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Service Delivery Innovation Profile

Multifaceted Program Helps Pediatricians Screen for Maternal Depression and Assess Infant Crying and Toilet Training, Enhancing Their Ability to Prevent, Identify, and Address Cases of Potential Child Abuse

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Pediatric primary care practices implemented a multifaceted child abuse and neglect identification and prevention program called Practicing Safety that involves screening, provision of enhanced "anticipatory guidance," and referral of new mothers/caretakers for maternal depression. As part of the intervention, pediatricians ask parents about crying, bonding/attachment, toilet training, and discipline and provide educational materials related to abuse and neglect prevention to patients and prominently in waiting and examination rooms. Practices use a quality improvement methodology to evaluate their use of the program. Evaluation data suggest that Practicing Safety changed practice-based behaviors (i.e., increased pediatricians’ awareness of abuse and neglect, enhanced their skills in discussing young children’s psychosocial issues and behaviors with parents, and improved their ability to identify and refer depressed mothers and at-risk children and families in need of additional assistance).

Evidence Rating (What is this?)

Suggestive: The evidence consists of pre-post implementation quantitative and qualitative data reports based on baseline and followup surveys, medical chart data, focus groups, and post-implementation interviews with staff and providers with five practices in New Jersey (Phase I) and 14 practices throughout the nation (Phase II).
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Developing Organizations

American Academy of Pediatrics; Jersey Shore University Medical Center; Thomas Jefferson University, School of Population Health, Philadelphia, PA
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Use By Other Organizations

  • The knowledge gained from the pilot tests will lead to future work with health plans and other health systems interested in implementing the program.

Date First Implemented

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Patient Population

Newborn to age 3.Vulnerable Populations > Children; Age > Infant (1-23 months); Newborn (0-1 month); Preschooler (2-5 years)end pp

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. Children of battered women are more likely to be abused.3
  • Failure to screen among pediatricians: Active screening of domestic violence, including having mothers assessed for maternal depression, are not a universal standard of care for most 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. 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. More effective approaches at the practice level are needed to alter how pediatricians provide preventive services.4

What They Did

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Description of the Innovative Activity

In a two-phase research effort, pediatric practices have redesigned care processes to more effectively screen for and address child abuse and neglect. Practices tested the use of seven modules to prevent abuse and neglect (Phase I) and a quality improvement methodology and three refined bundles of tools and procedures (Phase II) from the American Academy of Pediatrics (AAP) 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. Key elements of the redesign are described below:
  • Phase I Changes: The five practices participating in Phase I of the study implemented the following changes:
    • Screening for postnatal maternal depression: The pediatricians screen new mothers, using a postnatal depression scale, during the 2-week, 1-month, 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 examination 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.
    • 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 designate a staff member to learn about referral resources available within their community 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 are instructed to report cases of suspected drug or alcohol abuse among parents to providers and human services social workers.
  • Phase II changes: In the second phase of the study, 14 pediatric practices, recruited through the AAP's Quality Improvement Innovation Network (QuIIN), tested a revised intervention in which the Practicing Safety tools were redesigned to be more easily implemented into any type of pediatric practice.
    • Implementing three bundles of tools: The intervention now contains three bundles of tools and three levels of risk. The three bundles include screening and educational tools, which are provided to every parent at every visit, relate to three areas of abuse/neglect: (1) maternal/caretaker depression; (2) infant bonding and crying; and (3) toddler toilet training and discipline.
    • Assigning risk level and intervening accordingly: After implementation of the tools, providers assign one of three levels of risk: (1) green, indicating typical parental behavior; (2) yellow, indicating a concern that parents might be stressed and need for basic interventions (such as more information, tangible suggestions, and followup at next visit); or (3) red, indicating risk of abuse/neglect and need for referral to a social worker or other community service.
    • Participating in quality improvement methodology: The participating practices participate in a quality improvement methodology in which a quality improvement facilitator led learning collaboratives, held via group conference calls, to teach practices to evaluate their patient data and use Plan-Do-Study-Act (PDSA) cycles to determine whether they met their self-directed goals.

Context of the Innovation

Although pediatricians are often in a good position to screen for and help prevent child abuse and neglect, they often struggle to effectively broach these complex psychosocial issues with parents. To address this, the investigators in conjunction with the AAP developed a pilot program in 2003 called Practicing Safety that provided tools and screening prompts to help pediatricians identify, discuss, and prevent child abuse and neglect in infants and toddlers. The program addresses crying, toilet training, parenting, sleeping and eating, effective discipline, family environment, and child safety when in others’ care.

The investigators implemented Practicing Safety interventions in pediatric primary care practices first in New Jersey and later in practices around the nation. The sites varied significantly in terms of size, location, income levels of families served, and type of practice. The program targeted all parents (of patients age 3 years and younger), along with clinicians and staff at each site.

Did It Work?

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Quantitative and qualitative results available from both phases suggest that the program has increased identification of families at risk, and referrals to social workers at community agencies. Nearly all participating 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.

Phase I results:
  • 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. 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 practices reported more consistent identification of depressed mothers.

Phase II results:

  • Statistically significant increases in use of practice tools and processes: Practices evaluated their use of practice tools in place before the intervention and compared this usage with their use of these preexisting tools as well as the Practicing Safety tools after Practicing Safety was implemented. Results indicated a statistically significant improvement in the use of all three bundles of tools as well as the use of various strategies and processes (including practice guidelines and policies, anticipatory guidance for parents, documentation systems, and screening).
  • Process improvements: Practices reported improved and newly initiated relationships with social workers and community referral agencies; policy development to sustain practice change; and implementation of tracking procedures for families identified as “at-risk.”

Evidence Rating (What is this?)

Suggestive: The evidence consists of pre-post implementation quantitative and qualitative data reports based on baseline and followup surveys, medical chart data, focus groups, and post-implementation interviews with staff and providers with five practices in New Jersey (Phase I) and 14 practices throughout the nation (Phase II).

How They Did It

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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, working with a reflective adaptive practice team (made up of practice staff, physicians, and, where possible, a parent representative) to manage the implementation of the Practicing Safety methods in each practice and monitor ongoing progress. The facilitator first assessed each practice’s readiness to implement the program, using 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. The facilitator also 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 Phase I 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 practices took responsibility for maintaining the guide. In Phase II, the practices were asked to find and contact agencies in their communities.
  • 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 incorporate psychosocial topics.
  • Future use of community navigators: Future program implementation will include the use of community navigators to alleviate the burden on practices from the additional duties of finding community resources.
  • Future testing planned: The investigators are planning to test parental and child outcomes in 2012.

Resources Used and Skills Needed

  • Staffing: In both phases at the site level, no new staff were needed, as an internal champion and small team participate in the program as a part of their regular duties. The champion and 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. The project facilitator served as a consultant to the practices, analyzing practice culture and configurations, and working with the onsite implementation team.
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Funding Sources

American Academy of Pediatrics; Doris Duke Foundation
The study was funded by grants from the Doris Duke Charitable Foundation through the AAP.end fs

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:

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;34(2):106-15. [PubMed] Available at:

Adoption Considerations

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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.
  • Form team to revise current processes, job descriptions, and goals: Form the reflective adaptive process 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, and support services for psychosocial issues, health screening forms, parent education resources, provider–patient communication, and community relationships. Have the reflective adaptive process 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.
  • Adopt rapid cycle improvement: Program developers should adopt the PDSA cycle of quality improvement to implement each bundle of tools and strategies and monitor data to show improvement and opportunities for enhanced care.
  • 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 reflective adaptive process 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, review the program's goals and processes on a regular basis, including with all new staff.
  • Consider onsite social worker: The most successful practices 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. Practices can link to community agencies that may be willing to visit the office regularly to recruit clients to their agencies.
  • Cultivate places to refer those in need of help: Some participating 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. Other practices thought more creatively and asked parents where they get support. Parents are often a good source of information about community agencies.

Use By Other Organizations

  • The knowledge gained from the pilot tests will lead to future work with health plans and other health systems interested in implementing the program.

More Information

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Contact the Innovator

Diane J. Abatemarco, PhD, MSW
Director of Pediatric Population Health Research
Jefferson/Nemours Department of Pediatrics
833 Chestnut Street, Suite 1210
Philadelphia, PA 19107
(215) 861-0407

Steven W. Kairys, MD, MPH
Professor and Chairman of Pediatrics
Meridian Health
Jersey Shore University Medical Center
1945 Corlies Ave.
Neptune, NJ 07753
(732) 776-2411

Innovator Disclosures

Dr. Abatemarco and Dr. Kairys have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

(Added December 2011) Abatemarco DJ, Kairys S, Gubernick R , et al. Using genograms to understand pediatric practices’ readiness for change to prevent abuse and neglect. J Child Health Care. Epub ahead of print In print 2012 Feb 22. [PubMed]

Federal Interagency Forum on Child and Family Statistics. America’s children: key national indicators of well-being. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).

American Academy of Pediatrics Practicing Safety Web site. Also includes program information. Available at:

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;34(2):106-15. [PubMed] Available at:


1 Bethell C, Reuland C, Halfon N, et al. Measuring the quality of preventive health services for the young child: national estimates and patterns of clinicians’ performance. Pediatrics. 2004;113(6 Suppl):1973-83. [PubMed]
2 Wahl R, Sisk D, Ball T. Clinic-based screening for domestic violence: use of a child safety questionnaire. BMC Med. 2004;2:25. [PubMed]. Available at:
3 American Academy of Pediatrics Practicing Safety Web site. Available at:
4 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;34(2):106-15. [PubMed] Available at:
5 American Academy of Pediatrics. Recommendations for preventive pediatric health care. Pediatrics. 2000;105:645-6. Available at
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 26, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 03, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.