Pediatrics: Addressing Social Determinants of Health and Adverse Childhood Experiences
Social determinants of health (SDOH) and adverse childhood experiences (ACEs) are two areas gaining attention as predictors of an individual’s long-term mental and physical health. SDOH and ACEs are interconnected and may result in substantial childhood adversity and cause toxic stress—which in turn “disrupts the architecture of the developing brain, thereby influencing behavioral, educational, economic, and health outcomes decades and generations later.”1 Addressing SDOH and ACEs is a matter of high importance in healthcare, with particularly significant implications in pediatrics.
Social Determinants of Health
Access to social and economic opportunities plays a major role in an individual’s health. The Office of Disease Prevention and Health Promotion defines SDOH as “Conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”2 Examples of conditions that affect health include home and community environments, access to and quality of education, neighborhood safety, and access to transportation and healthcare.
Consider how SDOH factors might affect a child’s health in the following situations:
- Inadequate transportation impedes a family’s ability to keep scheduled medical or dental appointments.
- Low income prevents a family from choosing healthy food options.
- An unsafe neighborhood stops a child from playing outside.
- An inability to pay rent forces a family into a homeless shelter.
- Digital inequity creates a lack of access to the internet or technology resources that affects an individual’s ability to access telehealth or online learning resources.
Adverse Childhood Experiences
ACEs are traumatic events and unsafe or unstable environments experienced between the ages of 0 through 17, including physical, emotional, or sexual abuse and household factors, such as mental illness, substance abuse, violence, incarceration, and separation/divorce. ACEs may significantly affect childhood development, well-being, adult health, and social productivity.3 Although some children are more at risk than others, ACEs are common, interconnected, and appear across all socioeconomic boundaries. Two-thirds of adults have experienced at least one ACE. Because ACEs usually occur in clusters, an individual with one ACE has an 87 percent chance of having two or more. The more ACEs experienced as a child, the greater the individual’s risk for chronic disease and mental illness throughout life.4
In addition, the cumulative effects of strong, frequent, and prolonged stress can potentially influence an individual’s behavior and educational outcomes for decades—even into future generations.
To combat these negative outcomes, pediatricians across the country are joining the growing movement to screen children and their parents for ACEs. Physicians are asking critical questions that help them identify and understand the connection between childhood experiences and their long-term effects on health.
Strategies to Address SDOH and ACEs
Although routine healthcare addresses and manages symptoms of chronic conditions, the underlying issues remain largely ignored. Current strategies for SDOH and ADEs include meeting the challenges head-on by implementing evidence-based screening tools, validating trauma, encouraging prevention, promoting health, and establishing community resources and collaborations.
The American Academy of Pediatrics (AAP) recommends screening for SDOH risk factors during all patient encounters by using a tool to assess basic needs such as food, housing, and heat. Find resources for SDOH and ACE screening in the AAP’s Screening and Technical Assistance and Resource Center.
One of the primary benefits of screening for ACEs includes the validation and acknowledgment of trauma. Although addressing ACEs may seem daunting, the AAP provides a step-by-step Trauma Toolbox for Primary Care with guidelines for implementing ACE screening.
Prevention and Health Promotion Through Collaboration
Collaborating with the community and establishing community partnerships are essential to addressing SDOH and ACEs. A warm handoff to a trusted partner can bridge the gap and ensure timely help in interrupting the cycle of adversity and trauma. Examples of community partner recommendations include the following:5
- Early childhood home visiting programs—such as Early Head Start; Early On; Nurse Family Partnership; and the Maternal, Infant, and Early Childhood Home Visiting Program.
- Mentoring programs, such as Big Brothers Big Sisters of America.
- Afterschool programs.
- Victim-centered services.
- Family-centered treatment services for substance abuse.
- Mental health professionals and social workers.
- Trauma networks.
- Food pantries.
- Homeless shelters.
- Housing assistance.
- Utility assistance.
- Free legal assistance.
COVID-19 has caused major disruptions to healthcare, making disparities in access to care even more problematic. This situation has resulted in neglect of serious medical or dental conditions and delays in preventive care and immunizations. “Missed opportunities for care can have immediate and long-term consequences for children’s health, development, and welfare that are more severe for populations of children affected by inequities based on race, and/or ethnicity, disability, geography, socioeconomic status, and payer policies.”6
While telehealth availability has created greater access to care for many children and adolescents, gaps in digital infrastructure continue because of poverty and societal inequities that create barriers to accessible technology-enabled care.
Environments that were once safe and stable for children have been negatively impacted by efforts to control the pandemic.7 As stress levels and isolation have risen for adults, the risks for child abuse and neglect also rises.
Because of COVID-19 isolation, pediatricians have had fewer opportunities to assess and potentially intervene while children and their families have been most vulnerable. Well-child visits have declined during COVID-19 due to parents’ fears that their child could be exposed during an office visit. In this “new normal,” however, the healthcare professional is often one of the remaining checkpoints for risk factors contributing to abuse and neglect.
The AAP has published recommendations for healthcare provider interventions and parental recommendations to decrease the risk of violence and harm to children during periods of crisis.8
The role of the pediatrician encompasses the management of the physical, behavioral, and mental health of a child. The pediatrician’s continuity of care, in collaboration with community partners, is a critical component in preventing and mitigating childhood adversity and trauma.
For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.
- Garner AS, Shonkoff JP; Committee on Psychosocial Aspects of Child and Family Health. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012 Jan;129(1):e224-31. Reaffirmed July 2016. https://publications.aap.org/pediatrics/article/129/1/e224/31631/Early-Childhood-Adversity-Toxic-Stress-and-the
- Social determinants of health. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/social-determinants-health
- Preventing adverse childhood experiences. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/aces/fastfact.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Ffastfact.html
- Stevens J. The Adverse Childhood Experiences Study—the largest, most important public health study you never heard of—began in an obesity clinic. ACESTooHigh. Published October 2012. https://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/
- Preventing adverse childhood experiences (ACES): leveraging the best available evidence. Centers for Disease Control and Prevention. Published 2019. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf
- Curfman AL, Hackell JM, Herendeen NE, et al. Telehealth: improving access to and quality of pediatric health care. Pediatrics. 2021 Sep;148(3)e2021053129
- Sillman Cohen RI, Bosk EA. Vulnerable youth and the COVID-19 pandemic. Pediatrics. 2020;146:e20201306
- Humphreys KL, Myint MT, Zeanah CH. Increased risk for family violence during the COVID-19 pandemic. Pediatrics. 2020 Jul;146(1):e20200982. https://pediatrics.aappublications.org/content/early/2020/06/24/peds.2020-0982
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.