Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians
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
References (166)
- et al.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study
Am J Prev Med
(1998) - et al.
Depressive symptoms in disadvantaged women receiving prenatal care: the influence of adverse and positive childhood experiences
Ambul Pediatr
(2008) - et al.
Risky health behaviors among mothers-to-be: the impact of adverse childhood experiences
Acad Pediatr
(2010) - et al.
Evidence-based milestones for surveillance of cognitive, language, and motor development
Acad Pediatr
(2013) - et al.
Childhood maltreatment predicts allostatic load in adulthood
Child Abuse Negl
(2015) The continuing role of material factors in child maltreatment and placement
Child Abuse Negl
(2015)- et al.
Double jeopardy: the impact of poverty on early child development
Pediatr Clin North Am
(1988) - et al.
Prediction of special education placement from birth certificate data
Am J Prev Med
(1995) - et al.
Food insecurity and weight status among U.S. children and families: a review of the literature
Am J Prev Med
(2011) - et al.
Child food insecurity increases risks posed by household food insecurity to young children’s health
J Nutr
(2006)
Food insecurity is associated with adverse health outcomes among human infants and toddlers
J Nutr
The health of homeless children revisited
Adv Pediatr
Associations of neighbourhood greenness with physical and mental health: do walking, social coherence and local social interaction explain the relationships?
J Epidemiol Community Health
Housing and child health
Curr Probl Pediatr Adolesc Health Care
The predictive impact of domestic violence on three types of child maltreatment
Child Abuse Negl
Primary care-based interventions for intimate partner violence: a systematic review
Am J Prev Med
Maternal depression and parenting behavior: a meta-analytic review
Clin Psychol Rev
U.S. Census Bureau CPR, P60-249, Income and Poverty in the United States: 2013
Social Determinants of Health
Committee on Psychosocial Aspects of Child Family Health, Committee on Early Childhood, Adoption and Dependent Care, Section on Developmental Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress
Pediatrics
Adverse childhood experiences of low-income urban youth
Pediatrics
An agenda for children for the 113th Congress: recommendations from the pediatric academic societies
Pediatrics
Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening
Pediatrics
Section on Developmental Behavioral Pediatrics, Committee on Psychosocial Aspects of Child Family Health, Council on Early Childhood, Society for Developmental Behavioral Pediatrics, American Academy Of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems
Pediatrics
Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents
Routine assessment of family and community health risks: parent views and what they receive
Pediatrics
Primary care pediatricians׳ roles and perceived responsibilities in the identification and management of maternal depression
Pediatrics
Applying surveillance and screening to family psychosocial issues: implications for the medical home
J Dev Behav Pediatr
A randomized trial on screening for social determinants of health: the iScreen study
Pediatrics
British and American recommendations for developmental monitoring: the role of surveillance
Pediatrics
Screening for basic social needs at a medical home for low-income children
Clin Pediatr (Phila)
Addressing social determinants of health at well child care visits: a cluster RCT
Pediatrics
Improving the management of family psychosocial problems at low-income children׳s well-child care visits: the WE CARE Project
Pediatrics
The effects of poverty on children
Future Child
Prevalence of developmental delays and participation in early intervention services for young children
Pediatrics
Neuroimaging of child abuse: a critical review
Front Hum Neurosci
Understanding the risks of child neglect: an exploration of poverty and parenting characteristics
Child Maltreat
Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse
Pediatrics
Update on childhood sexual abuse
Curr Opin Pediatr
Significant Benefits: The High-Scope Perry Preschool Study Through Age 27
Counterfactual Models of Neighborhood Effects: The Effect of Neighborhood Poverty on Dropping Out and Teenage Pregnancy
Am J Sociol
Final reading outcomes of the National Randomized Field Trial of Success for All
Am Educ Res J
Early childhood stimulation in the developing and developed world: if not now, when?
Pediatrics
Home visiting and the biology of toxic stress: opportunities to address early childhood adversity
Pediatrics
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