The SEEK Approach
The core components are:
Training prepares primary care professionals (PCPs) to briefly assess and initially help address targeted problems.
- It is important that PCPs are adequately prepared to address psychosocial problems such as parental depression, major stress, substance use, intimate partner (or domestic) violence, food insecurity and harsh punishment.
- The free SEEK online training videos provide useful guidance. Supplemental materials are also available.
- Principles of motivational interviewing are incorporated to help engage parents as partners and in developing a plan. There are supplemental materials to learn more about motivational interviewing, an exciting advance in health care.
- PCPs are encouraged to also identify and utilize families' strengths and resources. These are often a “hook” to help engage parents constructively.
- Training and learning is naturally an ongoing process. Clinical experience and interacting with behavioral health professionals are valuable in enhancing competence.
The SEEK Parent Questionnaire-R (PQ-R) is a brief evidence-informed questionnaire to screen for prevalent and targeted psychosocial problems such as parental depression and substance use. The earlier version was revised in 2017 based on new knowledge and experience of those implementing the approach.
The PQ-R has 16 “yes/no” questions on one side of a page, and takes 2-3 minutes to complete. It has a user-friendly format that's easy for both parents and professionals.
As the PQ-R solicits sensitive information, the screen starts with an introduction that conveys an empathic tone and an interest in helping. The introduction builds upon a longstanding concern about ensuring children's safety and it conveys concern that the targeted problems are ones facing many families. The voluntary nature of the PQ-R is made clear. It begins with commonly asked questions such as about smoke alarms, before screening for more difficult problems.
Aggregate data from SEEK PQ-Rs offer a valuable needs assessment, documenting the prevalence of psychosocial problems in the families you serve. This can be used to improve the care you provide to children and their families, and to advocate for resources and services.
The SEEK PQ-R is:
A practical tool to briefly and systematically screen parents for prevalent psychosocial problems that are risk factors for child maltreatment, and that generally jeopardize children's health, development, wellbeing and safety. The targeted problems are:
- Parental Depression
- Parental Substance Use
- Major Parental Stress
- Intimate Partner (or Domestic) Violence
- Food Insecurity
- Harsh Punishment
The SEEK PQ-R is also:
- Designed to screen for, not diagnose, psychosocial problems
- Intended for parents to complete, voluntarily, in advance of their child's regular checkup
- Completed at selected checkups, such as at the 2, 9 and 15 month, and the 2, 3, 4, and 5 year visits
- Available in English, Spanish, Italian, Chinese, Portuguese. Related versions are available in Vietnamese, Swedish, Sorani, Thai, Tigrinya, Turkish, Arabic, Bengali, Dari, Finnish, Kurmanji, Russian and Somali. Note that these are moderately different from the PQ-R having been translated from the Swedish version.
Administering the PQ-R:
The PQ-R should be given to parents at regular checkups between 0-5 years of age. We don't suggest giving it at the first visit if there is not yet a relationship with the parent. It may be easiest to use at each visit, but it needs to fit in with other questionnaires so as not to overly burden parents and professionals. Parents have not complained about completing it repeatedly. As a family's circumstances can naturally change, it is important to ask parents to complete the PQ-R periodically.
Provide parents with the PQ-R in advance of the well child visit. Usually the medical or nursing assistant provides the PQ-R on a clipboard to the parent when placing them in an exam room. They can introduce the PQ-R saying something like "we're trying to improve the care we give to kids and families. Please fill this out and give it to your doctor/nurse at the start of the visit. The PQ-R is best completed in privacy rather than in a waiting area.
When is the Screen Positive?
- Food Insecurity: A ‘Yes’ to either food related question.
- Harsh Punishment: A ‘Yes’ to the “slap or hit” question or “….. child is difficult …..”
- Major Stress: A ‘Yes’ to “child is difficult”, “more help” or “extreme stress”.
- Depression: A ‘Yes’ to “feeling down” or “little interest”.
- Intimate Partner Violence: A ‘Yes’ to either of the two questions.
- Substance Use: A ‘Yes’ to either question.
Possible Concerns
Regarding a false positive screen:
- A screen is just a screen. A brief assessment should quickly help clarify whether this was falsely positive.
- Be careful not to convey a diagnosis, for example, of depression. Further evaluation should clarify that.
Regarding a false negative screen:
- It’s inevitable that some problems will be missed. There are many reasons why someone may choose not to disclose a problem.
- It’s possible that by asking the question(s), you've shown your interest, and sown a seed. They may disclose in the future.
- Parents who choose not to disclose are probably not amenable to intervention at this time.
For a more comprehensive screener, please check the SEEK PQ-Re.
Background
The SEEK Parent Questionnaire-Re ('e' for expanded) or PQ-Re, is the updated brief questionnaire to screen for prevalent and targeted psychosocial problems that are risk factors for child maltreatment and also Adverse Childhood Experiences (ACEs) or Social Determinants of Health (SDH). Aside from preventing possible abuse and neglect, addressing the targeted problems promotes children's health, development, wellbeing and safety, as well as the functioning of their parents and family.
Why the update? The PQ-Re was updated to include additional problems that primary care professionals (PCPs) have requested, such as gun safety and transportation. Further, we regularly reevaluate feedback from those in practice and consult with experts re. new knowledge. Finally, we’ve improved the design. We recommend replacing earlier versions with the improved SEEK PQ-Re.
Importantly, your practice can prioritize which issues to target or you can keep all that are there. This decision should be guided by the prevalence of the problem in the community served as well as the availability of a resource(s) to address it. It’s generally hard however to know how prevalent a problem is without systematic screening. Aggregate data from administering the SEEK PQ-Re for a few months serves as a valuable needs assessment, documenting the prevalence of problems in patients’ families. This information can be used to prioritize problems to target, to improve the care you provide to children and their families, and to advocate for resources.
Methodology: As stated above, we regularly obtain PCPs’ feedback regarding their experience with SEEK. We also periodically consult with experts on specific issues, such as substance use. Recognizing the time constraints in a busy practice, we aim to be practical, keeping the screener brief and easy to read and use – for parents and professionals. Of note, the PQ-Re has not been validated, meaning we have not examined the extent to which the screening questions accurately identify who has the problem and who does not.
The SEEK PQ-Re:
- Screens for, but does not diagnose, health-related social problems or risk factors for child maltreatment that are also ACEs or SDH.
- Solicits sensitive information, so the screener starts with an introduction that conveys an empathic tone and an interest in helping. It builds upon a longstanding concern about children's safety, beginning with commonly asked questions such as poison control before easing into more difficult problems. The introduction also conveys concern that the problems are ones facing many families; “normalizing” a problem helps reduce the possible stigma. Finally, the voluntary nature of answering questions is made clear.
- Targets:
- Home Safety
- Poison control info, smoke alarms, smoking, gun safety
- Child Behavior
- Difficult behavior, physical punishment, needing help
- Parental Wellness
- Stress, depression, partner violence, substance misuse, need for support
- Food Insecurity
- Other Needs
- Transportation, utility company, housing, childcare, immigration, employment, adult education, accessing healthcare, public benefits
- Home Safety
- Is intended for parents or primary caregivers to complete, voluntarily, in advance of their child's regular checkup, not at “sick” visits.
- Has “yes/no” questions on 1 side of 1 page and takes 3 minutes to complete.
- Is user-friendly and easy for parents to complete and for professionals to assess.
- Is completed at selected checkups, such as at the 2-, 9- and 15-month visits, and at the 2-, 3-, 4-, and 5-year visits. A practice can select which visits fit with their schedule.
- Is available in English and Spanish.
Administering the PQ-Re
- It should be given to parents or primary caregivers at regular checkups between 0-5 years of age. We don't suggest giving it at the first visit if there is not yet a relationship with the parent. Some use the screener with parents of older children.
- It may be easiest to use at each checkup. It should fit in with other questionnaires so as not to over burden parents and PCPs.
- As a family's circumstances can naturally change, it is important to ask parents to complete the PQ-Re periodically. Parents have not complained about completing it repeatedly. On the contrary, many have expressed gratitude that there is concern about the parent and family as well as the child.
- Administer the PQ-Re in advance of the visit – on paper or electronically.
- Usually a medical or nursing assistant provides the PQ-Re on a clipboard to the parent when placing them in an exam room; it’s best completed in privacy rather than in a waiting area. They can introduce it saying "we're trying to improve the care we provide to kids and families. Please fill this out and give it to your doctor/nurse at the start of the visit.”
- There are materials to help address positive screens, including for the recently added issues/problems: SEEK Guidelines, Responses to Barriers, and Parent Handouts.
When is a Screen Positive?
- A few problems have 2 screening questions (e.g., food insecurity). A ‘Yes’ to either question is a ‘positive’ screen (i.e., potentially having that problem).
- Most of the problems have only 1 screening question (e.g., intimate partner violence). For these, a ‘Yes’ is a positive screen.
Possible Concerns
- Regarding a false positive screen:
- A screen is just a screen. A brief assessment should quickly clarify whether this was falsely positive.
- Be careful not to convey a diagnosis, for example, of depression. Further evaluation should clarify that.
- Regarding a false negative screen:
- It’s inevitable that some problems will be missed. There are many reasons why someone may choose not to disclose a problem.
- It’s possible that by asking the question(s), you've shown your interest, and sown a seed. They may disclose in the future.
- Parents who choose not to disclose are probably not amenable to intervention at this time.
For more information, please visit the FAQs.
These guidelines help assess and address positive screens. Key questions are prioritized to make the approach efficient and incorporate principles of Motivational Interviewing. There are also suggested responses to possible barriers to parents engaging in help. Note that some guidelines for the PQ-R and the PQ-Re vary slightly.
Click to download a Guideline:
Parental Depression
PQ-R and PQ-Re
Unhealthy Substance Use
PQ-R
PQ-Re
Food Insecurity
PQ-R and PQ-Re
Tobacco Use
PQ-R and PQ-Re
Poison Control
PQ-R and PQ-Re
Smoke Alarms
PQ-R and PQ-Re
Gun Safety
PQ-Re
The SEEK Parent Handouts provide important and brief information that is easy for most to understand. The use of alternative handouts is still in keeping with the SEEK approach. The SEEK Handouts are adjuncts to advice given in your office or clinic.
They include national hotlines and websites for organizations with good resources. It's best to replace these with information on local resources. To do so, staff can help by searching findhelp.org or utilizing our Helpful Tips for Finding Local Resources to find local resources and a partial list of national ones. National resources can often identify local ones. The United Way’s number 211 is also valuable for identifying resources in many areas. Phone calls are recommended to ensure information is current, and the information needs periodic updating. We suggest doing so annually.
You may be able to send a handout to a parent’s careportal on your EHR. Also, you can post the handouts on your practice website.
If you need to translate the SEEK Parent Handouts, we’ve worked well with Southeast Spanish, Inc. They translate to/from Spanish, French, Italian, and Portuguese.
Parental Depression
English
Spanish
Parental Substance Use
English
Spanish
Major Parental Stress
English
Spanish