Pediatrics: Decreasing the Impact of Social Determinants of Health and Adverse Childhood Experiences

Marcie Ward, RN, Senior Clinical Consultant, Medical Advantage; and Cynthia Morrison, RN, CPHRM, Senior Patient Safety Risk Manager, The Doctors Company. (TDC Group of Companies)

Across the United States, the landscape of pediatrics has been quietly yet forcefully changing, leaving in its wake an awareness of a class of “new morbidities” that dramatically affects families and the health of children. This class of new morbidities includes development, behavior, education, and family difficulties—areas that many pediatricians find challenging to address.

Social determinants of health (SDOH) and adverse childhood experiences (ACEs) are two areas that are gaining attention as predictors of an individual’s long-term mental and physical health. SDOH and ACEs intertwine and may lead to significant 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 medicine, and it is even more significant in pediatrics.

Social Determinants of Health

Access to social and economic opportunities plays a significant role in an individual’s health. According to the Office of Disease Prevention and Health Promotion, “Social determinants of health are 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, quality of education, safety of neighborhoods, and access to transportation and healthcare. Consider the impact on a child’s health in the following situations: inadequate transportation impedes a family’s ability to keep scheduled medical appointments, low income prevents a family from choosing healthy food options, an unsafe neighborhood stops a child from playing outside, or an inability to pay rent forces a family into a homeless shelter.

Adverse Childhood Experiences

ACEs are traumatic events and unsafe or unstable environments experienced between the ages of 0 through 17. ACEs 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 they 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 effect of strong, frequent, and prolonged stress influences an individual’s behavior and educational outcomes for decades and continues to wreak havoc on future generations.

Across the country, pediatricians are joining the growing movement to screen children and their parents for ACEs. Physicians are asking difficult but critical questions that help them and the medical community understand the connection between childhood experiences and the long-term trajectory of an individual’s life.

Strategies

Although routine healthcare addresses and manages symptoms of chronic conditions, the underlying issues remain largely ignored. Current strategies include meeting the challenges head-on by implementing evidence-based screening tools, validating trauma, encouraging prevention, promoting health, and establishing community resources and collaborations.

Screening

The American Academy of Pediatrics (AAP) recommends screening for SDOH risk factors during all patient encounters by using a screening tool to assess basic needs such as food, housing, and heat. Find resources for SDOH 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. Most patients voice gratitude that someone cares enough to ask. 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

Collaborating with the community and establishing community partners are essential to addressing SDOH and ACEs. It is not uncommon for a pediatrician to find these situations challenging, but 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 Implications

Struggles to contain the pandemic have endangered our children’s safe and stable environments. As stress levels and isolation rise for adults, the risk for child abuse and neglect also rises. This, coupled with children’s anxieties over their changing world, is creating a perfect storm that challenges the best parents.

Stay-at-home orders intended to protect individuals and communities are likely to have unintended consequences for children and vulnerable families. Consider what happens if staying at home is not safe, and it causes children harm by forcing them to stay in dangerous situations. In normal circumstances, trusted adults are visiting homes, waiting at school, and attending afterschool activities, with trained and watchful eyes and a dutiful presence to report abuse.

Due to COVID-19 isolation, pediatricians have had less opportunity to assess and potentially intervene at a time when children and their families have been most vulnerable. Well-child visits have declined during COVID-19 due to parents’ fears that their child could potentially be exposed during an office visit. In this “new normal,” however, the medical professional is 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.6

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.


References

  1. 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. http://pediatrics.aappublications.org/content/129/1/e224.long?trendmd-shared=0. Reaffirmed July 2016.
  1. Social determinants of health. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
  1. Preventing adverse childhood experiences. Centers for Disease Control and Prevention. www.cdc.gov/violenceprevention/childabuseandneglect/aces/fastfact.html
  1. Stevens J. The Adverse Childhood Experiences Study—the largest, most important public health study you never heard of—began in an obesity clinic. ACESTooHigh. https://www.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/. Published October 2012.
  1. Preventing adverse childhood experiences (ACES): leveraging the best available evidence. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf. Published 2019.
  1. 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.

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