Improvements in Addressing Social Determinants of Health in Children and Families

Lauren Geary, M.P.H., American Academy of Pediatrics
Kathy Janies, American Academy of Pediatrics
Jane Bassewitz, M.A., American Academy of Pediatrics

Throughout the last decade, the field of maternal and child health has made many significant improvements. For example, significant energy has been poured into improving our understanding of the impact that social determinants of health (SDoH) has on children, families, and communities. The Centers for Disease Control and Prevention (CDC) defines SDoH as “the conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.”¹ In 2010,  Healthy People 2020 added “social determinants of health” as a new topic area. This decision to include SDoH signaled a shared understanding that “all Americans deserve an equal opportunity to make choices that lead to good health” and a commitment to creating environments that support good health for all.² Since 2010, the CDC, HealthyPeople.gov, and other public health organizations have worked to mitigate the risk factors and promote the protective factors related to SDoH that affect children, families, and communities through various programs and initiatives.

Bright Futures and Social Determinants of Health
Bright Futures is a national health promotion/disease prevention initiative led by the American Academy of Pediatrics (AAP) and supported by the Maternal and Child Health Bureau.³  The Bright Futures Guidelines are widely regarded as the standard for well-child care. Pediatric health care and public health professionals (those who are in training and those in practice) use these guidelines. The first section of the Guidelines contains important information about different aspects of child health organized into “Health Promotion Themes.” The second section outlines components of each well-child visit, from birth through age 21.

In 2017, the Bright Futures Guidelines, 4th Edition, was revised and released, and it focuses on the impact of SDoH. The new health promotion theme, Promoting Lifelong Health for Families and Communities, specifically addresses SDoH (both risk factors and protective factors) and it also identifies family strengths, like having supportive relationships and the ability to manage stress. The majority of Bright Futures well-child visits prioritize the need to identify and address the social determinants of health.⁴

Health promotion theme: Promoting lifelong health for families and communities
A fundamental principle of Bright Futures is that optimal health requires a healthy family and community. Promoting Lifelong Health for Families and Communities describes the growing body of evidence that demonstrates how SDoH highly influences the developmental trajectory of a child and family. This theme provides valuable information about the life course framework, and guidance for health care professionals to leverage strengths and protective factors and minimize risks to promote healthy development in children, families, and communities.⁴

Social determinants of health within Bright Futures well-child visits
In addition to the health promotion theme dedicated to social determinants of health, the Guidelines were revised to include the social determinants of health as one of the priorities for anticipatory guidance in most well-child visits. Sample questions facilitate conversations with families. For example, in the two-month well-child visit, a health care professional may ask the family: “Tell me about your living situation. Is permanent housing a worry for you?.”⁴ Other sample questions ask about food security, access to health insurance, and family support. Sample anticipatory guidance includes information about food assistance programs and dealing with unwanted advice from families and friends.

Training on Bright Futures
Since 1997, the AAP has surveyed graduating residents about their experiences in training. In 2008 and 2018, two questions about Bright Futures were included in the annual survey:

1. Was Bright Futures part of your preventive services curriculum during residency?
2. How would you rate your ability to implement Bright Futures Guidelines and recommendations?

In 2018, 87 percent of respondents reported that Bright Futures was part of their preventive services curriculum during residency (AAP, unpublished data). This is an improvement from 2008, when 59 percent of graduating residents reported that Bright Futures was included in the curriculum (AAP, unpublished data). In 2018, 57 percent of respondents reported having a “very good” or “excellent” ability to implement Bright Futures Guidelines— an increase from 34 percent reported in 2008 (AAP, unpublished data).

These data indicate a positive trend in terms of numbers of respondents who were familiar with the Bright Futures Guidelines who were able to implement the Guidelines into clinical practice. The Guidelines are more widely used in residency training now than in the previous decade. The increased focus on SDoH and emphasis on reinforcing the value of family strengths, the Guidelines facilitate health care professionals’ ability to identify and address SDoH in the well-child visit.

Resources from the American Academy of Pediatrics

The AAP is at the forefront of child health and has the unique opportunity to engage in research, create initiatives, and develop policy related to the impact of SDoH on children, families, and communities. Some of these resources include the following:

Screening Technical Assistance and Resource (STAR) Center
The AAP STAR Center offers information and resources to help health care professionals  “implement effective screening, referral, and follow up for developmental milestones, maternal depression, and social determinants of health.”5 Resources include screening tools, interactive trainings, screening process resources, and practice success stories. An increased focus will be placed on educational offerings and resources geared toward identifying and managing SDoH, including adverse childhood experiences, toxic stress, resiliency, and relationship building between the health care professional and family.

Additional Resources
Over the last 10 years, the AAP and colleagues have developed policies and guidelines related to addressing SDoH in children. Some key resources include:

• Preventive Factors
  • The Resilience Project
  • Pediatric Approach to Trauma, Treatment, and Resilience Project (PATTeR)
• Poverty
  • Policy Statement: Poverty and Child Health in the U. S.
  • Technical Report: Mediators and Adverse Effects of Child Poverty in the U. S.
  • Policy Statement: Promoting Food Security for All Children
  • Curriculum: Academic Pediatric Association (APA) U.S. Child Poverty Curriculum
• Toxic Stress and Trauma
  • Policy Statement: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health
  • Technical Report: The Lifelong Effects of Early Childhood Adversity and Toxic Stress
  • Toolkit: Trauma Toolbox for Primary Care
• Food Insecurity
  • Policy Statement: Promoting Food Security for All Children
  • Toolkit: Addressing Food Insecurity: A Toolkit for Pediatricians
• Substance Use
  • Policy Statement: Substance Use Screening, Brief Intervention, and Referral to Treatment
  • Peds 21: Opioids Through the Ages: Caring for Children and Families in the Wake of the Opioid Crisis (Videos)
  • Behavioral Health Simulation Training

References

1. Centers for Disease Control and Prevention. Social Determinants of Health: Know what Affects Health. cdc.gov. https://www.cdc.gov/socialdeterminants/index.htm. Updated January 29, 2018. Accessed January 2, 2020.
2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020. HealthyPeople.gov. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Updated January 1, 2020. Accessed January 2, 2020.
3. American Academy of Pediatrics. Bright Futures. BrightFutures.aap.org. https://brightfutures.aap.org/Pages/default.aspx. Updated December 2019. Accessed January 2, 2020.
4. Hagan, J. F., Shaw, J.S., Duncan, P.M., eds. (2017). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics. https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx. Accessed January 2, 2020.
5. American Academy of Pediatrics. STAR Center. STAR Center website. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/default.aspx. Accessed December 26, 2019.