Safe Environment for Every Kid (SEEK)

About This Program

Target Population: Primary Prevention use: Families with children aged 0-5 years. Secondary Prevention use: Families with children aged 0-5 years who have risk factors for child maltreatment such as parental depression or substance abuse

For children/adolescents ages: 0 – 5

For parents/caregivers of children ages: 0 – 5

Program Overview

SEEK utilizes pediatric primary care as an opportunity to help address social determinants of health and to prevent child maltreatment in families who may have risk factors for child maltreatment. Most children receive this care and there are frequent visits in the first 5 years. Also, the generally good relationship between health professionals and parents offers an opportunity to identify and help address prevalent psychosocial problems. By addressing these problems, SEEK aims to also help strengthen families, support parents and parenting, and promote children's health, development, and safety.

SEEK begins with training professionals to play this role. Online videos and other materials are available on the SEEK website. Continuing Medical Education (CME) credit is offered as well as Maintenance of Certification (MOC) Categories 2 and 4 and Performance Improvement (PI) credits (through the American Board of Pediatrics and the American Board of Family Medicine). The revised SEEK Parent Questionnaire-R (PQ-R) is a tool to screen for the targeted problems: parental depression, substance abuse, major stress, intimate partner violence, food insecurity, and harsh punishment. It is completed in advance and given to the professional at the start of a regular checkup.

The trained professional then briefly assesses and initially addresses identified risk factors and makes necessary referrals to community resources, ideally with the help of a behavioral health professional. Principles of Motivational Interviewing have been incorporated into SEEK. SEEK Parent Handouts are available as adjuncts to advice offered in the visit.

Program Goals

The goals of Safe Environment for Every Kid (SEEK) are:

  • Learn strategies and techniques to strengthen their family
  • Learn strategies to increase good parenting practices for young children
  • Learn how to increase their young child(ren)'s health, development, and safety
  • Decrease likelihood of abusing and/or neglecting their young child(ren)

Logic Model

The program representative did not provide information about a Logic Model for Safe Environment for Every Kid (SEEK).

Essential Components

The essential components of Safe Environment for Every Kid (SEEK) include:

  • Health Professional Training:
    • SEEK recognizes the importance of preparing child health professionals to assess and address problems such as parental depression and intimate partner violence.
    • Initial training is via online videos and other materials.
    • Ongoing training and support is offered.
    • CME credits are available, as well as MOC Categories 2 and 4 and PI credits are available through the American Board of Pediatrics and the American Board of Family Medicine.
  • Motivational Interviewing (MI): SEEK incorporates principles of Motivational Interviewing to improve upon the traditional prescriptive approach to more effectively work with parents in planning and engaging in services.
  • The SEEK Parent Questionnaire-R (PQ-R):
    • The PQ-R is a brief screening tool parents complete before seeing the health professional.
    • It has 15 questions and takes 2-3 minutes to complete.
    • It is currently available in English, Spanish, and Italian.
    • The prior version is also available in Chinese and Vietnamese.
    • It can be completed on paper or computer.
  • SEEK Parent Handouts:
    • User-friendly, one-page handouts are available for all of the targeted problems.
    • Handouts include space to list local resources and customized information about the practice.
    • It is critical that professionals know what is available in the community to help address identified problems, such as substance abuse.
  • Behavioral Health Professional:
    • It is recommended that medical professionals work with a behavioral health colleague, such as a social worker.
    • SEEK, however, has been designed to be deliberately flexible regarding who does what in addressing problems. Some medical professionals are interested in playing a substantial role, others less so.
    • Some parents may prefer discussing sensitive matters with the professional they know and trust. Thus, many health professionals do address psychosocial problems, with office or clinic staff helping to facilitate referrals.

Program Delivery

Child/Adolescent Services

Safe Environment for Every Kid (SEEK) directly provides services to children/adolescents and addresses the following:

  • At high-risk for maltreatment, including those experiencing food insecurity, hunger, poor growth, harsh punishment, having a parent who is depressed or abusing substances including alcohol, and having witnessed intimate partner violence (IPV)

Parent/Caregiver Services

Safe Environment for Every Kid (SEEK) directly provides services to parents/caregivers and addresses the following:

  • Depression, substance abuse, intimate partner violence (IPV), major parental stress, food insecurity, and use of harsh punishment
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: SEEK encourages enlisting family members for support, and/or referring to community resources for services such as substance abuse treatment. The response is carefully tailored to the needs and interests of the individual parent and family.

Recommended Intensity:

It is recommended that the SEEK Parent Questionnaire be administered at many of the regular checkups in the first 5 years, such as at 2, 9, 15, 24, 36, 48, and 60 months.

Recommended Duration:

Until the child reaches 5 years of age

Delivery Setting

This program is typically conducted in a(n):

  • Outpatient Clinic

Homework

This program does not include a homework component.

Languages

Safe Environment for Every Kid (SEEK) has materials available in languages other than English:

Chinese, Italian, Spanish, Swedish, Vietnamese

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • A "champion" to lead implementation of the Safe Environment for Every Kid (SEEK)
  • Buy-in from the health professionals in the practice, preferably all
  • 20 minutes to train office staff
  • Access to a behavioral health professional is ideal, but not essential

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Medical professionals should be licensed to practice as pediatricians, family medicine physicians, nurse practitioners, or physician assistants.

Behavioral health professionals need at least a Master's degree in a relevant field and to be licensed to provide clinical services.

Manual Information

There is not a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Online, electronically, webinars, phone

Number of days/hours:

Initial training: 2-3 hours

Ongoing training: Variable, depending on needs and interest

Maintenance of Certification (MOC) Category 4 or Performance Improvement (PI): 8 hours

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Safe Environment for Every Kid (SEEK) as listed below:

The SEEK Primary Care Professional Questionnaire assesses attitudes, knowledge, level of comfort, perceived competence, and practice behavior regarding addressing the problems targeted by SEEK..

Formal Support for Implementation

There is formal support available for implementation of Safe Environment for Every Kid (SEEK) as listed below:

The SEEK project office based in the Department of Pediatrics at the University of Maryland School of Medicine offers technical assistance to interested parties. Contact the program representative (see bottom of the page) for more information.:

Fidelity Measures

There are fidelity measures for Safe Environment for Every Kid (SEEK) as listed below:

  • The SEEK Primary Care Professional Questionnaire
  • The SEEK Medical Record Review

All of the measures can be obtained from the Evaluation section of the SEEK website.

Implementation Guides or Manuals

There are implementation guides or manuals for Safe Environment for Every Kid (SEEK) as listed below:

The SEEK website (http://www.SEEKwellbeing.org) has a section on Implementation that offers detailed information to assist with the implementation of SEEK, such as the SEEK Parent Questionnaire-R (PQ-R) and the SEEK Algorithms and Parent Handouts, information on CME, and MOC and PI processes, and responses to Frequently Asked Questions (FAQs).

Research on How to Implement the Program

Research has not been conducted on how to implement Safe Environment for Every Kid (SEEK).

Relevant Published, Peer-Reviewed Research

Child Welfare Outcomes: Safety and Child/Family Well-Being

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. https://doi.org/10.1542/peds.2008-1376

Type of Study: Randomized controlled trial
Number of Participants: 558

Population:

  • Age — Children: 0–5 years; Parents: Mean=25 years
  • Race/Ethnicity — 92% Black
  • Gender — 48% Female
  • Status — Participants were clients of a pediatric primary care resident continuity clinic serving a low income urban community of families involved with child protective services.

Location/Institution: Baltimore, Maryland

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the efficacy of Safe Environment for Every Kid (SEEK) in reducing the occurrence of child maltreatment. Participants were randomly assigned to SEEK or standard care (control) groups. Measures utilized include the Parent Screening Questionnaire (now called the Parent Questionnaire) and the Parent-Child Conflict Tactics Scale (CTSPC). Child protective services data were also examined, along with the child’s medical record. Results indicate that SEEK resulted in significantly lower rates of child maltreatment in all outcome measures: fewer child protective services reports, fewer instances of possible medical neglect documented as treatment nonadherence, fewer children with delayed immunizations, and less harsh punishment reported by parents. Limitations include relatively small sample size, concerns regarding generalizability to other populations, and lack true baseline data. In addition, families with prior child welfare involvement were not excluded from the study sample, blending results for primary, secondary, and tertiary prevention (intervention) samples.

Length of controlled postintervention follow-up: Varied by individual - between 7 months and 3.5 years.

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. https://doi.org/10.1542/peds.2010-1845

Type of Study: Randomized controlled trial
Number of Participants: 102

Population:

  • Age — Health Care Professionals: Mean=45 years
  • Race/Ethnicity — Not specified
  • Gender — Health Care Professionals: 68% Female
  • Status — Participants were child health care professionals that dealt with major risk factors addressing child maltreatment.

Location/Institution: 18 private practices in central Maryland, loosely associated with the University of Maryland

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine whether Safe Environment for Every Kid (SEEK) with enhanced primary care would improve the attitudes, knowledge, comfort, competence, and behavior of child health care professionals (HPs) regarding addressing major risk factors for child maltreatment (CM). Participants were randomly assigned to SEEK or control groups. Measures utilized were the Parent Screening Questionnaire (PSQ, now called the Parent Questionnaire) and the Health Professional Questionnaire (HPQ). The child’s medical record was also examined, and check-up visits were observed. Results indicate that SEEK led to significant and sustained improvement in several areas. Results revealed significant improvement in the SEEK group compared with controls in addressing depression, substance abuse, intimate partner violence, and major parental stress and in their comfort level and perceived competence. SEEK HPs screened for targeted problems more often than did controls -up to 24 months after the initial training. Limitations include relatively small sample size, possibility of socially desirable responses on self-reported measures, and lack of information on whether SEEK was related to prevention of child abuse and neglect.

Length of controlled postintervention follow-up: 6, 18, and 36 months.

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. https://doi.org/10.1016/j.acap.2011.07.005

Type of Study: Randomized controlled trial
Number of Participants: 95

Population:

  • Age — Pediatric Residents: Mean=28 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were pediatric residents in a primary care resident continuity clinic serving a low income urban community.

Location/Institution: Baltimore, Maryland

Summary: (To include basic study design, measures, results, and notable limitations)
The study used a sample from the same practice sites examined in Dubowitz, et al. (2009). The purpose of the study was to determine whether 1) Residents trained in Safe Environment for Every Kid (SEEK) model would report improved attitudes, knowledge, comfort, competence, and practice regarding screening for psychosocial risk factors (e.g., parental depression, parental substance abuse, intimate partner violence, stress, corporal punishment, and food insecurity); 2) Intervention residents would be more likely to screen for and assess those risk factors; and 3) Families seen by intervention residents would report improved satisfaction with their child’s doctor compared to families receiving standard care from control residents. Participants were randomly assigned to either SEEK or the control group on the basis of their assigned clinic day. Measures utilized include the Parent Screening Questionnaire (PSQ, now called the Parent Questionnaire) and the Physician Questionnaire (PQ). Results indicate that SEEK improved residents’ level of comfort, perceived competence, and practice behavior regarding prevalent psychosocial problems that are risk factors for child maltreatment. Limitations include generalizability of the findings may not apply to lower risk communities, private practice, or other settings; possible sharing of information between participants; and lack of information on whether SEEK was related to prevention of child abuse and neglect.

Length of controlled postintervention follow-up: 6 and 18 months.

Dubowitz, H., Lane, W. G., Semiatin, J. N., & Magder, L. S. (2012). The SEEK model of pediatric primary care: Can child maltreatment be prevented in a low-risk population?. Academic Pediatrics, 12(4), 259–268. https://doi.org/10.1016/j.acap.2012.03.005

Type of Study: Randomized controlled trial
Number of Participants: 1,119 Mothers

Population:

  • Age — SEEK Parents: Mean=33.4 years; Control Parents: Mean=34.5 years; SEEK Children: Mean=25 months; Control Children: Mean=26.7 months
  • Race/Ethnicity — SEEK Parents: Not specified; SEEK Children: 86% White, 8% Other, 4% African American, 2% Asian, and 1% Latino; Control Children: 75% White, 12% Other, 7% African American, 5% Asian, and 1% Latino
  • Gender — SEEK Parents: 100% Female; Seek Children: 50% Female; Control Children: 47% Female
  • Status — Participants were families at private pediatric practices loosely associated with the University of Maryland.

Location/Institution: University of Maryland

Summary: (To include basic study design, measures, results, and notable limitations)
The study used the same sample as Dubowitz et al. (2011). The purpose of the study was to examine the effectiveness of Safe Environment for Every Kid (SEEK) with enhanced pediatric primary care to help reduce child maltreatment in a relatively low-risk population. Participants were assigned to SEEK or control groups. Measures utilized include the Parent Screening Questionnaire (PSQ), [now called the Parent Questionnaire] and the Parent-Child Conflict Tactics Scales (CTSPC). Children’s medical records and child protective services data were reviewed. Maltreatment was assessed 3 ways: maternal self-report using the CTSPC, children’s medical records, and child protective services reports. Results indicate that in the initial and 12-month assessments, SEEK mothers reported less Psychological Aggression than controls and SEEK mothers reported fewer Minor Physical Assaults than controls. There were few instances of maltreatment documented in the medical records and few child protective services reports. Limitations include inability to collect true baseline data, some issues with the randomization process, and the study sample was primarily low-risk and thus provides limited information on secondary prevention for high risk populations.

Length of controlled postintervention follow-up: 6 and 12 months.

Lane, W. G., Dubowitz, H., Frick, K. D., Semiatin, J., & Magder, L. (2021). Cost effectiveness of SEEK: A primary care-based child maltreatment prevention model. Child Abuse & Neglect, 111, Article104809. https://doi.org/10.1016/j.chiabu.2020.104809

Type of Study: Randomized controlled trial
Number of Participants: 102 pediatric providers and 924 families

Population:

  • Age — Not specified
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were pediatric providers at 18 pediatric primary care practices, and families with children < 6 years receiving care by those providers.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to determine the (1) overall cost for implementing the Safe Environment for Every Kid (SEEK) model, (2) cost of implementation per child, and (3) cost per case of maltreatment averted. Participants were randomly assigned to either SEEK training and implementation or usual care. Measures utilized include the Conflict Tactics Scale Parent-Child version (CTSPC) and data from the U.S. Department of Labor, Bureau of Labor Statistics (BLS) was used to determine physician, social worker, and psychologist salaries. Results indicate that implementing SEEK in all 18 practices would have cost approximately $265,892 over 2.5 years; $3.59 per child per year; or $305.58 ($229.18–$381.97) to prevent one incident. Based on a very conservative cost estimate of $2779 per maltreatment incident, SEEK would save an estimated $2,151,878 in health care costs for 29,610 children. Adjusted rates of maltreatment (parent endorsing Psychological Aggression or Physical Assault on the PCCTS) were lower in SEEK families compared to control families. Extrapolating these rates to the entire SEEK and control patient populations, there were an estimated 2759 episodes of maltreatment among children age 0–5 years in SEEK practices vs. 3630 in control practices. Limitations include the intervention was implemented in a relatively low-risk population, significant differences in maltreatment between SEEK and control groups when using a continuous measure of maltreatment severity (CTSPC score), and lack of follow-up.

Length of controlled postintervention follow-up: None.

Additional References

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.2014.07.011

Selph, S., Bougatsos, C., Blazina, I., & Nelson, H. (2013). 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, 158(3), 179-190. doi:10.7326/0003-4819-158-3-201302050-00590

Contact Information

Howard Dubowitz, MD, MS, FAAP
Agency/Affiliation: University of Maryland School of Medicine
Website: www.SEEKwellbeing.org
Email:
Phone: (410) 706-6144

Date Research Evidence Last Reviewed by CEBC: January 2023

Date Program Content Last Reviewed by Program Staff: November 2019

Date Program Originally Loaded onto CEBC: April 2014