Preventing Child Violence

As a physician, how much time would you be willing to invest to curb violence and ensure a safer, healthier environment for children? Could you carve out an hour … 30 minutes … 15? According to a groundbreaking study led by Vanderbilt’s Shari Barkin, MD, physicians have the power to affect change in less than five minutes.

Using the window of opportunity provided by the well child visit, more than 200 providers at 137 practices affiliated with the American Academy of Pediatrics participated in the 5,000-patient study. The investigators from 41 states, Canada and Puerto Rico were all part of the AAP’s Pediatric Research in Office Settings (PROS) network.

Barkin, director of the Division of General Pediatrics at the Monroe Carell Jr. Children’s Hospital at Vanderbilt was the principal investigator for the Randomized Controlled Trial to Prevent Child Violence, which was conducted from 2002-2006. Results of the trial, commonly referred to as the Safety Check Approach, were published in the July issue of Pediatrics, the flagship journal of the AAP.

“In too many families and in too many communities, violence is a part of daily life,” said Barkin, of the impetus behind the NIH-funded study.

With a focus on prevention, Barkin said the intervention was conducted with parents of children between the ages of two and 11. The Vanderbilt professor noted it is the largest study to date showing that pediatricians can reduce violent behaviors.

“This concept of anticipatory guidance – that pediatricians can have a public health impact through a brief, one-time office intervention — is key,” said Barkin, who designed and implemented the study with co-authors while working at Wake Forest University School of Medicine.

She added the research focused on changing behaviors in three violence prevention domains: excessive media use, parental strategies for discipline and access to unsafely stored firearms.

“These are things that have already been shown to be associated with the manifestation of violence,” the board-certified pediatrician noted.

She explained the study was based on self-reported behaviors as parents completed a survey while waiting for their child’s appointment. After the brief office intervention, follow-up calls were made by survey research centers at the one- and six-month mark to ascertain whether the parents had implemented any changes, and the results were compared with a control group.

“We found out a brief office-based intervention decreased media exposure and increased safer firearm storage,” Barkin said, adding there was not a significant impact on disciplinary measures, which are typically more complicated and vary by scenario.

The three key components of the intervention were to identify parental concerns in the areas of focus, to utilize parent-centered solutions to change behaviors, and to provide tangible tools to help parents adhere to recommendations.

Barkin noted, for example, the pediatricians provided firearm cable locks to those who reported they had guns in the home that weren’t locked up and suggested using minute timers to limit the amount of screen time.

“Fifty percent of gun-owning families were concerned their children would find their guns and play with them,” Barkin said. “The majority did not store their firearms safely. When offered free cable locks, more than 80 percent were interested.”

During the follow-up calls, a significant number of parents reported implementing the suggested tools. Children in the intervention group watched, on average, 45 minutes less media per day than those in the control group six months after the physician office visit. In the case of firearms, those exposed to the intervention were twice as likely to store their guns more safely. While there wasn’t a statistically significant change in the use of “time outs,” the families in the intervention group did have a decrease in reported uses of corporal punishment in comparison to the control group.

Barkin said not only is this the first study to show the effectiveness of such office-based preventive measures to curb violence, but that it is also a potential means to achieve a much larger public health benefit.

“If you extrapolate our findings to families who go see primary care providers, there is the potential to impact more than 800,000 children to decrease media exposure and the negative consequences such as aggression,” she stated, adding that another 200,000 children could be positively impacted with a reduction in firearm-related injuries each year.

“We know it works,” she concluded of the experience, “So now it’s about using this approach regularly to impact sustained change and improved child health.”

(Source: Pediatrics: Vanderbilt: August 2008)