Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

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Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Introduction

According to the 2013 United States (U.S.) Census Bureau, 14.7 million (19.9%) children less than 18 years were living in poverty, and 31.4 million (42.6%) children were living below the 200% poverty threshold.1 Social determinants of health, defined as the social circumstances in which people live and work, powerfully influence health and development, particularly for children growing up in poverty.2 A rapidly expanding body of research has documented that adverse childhood experiences (ACEs), defined as traumatic experiences occurring before the age of 18, have long-term health outcomes and result in continued intergenerational toxic stress, ultimately impacting personal and family physical and mental health, and socioeconomic status.3 The ACE Study, instrumental in demonstrating the association between childhood adversity and an increased risk for medical and psychosocial morbidity,4 has influenced other researchers to study the association between ACEs and health-related problems that affect families living in poverty.5, 6, 7 There is a consistent dose–response effect whereby those with more ACEs, or a higher ACE score, have a higher likelihood of negative health outcomes in childhood and adulthood.4, 5, 6, 7 Child health clinicians are in a unique position to address social determinants of health and to help prevent child adversity, but they require the tools and resources to do so effectively.

The Academic Pediatric Association (APA) and the American Academy of Pediatrics (AAP) recently authorized task forces to address child poverty.8 As a workgroup of the APA Childhood Poverty Task Force Health Care Delivery Committee, we provide an evidence-based, practical approach to those aspects of surveillance and screening that apply particularly to children and families living in poverty. In the patient-centered medical home, all children should be assessed for developmental, behavioral, and emotional concerns, based on published Bright Futures and AAP policy statements and clinical reports.9, 10, 11 The following guidelines provide an overview of the social determinants impacting the health of children living in poverty and provide clinicians with practical tools and resources.

As research furthers our understanding of the causal mechanisms by which social factors impact health, comprehensive assessments need to address more broadly the diverse components of social determinants of health. Despite the detrimental effects of social determinants on child health, few child health clinicians routinely address the social and psychosocial factors that affect children and their families during routine primary care visits.12 Barriers to assessing social determinants include a lack of recognized impact or measurable outcomes and lack of time, professional training, familiarity with relevant assessment tools and knowledge about the availability of relevant community resources.12, 13

Section snippets

Screening for Social Determinants of Health

The process of surveillance and screening can be applied to the social determinants of health as it is for developmental delay.9, 14, 15 Surveillance is defined as “a flexible, longitudinal, and continuous process whereby knowledgeable professionals perform skilled observations during the provision of health care,” whereas screening involves the use of standardized tools.16 Surveillance and screening for social determinants include the following core components: (1) eliciting and attending to

Child Maltreatment

More than a quarter million U.S. children are victims of child maltreatment, or abuse and neglect each year, with approximately 1640 children dying from maltreatment.23 Child maltreatment results in short- and long-term consequences ranging from the immediate fractures, abdominal trauma, head injury, and death to residual and long-lasting neuropsychological and physical health problems.24, 25 All forms of child maltreatment—child physical, sexual, and psychological abuse, and child neglect—are

Concluding Remarks

Children live in poverty throughout the U.S., in rural, urban and suburban neighborhoods. While some families will live their entire lives in poverty, other families may move in and out of poverty with changing needs and hardships. Families living in poverty face numerous challenges that impact health and require the attention of their healthcare clinician. Sometimes families will have to choose between basic needs and medical treatment. Such “trade-offs,” for example, may involve a family

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