Dr. Howard Dubowitz
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Dr. Howard Dubowitz is a Professor of Pediatrics and Director of the Center for Families at the University of Maryland, Baltimore School of Medicine. He is known for being a leader in child neglect prevention and for his numerous publications and presentations on the topic.
Recent Submissions
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The Neglect of Children: Food for Thought and ActionThis commentary highlights several challenges concerning the conceptualization of child neglect and the approach to this prevalent problem, with the goal of stimulating further thought and hopefully action. Examples include consideration of potential harm, the role of culture, intentionality, and new forms of neglect related to new knowledge of children’s needs. Assessment of possible neglect, interviewing children, use of motivational interviewing, and the importance of identifying families’ strengths are additional issues. Finally, the commentary addresses alternative response systems, resilience, prevention, and advocacy. We suggest ways to tackle these challenges.
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Kinship Care: Suggestions for Future ResearchControversial issues concerning kinship care are presented, followed by a brief presentation of findings from a survey of child welfare experts on their research priorities for kinship care. These suggestions for future research, as well as those of the author, are discussed in the following categories: children, families, services, state policies, experience of professionals and families, practice issues, and training.
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Protocol for comparing two training approaches for primary care professionals implementing the Safe Environment for Every Kid (SEEK) modelChild maltreatment (CM) is a major public health problem, affecting many lives, in the short and long term, and costing individuals, families, and society dearly. There is a need for broad implementation of evidence-based preventive interventions, such as the Safe Environment for Every Kid (SEEK) model, developed for pediatric primary care. Primary care offers an excellent opportunity to help address prevalent psychosocial problems (e.g., parental depression) that are risk factors for CM. By addressing such problems, SEEK can strengthen families and support parents; promote children’s health, development, and safety; help prevent CM; and benefit the health of the US population. This study will examine intervention strategies for optimizing SEEK’s adoption, implementation, and sustainment, and its effectiveness in preventing CM. Despite strong evidence from two federally funded randomized controlled trials, SEEK has not been widely adopted. The goal of this study is to examine technology-driven implementation strategies to scale-up SEEK—in pediatric and family medicine primary care settings. The aims are to (1) evaluate the effectiveness of training strategies on SEEK’s implementation in primary care practices, (2) evaluate barriers and facilitators to successful implementation and sustainment of SEEK, and (3) examine the model’s effectiveness in preventing CM and the economic costs of implementing SEEK.
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Childhood neglect: The role of the paediatricianNeglect is a pervasive form of child maltreatment. Health care practitioners often struggle with deciding when an action (or lack of action) by a caregiver constitutes inadequate care and is neglectful. The present article discusses the epidemiology, risk factors and outcomes of neglect. In addition, assessment using objective markers, such as harm and potential harm, in the identification of neglect is described, and unique factors that impact assessing and addressing issues of neglect in the clinical setting are discussed. Practical strategies for intervening in cases of neglect are discussed, including how to engage families in which there are concerns for neglect, mandated reporting, working collaboratively with children’s services, ongoing monitoring of families, and how health care professionals can effectively engage in neglect prevention and advocacy.
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Child Sexual Abuse Evaluations: Adherence to RecommendationsSixty-eight parents of children with alleged child sexual abuse (CSA) were surveyed 4 months after visiting an interdisciplinary CSA evaluation clinic in order to examine the extent to which recommendations were recalled and implemented. Of those parents for whom specific recommendations were provided, 9% recalled recommendations for medical follow-up, 79% recalled recommendations for child therapy, and 43% recalled recommendations for parental therapy. Families were more likely to receive and adhere to recommendations when there were behavioral problems and a strong indication of CSA. To improve communication with families, the reasons for recommendations must be clearly conveyed, and possible barriers to implementation should be anticipated and addressed. In addition, recommendations need to be realistic, and professionals need to facilitate the implementation of their treatment plan.
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Health Care Needs of Children in the Foster Care SystemNearly 750 000 children are currently in foster care in the United States. Recent trends in foster care include reliance on extended family members to care for children in kinship care placements, increased efforts to reduce the length of placement, acceleration of termination of parental rights proceedings, and emphasis on adoption. It is not clear what impact welfare reform may have on the number of children who may require foster care placement. Although most children enter foster care with medical, mental health, or developmental problems, many do not receive adequate or appropriate care while in placement. Psychological and emotional problems, in particular, may worsen rather than improve. Multiple barriers to adequate health care for this population exist. Health care practitioners can help to improve the health and well-being of children in foster care by performing timely and thorough admission evaluations, providing continuity of care, and playing an active advocacy role. Potential areas for health services research include study of the impact of different models of health care delivery, the role of a medical home in providing continuity of care, the perception of the foster care experience by the child, children's adjustment to foster care, and foster parent education on health outcomes. Pediatrics 2000;106:909±918; foster care, child welfare, children with special health care needs.
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A Conceptual Definition of Child NeglectAlthough child neglect is the most common form of child maltreatment, considerable confusion remains regarding its definition. A conceptual definition of neglect is presented based on an ecological model of child maltreatment. The definition focuses on the basic needs of children that are not met, rather than on the intentions or behavior of parents. The replacement of parental culpability by a shared responsibility including parents, families, the community, and society is suggested. Neglect is seen as a heterogeneous phenomenon that varies by type, severity, and chronicity. In addition, neglect is understood as existing on a continuum ranging from optimal to grossly inadequate care. The context within which neglect occurs, including parents' understanding of children's needs, religious and cultural beliefs, and poverty, influences the approaches of clinicians, researchers, and policymakers toward the problem of child neglect.
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Initial Medical Assessment of Possible Child Sexual Abuse: History, History, HistoryPrimary care professionals (PCPs) can play a valuable role in the initial assessment of possible child sexual abuse (CSA), an all too prevalent problem. PCPs, however, are often reluctant to conduct these assessments. The goal of this paper is to help PCPs be more competent and comfortable playing a limited but key role. This is much needed as there may be no need for further assessment and also because of a relative paucity of medical experts in this area. While some children present with physical problems, the child's history is generally the critical information. This article therefore focuses on practical guidance regarding history-taking when CSA is suspected, incorporating evidence from research on forensic interviewing. We have been mindful of the practical constraints of a busy practice and the role of the public agencies in fully investigating possible CSA. The approach also enables PCPs to support children and their families.
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Validation of the Swedish version of the safe environment for every kid (SEEK) parent screening questionnaireBackground: Psychosocial risk factors in the home may impair children's health and development and increase the risk of maltreatment. The Safe Environment for Every Kid (SEEK) model was developed to provide pediatric primary care professionals with a structured way to identify common psychosocial problems. The SEEK model includes use of the Parent Screening Questionnaire (SEEK-PSQ) at routine preventive child health visits, discussion with parents about their responses and, when indicated, referral to relevant services. The SEEK-PSQ has not previously been available in Swedish. The aim of the present study was to evaluate the psychometric properties of an adapted Swedish version of the SEEK-PSQ (PSQ-S). Methods: This study is part of a cluster-randomised controlled trial of SEEK in the Swedish child health services. To validate the PSQ-S, parents (n = 852) with children 0-18 months of age were invited to complete a survey including the PSQ-S as well as evidence-based standardized instruments for the targeted psychosocial risk factors: economic worries, depressive symptoms, parental stress, alcohol misuse and intimate partner violence (IPV). Baseline data from 611 (72%) parents were analysed regarding sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each risk factor. Results: As a whole, the PSQ-S had a sensitivity of 93%, specificity of 52%, PPV of 67% and NPV of 87%. For mothers and fathers combined, sensitivity was 80% for economic worries, 89% for depressive symptoms, 78% for parental stress, 47% for intimate partner violence (IPV) and 70% for alcohol misuse. Specificity was highest for IPV and alcohol misuse (91%) and lowest for depressive symptoms (64%). NPV values were high (81-99%) and PPV values were low to moderate (22-69%) for the targeted problems. Sensitivity was higher for mothers compared to fathers for economic worries, depressive symptoms and IPV. This difference was particularly evident for IPV (52% for mothers, 27% for fathers). Conclusion: The SEEK-PSQ-S demonstrated good psychometric properties for identifying economic worries, depressive symptoms, parental stress and alcohol misuse but low sensitivity for IPV. The PSQ-S as a whole showed high sensitivity and NPV, indicating that most parents with or without the targeted psychosocial risk factors were correctly identified.
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Assessment of Adoption and Early Implementation Barriers and Facilitators of the Safe Environment for Every Kid (SEEK) ModelObjective: Although the use of interventions for screening for social determinants of health of families in pediatric primary care clinics has increased in the past decade, research on the barriers and facilitators of implementing such interventions has been limited. We explored barriers, facilitators, and the mechanisms clarifying their roles in the adoption and implementation of the Safe Environment for Every Kid (SEEK) model, an approach for strengthening families, promoting children's health and development, and preventing child maltreatment. Methods: A total of 28 semistructured interviews were completed with 9 practice champions, 11 primary care professionals, 5 behavioral health professionals, and 3 nursing/administrative staff representing 12 pediatric primary care practices participating in a larger randomized control trial of implementing SEEK. Results: We identified several barriers and facilitators in the stages of SEEK's adoption and early implementation. Barriers associated with outer and inner setting determinants and poor innovation-organization fit declined in importance over time, while facilitators associated with SEEK characteristics increased in importance based on participants' responses. Barriers and facilitators were linked by mechanisms of comparison and contrast of burdens and benefits, and problem-solving to address limited capacity with available resources. Conclusions: Any screening for and addressing social determinants of health demands greater attention to adoption and implementation mechanisms and the processes by which primary care professionals assess and utilize facilitators to address barriers. This occurs in a context defined by perceived burdens and benefits of innovation adoption and implementation, the capacity of the practice, and changes in perception with experiencing the innovation.
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Addressing Adverse Childhood Experiences in Primary Care: Challenges and ConsiderationsThis article draws attention to the overlapping literature on social determinants of health and adverse childhood experiences, and the growing clinical interest in addressing them to promote children's and parents' health and well-being. We address important considerations and suggest solutions for leaders and practitioners in primary care to address social determinants of health/adverse childhood experiences. Priorities include: begin with a few prevalent conditions for which there are helpful resources; focus on conditions that are current or recent and where parents may be more apt to engage in services; focus initially on families with children aged <6 given the frequency of well-child visits and the especially strong relationships between primary care professionals and parents during this period; ensure training of primary care professionals and staff to help them play this role competently and comfortably; and have good referral processes to facilitate additional evaluation or help.
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Neglect in Childhood, Problem Behavior in AdulthoodFew studies have reported problem behaviors in adulthood related to the timing of child neglect. The objective was to examine the relationship between classes of child neglect and later behavior. The sample included 473 participants from the prospective Longitudinal Studies of Child Abuse and Neglect (LONGSCAN); their mean age was 23.8 years. They completed an online survey regarding behaviors and experiences in early adulthood. Neglect was assessed via Child Protective Services (CPS) and self-reports of neglect. Latent class analysis (LCA) identified three classes: Late Neglect, Chronic Neglect, and Limited Neglect. There were significant differences between Limited and Late Neglect regarding later intimate partner aggression and violence (IPAV) and psychological distress, and among all classes for criminal behavior. High-risk youth experiencing neglect beginning in mid-adolescence appear especially vulnerable to later criminal behavior, psychological distress, and IPAV. Those working with such youth can help ensure that their needs are adequately met, to prevent or mitigate problems in adulthood.
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Adolescent Neglect and Health RiskThis study examined relationships between adolescent neglect and abuse and later health risk in a sample of 1050 youth (53% female, 56% Black, and 24% White) from the Longitudinal Studies of Child Abuse and Neglect. At age 16, the youth reported any adolescent exposure to neglect and physical, sexual, and emotional abuse. At age 18, they reported risk behaviors (delinquency, substance use, and sexual behavior) and emotional and behavioral problems (externalizing and internalizing problems, suicidality). Control variables were childhood maltreatment (self-reports and early childhood child protective services reports), risk behaviors and emotional and behavioral problems at age 16, and demographics. Analysis confirmed a 5-factor model of adolescent neglect (Exposure to Risk, Inadequate Monitoring, Inattention to Basic Needs, Permitting Misbehavior, and Inadequate Support). Inadequate Support and Exposure to Risk were associated with more substances used; Exposure to Risk was also associated with delinquency and suicidality. Adolescent emotional abuse was associated with not using a condom use and internalizing and externalizing problems. Findings underscore the importance of preventing or addressing neglect during adolescence.
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Social determinants of health, personalized medicine, and child maltreatmentThis review begins with a brief summary of the importance of child maltreatment as a major public health problem, given its prevalence and the substantial human and economic costs involved. The focus then shifts to consideration of personalized medicine and child maltreatment, including genetic and genomics factors, as well as the role of social determinants of health. Research on epigenetics related to child abuse and neglect is presented, followed by that pertaining to a few specific social factors, such as poverty, parental depression and substance use, and domestic (or intimate partner) violence. The review ends with a discussion of interventions to help address social determinants of health with brief descriptions of several model programs, and thoughts concerning the role of personalized medicine in addressing child maltreatment in the foreseeable future. IMPACT: This paper synthesizes knowledge on social determinants of health and advances in genetics and genomics related to the prevention of child maltreatment. It provides examples of model approaches to addressing the prevention of child maltreatment in primary care practices.