educational materials from AAP's Practicing Safety Web site. For example, information about the average length of crying for infants and how that varies by individual temperament is provided. Written materials on strategies for handling crying, such as swaddling and use of a timer, are inserted in newborn packets and patient handouts, and are prominently featured on posters and in other age- and topic-specific materials placed in patient waiting and exam rooms.
• Asking about toilet training: Because toilet training is another high-stress parenting endeavor, pediatricians screen parents about their children’s experience by asking if the child is showing any interest in potty training, if diapers are ever dry after a nap, how the parents know when a child is ready for toilet training, what the parent’s potty training plan is, and if other caregivers will participate. Pediatricians also provide “anticipatory guidance,” suggesting that parents do the following: not pressure children to use the potty, use consistent encouragement, allocate a block of time for toilet training, and use a potty instead of a seat that fits over the toilet seat. Providers also ask parents about their own childhood experiences, any negative memories of their own toilet training, and what influences their reactions may have on their children.
• Providing information about domestic violence: Most participating practices place small cards in the bathroom that promote a domestic violence hotline and provide other information about domestic abuse. One practice also began asking parents direct questions related to domestic violence.
• Improving awareness of community resources and referral sources: All practices have designated a staff member to learn about referral resources that are available within their communities that can provide parent education, child abuse intervention, domestic abuse services, and family counseling and therapy.
• Reporting suspected parent drug and alcohol abuse: Front desk staff within the practice are instructed to report cases of suspected drug or alcohol abuse among parents to providers and human services social workers.

References/Related Articles

Federal Interagency Forum on Child and Family Statistics. America’s children: key national indicators of well-being. Washington, DC: U.S. Government Printing Office; 1999. Available at: http://www.cdc.gov/nchs/data/misc/amchild.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software.)

American Academy of Pediatrics’ Practicing Safety Program. A program that works to decrease child abuse and neglect by expanding anticipatory guidance and increasing screening for possible child abuse and neglect by pediatric practices to parents of children ages 0-3. Available at: http://www.aap.org/practicingsafety

American Academy of Pediatrics Practicing Safety Web site. Available at: http://www.aap.org/practicingsafety/index.htm

Abatemarco D, Kairys S, Gubernick R, et al. Expanding the pediatrician's black bag: a psychosocial care improvement model to address the "new morbidities." Jt Comm J Qual Patient Saf. 2008 Feb;34(2):106-15. [PubMed] Available at: http://www.ingentaconnect.com/content/jcaho/jcjqs/2008/00000034/00000002/art00005

Contact the Innovator

Results

Although no quantitative results are available, qualitative data from focus groups of pediatric staff and in-depth interviews with pediatricians from each practice following implementation suggest that two practices have increased referrals of at-risk families to its onsite social workers. Nearly all providers believe they are now more aware of the potential for child abuse and neglect and more effective in communicating with parents, screening mothers for postnatal depression, and asking about crying and toilet training.

• Increased awareness and better communication: Providers and office staff report increased awareness about child abuse and improved communication with parents.
• Expanding referrals and referral relationships: Two practices report having increased referrals to its onsite social worker, thus allowing more at-risk families to get the services they need. While the other three practices could not document an increase in referrals, four out of five practices report having established or strengthened relationships with community-based social service agencies that offer interventions, classes, and other parenting support.
• More comprehensive screening for psychosocial issues: All practices report increased questioning about chronic crying and toilet training, and four out of five more consistent identification of depressed mothers.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps in the planning and development process included the following:

• Forming a team to prepare for implementation: A project facilitator worked with a reflective adaptive process (RAP) team made up of practice staff; physicians; and, where possible, a parent representative, managed the implementation of the Practicing Safety methods in each practice and monitored ongoing progress. The facilitator first assessed each practice’s readiness to implement the program, using such methods as chart audits to determine how many families received psychosocial counseling and/or written educational materials about behavioral development and a survey to determine how much of the clinic’s physical space was dedicated to patient education. Implementers examined relationships and patterns of behavior within the practice, office routines, processes, and external factors that could affect the practice’s capacity to restructure its psychosocial care.
• Implementing the program: Each practice reviewed all modules and tools available through Practicing Safety and selected the materials and tools appropriate for its practice. Each practice identified staff members to be responsible for implementing the modules.
• Identifying community resources: The project team developed resource guides for each practice that identified parenting classes, social service agencies, and other community-based organizations that provide help when additional education, support, or child welfare intervention is needed. The practice was then asked to develop and maintain the guide.
• Ongoing monitoring: The project team conducted periodic post-implementation chart reviews to determine the number of referrals, assess the degree of patient education, and document the degree to which changes in well-child screening practices now incorporate psychosocial topics.

Resources Used and Skills Needed

• Internal staffing impact: Academic researchers worked with practice staff to map each site's current practices and to form the implementation teams. At the site level, no new staff were needed, as an internal champion and/or small team participate in the program as a part of their regular duties. This champion/team takes responsibility for working with the researchers to review internal processes, recruit patients, implement strategies to improve identification and screening, distribute educational materials, and cultivate relationships with community-based organizations.
• Role of consultant: The project facilitator served as the consultant to the practices to analyze practice culture, configurations, and work with the onsite implementation team. The innovator plans to develop a train-the-trainer program to provide more opportunities for practices to implement the program.

Funding Sources

American Academy of Pediatrics; Doris Duke Foundation

Tools and Other Resources

American Academy of Pediatrics’ Practicing Safety Web site. Provides guidelines, handouts, professional training materials, posters, and other information on all seven modules. Available at: http://www.aap.org/practicingsafety/index.htm

Abatemarco D, Kairys S, Gubernick R, et al. Expanding the pediatrician's black bag: a psychosocial care improvement model to address the "new morbidities." Jt Comm J Qual Patient Saf. 2008 Feb;34(2):106-15. [PubMed] Available at: http://www.ingentaconnect.com/content/jcaho/jcjqs/2008/00000034/00000002/art00005

Getting Started with This Innovation

• Analyze current practice: Perform a genogram of the practice to map staff relationships, review job descriptions, and understand how staff members communicate within and outside established channels and meetings. Map a patient’s experience within the practice, from the initial telephone call to the end of the visit, including who has access to the patient and where opportunities exist to provide information and education, including through well-child development forms and newborn parent packets.
• Have RAP team revise current processes, job descriptions, and goals: Form the RAP team (which should include staff representatives and at least one parent) and charge team members with identifying the Practicing Safety modules that are most appropriate for the practice's families. Have the team assess needed changes in staffing, job descriptions, support services for psychosocial issues, health screening forms, parent education resources, provider-patient communication, and community relationships. Have the RAP team monitor and evaluate changes on an ongoing basis, including use of new screening methods for domestic abuse and the number of referrals made to parent education or counseling services.
• Identify community resources: Identify parenting classes, support groups, professional training sources, social workers, counselors, and other community resources for parents. Where feasible, provide information on these resources in the waiting area.
• Start small: Most practices chose to implement only two or three of the Practicing Safety program's seven modules.

Sustaining This Innovation

• Maintain ongoing monitoring: Maintain the RAP team, and hold regular meetings to monitor progress. The team should be charged with identifying opportunities to expand the intervention by improving parent education, enhancing well-child forms, and improving other psychosocial interventions.
• Plan for staff turnover: Because of high staff turnover within many practices, it is important to review the program's goals and processes on a regular basis, including with all new staff. 

Additional Considerations and Lessons

• Advantages to onsite social worker: The practices that are most successful in abuse and neglect prevention become “medical homes” in the psychosocial arena. For example, the one Federally Qualified Health Center that participated appeared to have the greatest success with the program, due primarily to its onsite social worker who works with patients in the office and makes home visits as needed.
• Lack of referral sources hinders success: Some providers reported lacking appropriate community referral sources for depressed mothers or parents suspected of substance abuse. As a result, they deliberately did not address those issues during office visits.

Use By Other Organizations