HPs in pediatric primary care can play an important role in helping to identify and address prevalent psychosocial problems that impair parental and family functioning and constitute risk factors for CM.15,16,19
The SEEK model of pediatric primary care was developed to help HPs play this preventive role. To our knowledge, it is the first such randomized controlled trial regarding this issue.
We hypothesized that SEEK would improve HPs' attitudes, knowledge, comfort, competence, and practice behavior in addressing the targeted risk factors. Long after the initial training, SEEK HPs reported greater improvement than controls in their overall comfort and competence concerning all the risk factors. They similarly reported improved attitudes and behavior concerning IPV, substance abuse, and major parental stress. The enduring improvement up to 36 months is especially encouraging, as early improvements found in demonstration projects are often not sustained.4
We examined the HPs' practice behavior in 2 additional ways: (1) by reviewing the children's medical records; and (2) observing the HPs conducting routine checkups. Both revealed that mothers in the SEEK group were more likely to be screened compared with controls. It is noteworthy how seldom screening occurred without the SEEK model, including while being observed. Again, it is encouraging that the improved screening was evident 2 years after the initial training.
The PSQ contributed substantially to the improved screening. This attests to the value of having a practical, brief tool as part of SEEK. It was automatically included in selected well-child visits and HPs did not need to make additional efforts.
We probed what explained the change in HPs' attitudes and behavior. Changes in HPs' comfort level, perceived competence, attitudes, or knowledge did not mediate SEEK's relation with improved screening for depression, substance abuse, or major stress. Perhaps the PSQs were the primary reason for the improved screening, which also suggests the usefulness of a practical screening tool.
However, for IPV screening, we found that improved attitudes and comfort level specific to IPV partially explained improved IPV screening. This supports earlier research suggesting that a lack of comfort impeded screening for IPV in private pediatric practice.20
It is clear that HPs need to be prepared to tackle this challenging problem.
We also examined whether SEEK training would affect male and female HPs differently. Previously, female physicians were found to engage more in psychosocial issues.21,22
However, we found that male and female HPs improved similarly in their screening behavior. Perhaps gender differences are becoming less significant as more male HPs accept the importance of psychosocial issues in health care. Gender differences may also have been minimized by most SEEK HPs being highly motivated by the model.
To further probe what influenced screening, we examined the impact of HPs' duration in practice. Previous literature has not identified whether duration in practice is associated with screening for psychosocial problems.23,24
Baseline screening percentages did not differ, but at follow-up, screening for depression and substance abuse was more frequently documented in the medical records by more experienced SEEK HPs. Possibly, more experienced HPs felt more comfortable in their practice and open to incorporate something new compared with younger HPs.
There are several limitations to this study. The relatively small sample might limit the generalizability of our findings. However, we think that our sample of HPs is probably representative of those in pediatric private practice. In addition, the findings are comparable to those in a similar study done in resident continuity clinics serving a high-risk urban population.5
SEEK HPs may have been more aware of the study goals, modifying their responses to the HPQ and their behavior when observed. A limitation of self-report data is the possibility of respondents providing socially desirable information.
Improvement in screening is an important first step. However, identification of risk factors alone does prevent CM. We did find less psychological aggression (eg, swore or cursed) and minor physical assault (eg, shook or slapped) reported by mothers toward their children in the SEEK practices (data not shown); these findings support those of the previous SEEK study in a high-risk population.5
Our data (not shown) also indicate that after a positive screen, HPs did generally assess and take some action.
Despite recommendations to screen for psychosocial problems, physicians often state that they lack the knowledge, tools, or time.25–27
SEEK provides the necessary tools, enabling HPs to meet the goals of Bright Futures
This study shows how the SEEK model of pediatric primary care offers a practical approach to helping address serious and prevalent psychosocial problems that jeopardize children's health, development and safety. The training, the PSQ, and parent handouts, and the availability of a social worker are all likely to have contributed to the HPs' gains in comfort level, competence, and increased screening.
These findings offer promise that pediatric primary care HPs can be effectively equipped to help address psychosocial problems confronting many families and children. It is especially encouraging as the SEEK model has been associated with reductions in child maltreatment.5
Thus, the SEEK model may help move pediatric practice beyond a focus on the identification and reporting of CM into the realm of prevention.