Today, more than 1 in 5 American children live in poverty. More than 14.8 million children suffer each day from hunger and more than 1,854 children from abuse or neglect.[I] The adverse childhood experiences faced early on by children are the leading cause of the dramatic health and social disparities that exist later on in life.Adverse childhood experiences regarding child maltreatment, child care, maternal depression, hunger, family mental illness and substance abuse, physical environment or violence are strongly linked to toxic stress, developmental delay, asthma and heart disease.[ii]When members of our health community talk about addressing the social determinants of health, the conditions in which children live in need to be at center of every conversation.
Pediatric clinicians have a unique and expanding role to play in bettering the social determinants of health. Children have two required contact points with those outside of their families: schools and health care providers. Since a child’s education doesn’t fully begin until age five, this means that pediatric clinicians often serve as the first connecting point for a child to a larger system of care and resources. As such, the screenings that these clinicians conduct and the referrals and suggestions that they make to parents provide for the earliest venue for the social determinants of health to be addressed. This unique space for intervention however is too often underutilized by pediatrics who do not have the proper training and tools to ask families about the conditions that they live in, identify unspoken concerns and prescribe appropriate actions for improvement.
In the last decade, efforts to expand the pediatric role into the social and community sphere have increased. The Academic Pediatric Association (APA) and the American Academy of Pediatrics (AAP) recently authorized a task forces to address child poverty and provide an evidence-based, practical approach for screenings and surveillance. Pediatricians are urged to work around a framework with the following components:
- Inquiring about and attending to parents’ concerns by asking general questions at routine visits (ex. what are your family concerns or needs? How can I help you?)
- Identifying the presence of risk factors and protective factors
- Screening for social issues at periodic visits
- Referring patients with identified needs to professionals in other disciplines and community agencies (Medicaid office, legal advocacy organization)
An extensive list of evidence-based screening tests have also been developed by different organizations and agencies to provide standardized tools for pediatricians to use. For example, the U.S Department of Agriculture has a “Household Food Security Module” consisting of 18 questions to gauge how severe a family’s food insecurity is. Or there is the Safe Environment for Every Kid (SEEK) parent screening questionnaire that takes 5 minutes for parents to answer to provide pediatricians with information about possible household substance abuse. Similar tests exist for pediatricians to gage educational gaps, financial insecurity and more. [iii]
The American Academy of Pediatrics demonstrated their commitment to addressing the social determinants of health for children when in 2017 they recommend screenings for poverty and the social determinants of health be included their Bright Futures Guidelines which have been adopted by CMS to set the standards for pediatrics visits covered under Medicaid. Many states have adopted the Bright Futures as a requirement for pediatricians. [iv]
Once harmful living conditions have been identified, pediatricians must be aware of the best next step. What resources are available? Who can they refer to? In many cases, with proper knowledge, pediatricians can recommend the next step for the family themselves- for example, referring them to apply for the Supplemental Nutrition Assistance Program or to seek consultation with the local health department. In other cases, pediatricians can rely on community partnerships. For example, medical-legal partnerships have been increasingly utilized in the pediatric field. Pediatricians can refer families to subsidized legal services (often housed in pediatric hospitals) where attorneys with expertise in poverty can then help families deal with common issues such as substandard housing, denial of public benefits, intimate partner violence, etc.). Another example can be pediatric partnerships with local food banks such as with the Keeping Infants Nourished and Developing (KIND) which collects formula milk for in-need families.[v]While small pediatric practices may be limited in their ability to invest in partnerships, larger health systems have the resources and local influences to not only work with existing community efforts to help low-income families but also to create their own programs to do so.
Training on addressing social determinants is increasingly being made available to pediatricians. The AAP’s Community Pediatrics Training Initiative (CPTI) has provided grants, educational tools and mentoring to pediatric residency programs across the nation to prepare pediatricians to integrate their care with community resources and practice medicine with an informed population-health approach.[vi] The more pediatricians know, the more they can help.
Pediatricians are just one component of the larger system needed for fostering the proper developmental and wellbeing of a childhood. It does not fall on these specialized providers alone to improve the living conditions of children. That being said, pediatricians fill a unique role that is vital to implementing the first steps in towards a happier and nourished child. Small investments in a child can ripple into lifelong improvements in their quality of life.
[i]Children’s Defense Fund. “The State of America’s Children.” Childrensdefense.org. 2017. http://www.childrensdefense.org/library/state-of-americas-children/2017-soac.pdf.
[ii]Felitti, Vincent, and Robert Anda. “The Relationship of Adverse Childhood Experience to Adults Health Status.” https://www.acf.hhs.gov/sites/default/files/cb/nccan14_opening_plenary.pdf.
[iii]Chung, Esther, Benjamin Siegal, and Arvin Gang. “Screenings for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians.” Current Problems in Pediatric and Adolescent Health Care46, no. 5 (May 2016): 135-53.
[iv]Brooks, Tricia. “AAP’s Bright Futures Takes Step Forward to Incorporate Social Determinants of Health.” Center For Children and Families. April 03, 2017. Accessed June 29, 2018. https://ccf.georgetown.edu/2017/04/03/aaps-bright-futures-takes-step-forward-to-incorporate-social-determinants-of-health/.
[v]Henize, Adrienne W., Andrew F. Beck, Melissa D. Klein, Monica Adams, and Robert S. Kahn. “A Road Map to Address the Social Determinants of Health Through Community Collaboration.” Pediatrics. October 01, 2015. Accessed June 29, 2018. http://pediatrics.aappublications.org/content/136/4/e993.
[vi]Plax, Katie, Jeanine Donnelly, Steven Federico, Leonatrd Brock, and Jeffrey Kacxorowski. “An Essential Role for Pediatricians: Becoming Child Poverty Change Agents for a Lifetime.” Academic Pediatrics16 (2016): 147-54.