Transcript Practicing Safety: Helping the Pediatric Office Prevent Child Abuse and Neglect Tammy Piazza Hurley, Project Director Manager, Child Abuse & Neglect.

Practicing Safety: Helping the
Pediatric Office Prevent Child
Abuse and Neglect
Tammy Piazza Hurley, Project Director
Manager, Child Abuse & Neglect
Background
 10-15% of young children are victims of serious physical
trauma (Finkelhor and Straus)
 Children < age 3 account for nearly 30 percent of
victims.
 Major morbidities of childhood: child abuse, discipline,
family stressors, divorce, depression, financial
concerns, violence, drug uses, affect many children
seen by pediatricians.
 Nearly 90% of children under age of 6 are seen by a
pediatrician and seen avg. 8 times in first 3 years of
life.
 Over 2/3 of parents discuss non-medical concerns w/
pediatrician.
Anticipatory Guidance
Two surveys assessing content of
health supervision of children
under 3 years of age
 National Survey of Early Childhood
Health (NSECH) – In 2000, parents of
children ages 4-35 months
 AAP Periodic Survey of Fellows – In 2000,
67% of U.S. random sample of 1600
members of AAP.
Parent Report of Topics Discussed
 Immunizations and feeding issues discussed
most with children of all ages up to 35 mos.
 With children ages 4-9 mos.child care, burn
prevention and reading were least
discussed.
 However unaddressed topics most valued by
parents of children ages 4-9 mos. Include
child care, reading, burn prevention, night
waking and how a child communicates.
Topics discussed 10-35 mos.
Least Discussed
Unmet Needs
10-18
mos.
 Discipline (43%)
 Child Care (35%)
 Toilet training (18%)
19-35
mos.
 Bedtime routine (47%)  toilet training
 Toilet training (45%)
 Discipline (45%)
 Child care (26%)




toilet training
child care
discipline
reading
 discipline
 getting along
 avoiding danger
Family & Community Risks
 Parents asked whether pediatric
clinician ever asked about well-being,
economic issues, substance use and
community violence.
 89 % of parents in favor of asking
parents about alcohol or drug use in
home but only 44% recalled being asked.
 Only 12% of parents indicated being
asked financial situation, yet 75%
believe it should be discussed.
Practicing Safety
Overall Goal:
Decrease child abuse and
neglect by increasing screening
and improving anticipatory
guidance provided by pediatric
practices to parents of children
ages 0-3.
Methodology
Complex Adaptive Systems Hypotheses:
1. The unit of change is not the provider - the unit
of change is the office.
2. The office is a complex adaptive system.
3. Any change that occurs is non-linear.
4. Each practice is an individual entity with its own
culture, its own systems.
5. Practices are not constructed to understand and
therefore modify their own systems.
6. Change to be effective must engage the practice
in self awareness.
Rationale for Methodology
At The Practice Level
1. The data on changing physician practice
2. Systems Approach
3. Impact Model
• A champion in the practice
Site selection criteria
• A practice capable of change
MAP Assessment
• Tools for System change
MAP/RAP
Multi-method Assessment Process (MAP)
 Direct observation of practice and clinical encounters
(2-5 days)
• Participant observation field notes
• Patient Pathways
• Structured and unstructured checklists
• Informal and formal interviews
• Practice Genogram
 Physician, staff, and patient surveys
 Chart reviews
Feedback & Facilitation
 Practice report (MAP Summary Report aka MSR)
generated and shared with practice stakeholders
 Values, structures, processes, and outcomes
shared along with reflection points
 Negotiated intervention
• Instrumental approaches
• Motivational approaches
 Follow-up & facilitation
Practice Genograms
Baseline survey responses from physicians
vs. other staff (N=124)
51
This practice is stressful.
31
staff
physicians
13
This practice is almost
always in chaos
4
0
20
40
60
% agree or strongly agree
Baseline survey responses from
physicians vs. other staff (N=124)
63
The staff and clinicians here
practice as a real team.
60
staff
physicians
This practice defines success
as teamwork and concern
for people.
85
86
0
20 40 60 80 100
% agree or strongly agree
Parent’s Experiences with Child’s Health Care
(Baseline)
Topic
%
Provider builds my confidence as a parent
85.3
Provider respects me as an expert about my child
82.7
Provider takes time to understand my child’s needs
81.0
Provider takes time to understand my family and how I
prefer to raise my child
58.3
Provider asks about how I feel as a parent
51.7
Reflections on the MAP
 Allowed for an “outsider’s view” of
the practice/health center
 Built a relationship with the
physicians and staff before
facilitation
 Created trust and buy-in between
the staff and the facilitator
 MAP “lite” had value
Reflective Adaptive Process (RAP)
 Facilitated, team-based intervention to
restructure psycho-social care.
 Cross-section of staff roles and a parent
as participants
 “Brown bag” working group, met weekly
for approx. 12 weeks
 Introduction of 7 PS modules
 Community resources
 Opportunity to “pilot” change.
PS Lite
TOOLKIT
7 Practicing Safety Modules
Focus on Prevention
Color coded Practice Guides:
 Red: Coping with Crying/SBS Prevention
 Purple: Parenting
 Pink: Safety in Others’ Care
 Blue: Family & The Environment
 Orange: Effective Discipline
 Green: Sleeping/Eating Issues
 Aqua: Toilet Training
Practicing Safety Modules include…
Practice Guides with:

Background information about
each topic

Assessment Questions

Anticipatory Guidance

Parent Educational Materials

Office Marketing Tools

Staff tools

Moderate Interactives/Tangibles

Issues Management
Practice Guide
A tool for the clinician
 Explanation of topic
 Stages to introduce and
reinforce information
 Assessment Questions
 Anticipatory Guidance
 Materials for the office,
parents, and staff
 Issues Management
Practice Guide - Utilization
A tool for the clinician
 Assessment
Questions
 Anticipatory
Guidance
Incorporate the materials into your
routine patterns of practice
Create and use a Community Resource Guide
First Module: Crying
Crying Assessment
Parents will not always bring up crying and they
are frustrated so ask
Is crying a problem?
How do you feel when this happens?
Who do you trust when you feel
overwhelmed?
Clinicians need to routinely discuss it at the
first few visits
Introduce at 2 weeks to 4 weeks
Reinforce at 2 months
Coping with Crying
Cry
Anticipatory Guidance
 Crying is natural
 It’s the way babies express
themselves
 It doesn’t always mean
something is wrong
Make suggestions
 Soothe the baby by
swaddling, cuddling or
rocking
 Play soft music
 Take a walk
 Take a time out
Coping with Crying
Suggest interventions that might help:
 Validate the parents’ feelings of stress, inadequacy or
even anger
 Ask routinely about sources of support, as well as
stressors
 Teach parents how to be aware of their baby’s
temperament
 Teach parents methods to calm their baby
Tools:
• Crying poster and cards * Prescription pad
• Swaddling guide
* Support magnet
• AAP Parenting brochure * Timer for parent time-out
When you believe that
the parents need more help…
 Have someone at the office make a
follow up call to see how the family is
doing
 Consider doing a home visit
 Schedule another appointment for the
family to come in the following week
 If it seems appropriate, consider
calling child protective services
Module 2: Parenting
Important topics to discuss as
part of well-child care
 The mental health of
parents
 Parenting styles
 Infant bonding and
attachment
Post Partum Depression
 The most common
complication of
childbearing
 10% of all new mothers
experience various
degrees of PPD and many
remain untreated
 These mothers may cope
with their baby and the
household tasks, but
enjoyment of life is
seriously affected.
 Possible long-term
effects on the family
Post-Partum Depression
Using the Edinburgh Postnatal
Depression Scale (EPDS)

A 10-question screening tool,
developed to assist primary care
health professionals

Easy to administer.

Proven valid and reliable

Indicates how the mother has felt
during the previous week

A woman scoring 9 or more pts. or
a 1 or higher on question #10
should be referred for follow-up.

It is important to screen all moms
at 1, 2, and 15 month old well-care
visits
J.L. Cox, J.M. Holden, R. Sagovsky. Detection of postnatal depression:
development of the 10-item Edinburgh Postnatal Depression Scale.
British Journal of Psychiatry, 1987; 150: 782-786
Parenting
Anticipatory Guidance
• Ask what the parents do for fun away
from child.
• Also ask about parenting styles and
how they were raised.
• Discuss the importance of spending
time playing with, talking with and
cuddling their baby
• Be sure to mention that the parent
cannot spoil their children by holding or
comforting too much.
Parenting
Tools
Parent Educational Materials
• ACOG PPD brochure
• AAP Parenting Your Infant brochure
• PCAA Bonding with your Child
Office/Staff Tools
• Poster
• Reading button
• Edinburgh Depression Scale
Module 3: Safety in Others’ Care
Anticipatory Guidance
• Selection of a childcare provider is an important decision
• Ask questions about child care practices, discipline, TV use
• What safety features
• Criminal background checks on employees
Patient Educational Materials
• Babysitter Reminders
• AAP/CDC A Parent’s Guide to Choosing Safe
and Healthy Child Care:
• Local Child Care Connection Sheet
Safety in Others’ Care
Office Marketing Tools
* “The Choice You make Today will last a lifetime”
poster
Moderate Interactive
• Support Magnet
Module 4: Family & the Environment
Assessment and Anticipatory Guidance
• If you need to get away for an hour, who do you call
• Are you OK financially
• Who helps with the baby
• Are you involved in community groups
Ask About these topics at every visit
• Domestic situation assessment
• Adequate housing
• Neighborhood safety
• Transportation
• Substance abuse
Family & the Environment
Patient Education Materials
• ACOG Patient Pocket/Shoe Card
(Domestic Violence)
• AAP Sibling Relationship brochure
• Single Parenting Brochure
Office Marketing Tools
• Refresh. Renew. Recharge. poster
Family & the Environment
Staff Tools
• Pediatric Intake Form: Bright Futures
• It’s Time to Ask: An Instructional Program for
Identifying and Intervening in Intimate Partner
Violence in the
• Parental Substance Abuse History Scripts
Moderate Interactives
• “You’re My Support” Postcards
• Support Telephone Numbers Magnet
Module 5: Effective Discipline
Assessment and Anticipatory Guidance
• Finding outlets for your child’s
autonomy/tantrums
• Problem Solving – a behavioral issue
• Normal childhood Aggression
• Positive Reinforcement
• Limit Setting
• Playing with your child
Effective Discipline
Patient Educational Materials
•“Playing is How Toddlers Learn”
brochure
•“Teaching Good Behavior: Tips on
How to Discipline”
brochure
•“Temper Tantrum” brochure
•“How Do Infants Learn” brochure
Effective Discipline
Office Marketing Tools
• Routine. Reading. Relationships. Rewards Poster
• Discipline: Teaching Limits with Love Video
Staff Tools
• Physician Prescription Pads
Moderate Interactives
• Sample Sticker Charts
• Sample Behavior Charts
• Sample Behavior Diary
Module 6: Sleeping and Eating Issues
Assessment and Anticipatory Guidance
• Do you have a bedtime routine
• Where does your child sleep
• Does your child sleep through the night
• What is the present mealtime experience
• Is there consistency in mealtime routines
• What is the child’s feeding history
Sleeping and Eating Issues
Parent Education Materials
• AAP “Sleep Problems in Children”
brochure
• “Feeding Kids Isn’t Always Easy”
brochure
Office Marketing Tools
• Four R’s Poster
Reading. Relationships. Routine.
Rewards.
Module 7: Toilet Training
Assessment and Anticipatory Guidance
• How will you know when you child is ready to toilet train
• What is your plan for toilet training
• What was your experience like
• Don’t be pressured by family or day care
Parent Education Materials
• Toilet Training brochure: AAP
• Toilet Training Guidelines –
The Role of Parents in Toilet Training (AAP)
• Toilet Training Guidelines: Day Care Providers –
The Role of Day Care Providers in Toilet Training (AAP)
Toilet Training
Staff Tools
• Toilet Training
Guidelines: The Role of
Clinicians in Toilet
Training: AAP
• Barton Schmitt Protocol
Moderate Interactives
• Potty Charts and Stickers
Implementation
Practices’ Change Outcomes – How 3 Practices Incorporated
Practicing Safety into Office Systems
Good Faith
Pediatrics*
Physician-owner
found routine
practice change
difficult, although
awareness of
importance &
purpose of PS has
increased.
Down Home
Pediatrics*
Corporate Health Pediatrics*
New well child visit
forms developed
were found not to
meet the needs of
all of the physicians
& were
discontinued.
Initially, RAP Team members did
not consistently communicate
with Division Dir. or Division Dir. to
Medical Dir. about well child care.
Practice grew more empowered to
impact effective change & works
creatively within local context to
achieve commitment from Medical
Dir. to bring ideas up through
corporate hierarchy.
* Names have been changed for confidentiality purposes.
Practices’ Change Outcomes – How 3 Practices Incorporated
Practicing Safety into Office Systems
Good Faith
Pediatrics
Down Home Pediatrics
Corporate Health
Pediatrics
-Perceived difficulty
to address abuse &
violence issues with
patient population
served.
-One physician on RAP
Team expressed concern
that not using forms led to
inconsistent
documentation.
-Psychosocial
assessment
processes
integrated into
routine practice
(e.g., crying,
parenting,
personality
concerns/issues).
-RAP Team working to
adapt existing
psychosocial assessments
forms to use in routine
practice. New forms will
include components from
the AAP form that prompt
for & document PS issues.
-RAP Team identified
opportunities for
providing Practicing
Safety education.
Presented a proposal to
Division Dir. & Medical
Dir. that outlined new
ways to implement PS
outside the well-child
visit (i.e., ongoing
group sessions in
waiting area with a
health educator).
Practices’ Change Outcomes – How 3 Practices
Incorporated Practicing Safety into Office Systems
Good Faith Pediatrics
-Practice proactively
initiates assessment of
psychosocial issues.
-Practice is more
reflective: awareness
has increased.
RAP Team continues to
hold co-facilitated
meetings.
Down Home
Pediatrics
- RAP Team
continues to
hold cofacilitated
meetings with
focus on forms
and
introduction of
new materials.
Corporate Health Pediatrics
-Post-natal Depression scale now
used at all 4 practice sites.
-Initiated use of Practicing Safety
newborn materials and resources.
-Review of current well-child visit
forms was conducted to address
redundancy and allow more time to
apply Practicing Safety anticipatory
guidance materials.
Data Analysis
Pre-Post Test Significance: Staff Responses
Tension in practice
Stressfulness in practice
data collected at
baseline or follow-up
Baseline
Follow-up
Data collected at
baseline or follow-up
Baseline
Follow-up
60.0%
Percent
Percent
60.0%
40.0%
40.0%
20.0%
20.0%
0.0%
Disagree
Agree
This practice is stressful.
0.0%
Disagree
Agree
There is often tension among people in this practice
Pre-Post Test Significance: Staff Responses
Difficulty making changes in practice
data collected at
baseline or follow-up
Baseline
Follow-up
100.0%
Percent
80.0%
60.0%
40.0%
20.0%
0.0%
Disagree
Agree
It's hard to make any changes in this practice
because we're so busy seeing patients.
Pre-Post Test Significance: Staff Responses
Use of screening tool for depression
Counseling for maternal depression
Data collected at
baseline or follow-up
Baseline
Follow-up
80.0%
60.0%
60.0%
Percent
Percent
Data collected at
baseline or follow-up
Baseline
Follow-up
80.0%
40.0%
40.0%
20.0%
20.0%
0.0%
Never or rarely
At least occasionally
How often do you use a health risk assessment (HRA)
protocol or questionnaire to identify parents or
patients who may benefit from counseling or other
interventions for the following - Maternal depression
0.0%
Never or rarely
At least occasionally
How often do you use nurses or health educators,
within your practice, for individual counseling to your
patients with - Maternal depression
Pre-Post Test Significance: Staff Responses
Use of group counseling for maternal
depression
Referrals for maternal depression
Data collected at
baseline or follow-up
Baseline
Follow-up
60.0%
Data collected at
baseline or follow-up
Baseline
Follow-up
100.0%
50.0%
80.0%
Percent
Percent
40.0%
30.0%
60.0%
40.0%
20.0%
10.0%
20.0%
0.0%
Never or rarely
At least occasionally
How often do you refer your patients to community
programs (e.g.) patient education classes, support
groups, and/or individual counseling) for - Maternal
depression
0.0%
Never or rarely
At least occasionally
How often do you use group-counseling activities
within your practice for patients with - Maternal
depression
Pre-Post Test Significance: Staff Responses
Counseling for parental stress
Counseling for parent substance use
Data collected at
baseline or follow-up
Baseline
Follow-up
60.0%
Data collected at
baseline or follow-up
Baseline
Follow-up
80.0%
Percent
Percent
60.0%
40.0%
40.0%
20.0%
20.0%
0.0%
0.0%
Never or rarely
At least occasionally
How often do you use nurses or health educators,
within your practice, for individual counseling to your
patients with - Parental stress
Never or rarely
At least occasionally
How often do you use nurses or health educators,
within your practice, for individual counseling to your
patients with - Parental substance abuse
Parent Survey
Methods
 100 parents of children under age 4 recruited at each site
(by office staff and/or PS team)
 14-page survey (English and Spanish) with skip patterns for
age-specific items administered in office and/or by mail
 Up to 4 mailings and $10 incentive for completion of survey
Results
 High response rates for baseline surveys
NJ sites: 96% – 72%
PA sites: 90% - 44%
 Time for office staff to collect informed consents and/or
administer surveys on site: weeks – months
Pre-Post Test Significance: Parent Responses
Asked about depression
data collected at
baseline or follow up
Baseline
Follow up
80.0%
Percent
60.0%
40.0%
20.0%
0.0%
Yes
No
In the last 12 months, have your child’s doctors or
office providers in this practice asked you: If you
ever feel depressed, sad, or have crying spells
Pre-Post Test Significance: Parent Responses
Reading to your child
data collected at
baseline or follow up
Baseline
Follow up
Percent
30.0%
20.0%
10.0%
0.0%
Not at all
Once or
Twice
Several
Times
About once a
day
More than
once a day
How many times in the past week did you look at or
read a book with your child?
Pre-Post Test Significance: Parent Responses
Safety in the home
data collected at
baseline or follow up
Baseline
Follow up
80.0%
Percent
60.0%
40.0%
20.0%
0.0%
Yes
No
Have you Put up baby gates or other safety barriers
in your home?
Qualitative Medical Record Review
Methods:
 50 charts/practice at baseline and
50 charts/practice post-intervention
 Multiple reviewers
 Instrument included open ended items corresponding to
the PS modules
 Reviewed three most recent WC visits
Qualitative Medical Record Review (cont.)
PS Topic
Feeding
Sleeping
Safety in others’ care
Parenting
Discipline
Toilet training
Family & environment
Coping with crying
*268 charts total
Baseline charts
with documentation*
97%
78%
49%
47%
40%
29%
17%
6%
Qualitative Medical Record Review (cont.)
Examples of baseline abstractions (intake)
 Parent concern: “screamed for ~1 hr yesterday at ball
field – even BF didn’t calm completely”
 Concerns/questions: “high energy, intense baby”
 “No concerns - Mom feeling well and not too
overwhelmed”
 Home: mom – rest  support  blues 
 Sleep: “dreadful; with parents”
Examples of baseline abstractions (advice)
 Parent sheet: “read together”
 “Antic. Guidance: consistent discipline, time out”
Qualitative Medical Record Review (cont.)
Post intervention review currently underway
Examples of post intervention abstractions (intake)
 Concerns and questions: “mom concerned re: poor eating”
 Child care: “G-mom x3/wk”
 “Mom due in January - new baby”
Examples of post intervention abstractions (advice)
 A/G: family relationships , sibling rivalry , age
appropriate discipline , set limits and time out 
 Sleep: “not sleeping with mom now; still waking @ night –
discussed”
Tool-kit Evaluation
Tool Evaluation Summary
Overall usefulness of modules (Percentage of respondents
who rated module as 3 or 4)
Module 1:
Coping with
Crying
Module 2:
Parenting
Module 3:
Safety in
Others’ Care
Module 4:
Family & the
Environment
Module 5:
Effective
Discipline
Module 6:
Sleeping and
Feeding
Module 7:
Toilet Training
90
80
70
60
50
40
30
20
10
0
1
ule
d
Mo
2
ule
d
Mo
3
ule
d
Mo
4
ule
d
Mo
le
du
o
M
5
le
du
o
M
6
7
ule
d
Mo
Tool Evaluation by Module
Coping with Crying Module
Rated most useful

“Coping with Crying” posters
(95% rated 3 or 4)

“World of Parenting” brochure
(83% rated 3 or 4)
Parenting Module
Rated most useful

“Post-partum Depression” brochure
(89% rated 3 or 4)

“Bonding With Your Child” booklet
(88% rated 3 or 4)
Safety in Others’ Care Module
Rated most useful

Support telephone numbers magnet
(82% rated 3 or 4)

“Choosing Child Care: What’s Best for Your
Family” (59% rated 3 or 4)
Family and the Environment Module
Rated most useful

Support telephone numbers magnet (88% rated 3 or 4)

Domestic violence pocket/shoe card (74% rated 3 or 4)
Effective Discipline Module
Rated most useful

“Teaching Good Behavior—Tips on Discipline” brochure
(88% rated 3 or 4)

“Temper Tantrums: A Normal Part of Growing Up”
brochure (87% rated 3 or 4)
Sleeping and Feeding Module
Rated most useful

“Sleep Problems in Children” brochure
(75% rated 3 or 4)

“Feeding Kids Isn’t Always Easy” brochure
(75% rated 3 or 4)
Toilet Training Module
Rated most useful

“Toilet Training” brochure (95% rated 3 or 4)

“Bed-wetting” brochure (89% rated 3 or 4)
Successes With Tool-kit Implementation
1.
2.
3.
4.
5.
6.
7.
8.
Crying, the #1 leading indicator for SBS – all 6 practices in NJ
and 2 in PA now discussing normal crying behaviors of infants
and how to cope with it.
All 6 practices in NJ screen for maternal depression.
5 of NJ practices who did not provide info/support on good
child care opportunities are now doing so.
All practices now discussing toilet training, liked tool to help
parents encourage children to be consistent, also stressing
importance of not punishing for accidents.
All practices like Connected Kids brochures – important
messages that are being reinforced by pediatrician/nurse.
Posters developed are well-liked by practices. Receiving
requests from other pediatricians for copies.
Some practices commented how easy to implement
materials and discussion.
Helpful to have tools in English and Spanish.
LESSONS
LEARNED
Lessons Learned
Practice Change
1.
Some idea of how the practice works (MAP) is
needed but not the depth of the analysis as
currently done.


2.
Providing a summary of the data to the practices is
very useful for sustaining the effort.
Many practices have not thought about their
environment of care and how improving it helps to
let the family know what is important to the
practice.
Different practices require different
intensities of implementation.
Lessons Learned
Practice Change Cont’d.
3.
Interoffice communication and problem solving may be
most important piece of creating and sustaining
change.


4.
Many practices are silos and don’t communicate.
They don’t know what community resources exist.
Getting the whole practice involved and looking at
new roles for the office staff is very useful.

5.
The practice champion isn’t always the pediatrician and
doesn’t need to be.
Reflective learning is very helpful to a practice in
making change.

Practices need to decide what pieces work best for them
and be allowed to individualize the process of care.
Lessons Learned
Practice Change Cont’d.
6.
Some type of facilitation is needed to help
the practices make change.
It takes time for change.
7.


Practices get overwhelmed easily with new
materials, particularly if they might lead to extra
time with the family or the need to work out new
care plans of referrals.
Seven modules may have been too much to
implement in too short of a time period.
Lessons Learned
Tools/Anticipatory Guidance
1.
Most practices are not talking about these
topics but see need to do so and want
guidance and tools.
Universal use of the tools is the best
approach rather than targeted use.
Practices like short screening tools that can
easily determine if a referral needs to be
made (eg, maternal depression.)
2.
3.

Reluctance however to screen for domestic
violence and substance abuse using tools.
Lessons Learned
Tools/Anticipatory Guidance Cont’d.
4.
The tools were well received; primarily the
posters, brochures and scripts were
identified as most useful.
Need to get the materials into an electronic
format for ease of building the materials into
the core of the practice style.
5.

6.
The cost of the materials and therefore ongoing
use remains an unanswered question.
Strong need for better connection to
community resources.
How do I get the toolkit?
Visit us at our Web site at
www.aap.org/practicingsafety
Current Grant
Funding from DDCF to:
1. Refine the tool-kit and materials.
2. Identify new strategies for linking pediatric practices
to community-based resources and service providers.
3. Further streamline the office-based change
methodology while identifying alternative approaches
for dissemination of Practicing Safety model.
4. Develop an outcome-based research design, including
identification or development of a parental
assessment instrument to assess changes in
knowledge, behavior and attitude of parents of
children ages’ birth to 3 years old.
WHAT’S NEXT?
3.
4.
Further streamline the office-based change
methodology while identifying alternative approaches
for the dissemination of the Practicing Safety child
abuse prevention model.
Develop an outcome-based research design, including
identification and development of a parental
assessment instrument to assess changes in
knowledge, behavior and attitude of parents of
children ages’ birth to 3 years old for prevention of
child maltreatment.
Further Assessment
 Focus group discussion sessions were
conducted with 5-8 members of the practice
staff, including members and non-members
of the Reflective Adaptive Process (RAP)
team.
 In-depth telephone interviews were
conducted with a physician in each of the
practices.
 Qualitative data collected were reflexively
coded by 3 members of the research team
separately. Inter-rater reliability was
checked.
Changes in practice
 Raised awareness about child abuse and neglect.
 Maternal depression screening was adopted by 4
of the 5 pediatric practices. The practice that did
not adopt screening identified lack of a referral
source for depressed mothers within the
community.
 Infant crying, discipline and toilet training
modules were also implemented by the practices.
 Maternal drug and alcohol issues were generally
difficult for practices to address although those
with established referral systems to social
workers fared better.
 Most practices noted that the intervention
program contained too much information.
Strengths of Practicing Safety
Staff focus groups
 Raised staff and MD awareness of issues and approach
to patients/parents.
 Helped institute depression screening and discussion
of toilet training.
 Provided opportunity for practice to reflect
 Materials and helping identify parents at risk
Physician interviews
 Increased awareness of problems leading to child
abuse & neglect
 Developed more systematic ways of sharing
information
Weaknesses
Focus Groups
 Too much information (and cost of materials)
 Not targeted to varied audience
 Lack of feedback loop – from docs back to staff and
from parents back to staff – staff discontent with
not knowing impact of PS materials/efforts
 No change in roles; staff wanted to play a bigger
role
Physician Interviews
 Too many meetings
 Materials too wordy, language barriers
 Staff complained of too much work
Revisions
5 Points to Practicing Safety
1. Reflective Practice Change
2. Infant
3. Mother
4. Toddler
5. Community
Toolkit Revision
BUNDLES
Infant
Mother
Toddler
INFANT
Crying
Key questions/messages
 Is crying a problem
 Babies cry 2-4 hrs/day
 Who can you call if you need a break
Tools
 Crying poster
 Welcome to World of Parenting brochure
 Swaddling Guide
 Crying cards
MOTHER
Maternal Depression
Key questions/messages
 In past year, have you had 2 weeks of sadness?
 Is father around for support?
 What have you done for fun?
Tools
 Edinburgh depression screening tool
 ACOG maternal depression brochure
 Bonding poster
 Crying cards
TODDLER
Toilet Training
Key questions/messages
 How is potty training going?
 What do you do when your child has an
accident.
 Don’t punish your child for accidents.
Tools
 AAP brochure
 Potty chart
TODDLER
Discipline
Key questions/messages
 How often does your child have tantrums?
What do you do?
 How do you punish your child?
 How do you reward them?
 Normal developmental stages
Tools
 AAP brochures
 Reading, Routine, Relationships, Rewards
poster
SPREAD
Two approaches:
1. Institutional partner


Such as a children’s hospital with a
network of practices
Use their current QI model
2. AAP Chapters



RFP to find chapter with capacity
Modified MAP/RAP
Virtual facilitation via phone
Acknowledgements
Funding for this project has been provided by the Doris Duke
Charitable Foundation. This project was coordinated by the
American Academy of Pediatrics, in partnership originally with
the University of Medicine and Dentistry of NJ-School of Public
Health and currently with the University of Pittsburgh School of
Public Health.
Project Team
Steve Kairys, MD, MPH
Diane Abatemarco, PhD, MSW
Principal Investigator
Co-Investigator
[email protected] [email protected]
Tammy Piazza Hurley
Project Director
[email protected]
Ruth Gubernick, MPH
Practice Facilitator
[email protected]
[email protected]