All adults once were children. Who we are, how we function, how we think and perform, and many other traits have their beginnings in our earliest years. Although the foundation of the United States is embedded in the concept of equality, it is certainly true that not all children have similar advantages as they move through their first several years of life. Many of the inequalities that affect health in general, and brain health in particular, may be evident to astute pediatricians and their medical home team partners while they are providing primary care visits with families. In their article, “Addressing Social Determinants of Health at Well-Child Care Visits: A Cluster RCT,” Garg, Toy, and colleagues address the utility of systematically screening for unmet basic needs at well-child visits and providing “simple” referrals and follow-up. They present their data from a randomized controlled study to provide an initial evidence base for the value of screening.1 Although evidence is the often-sought “holy grail” to answer the question, “Does this work?” the answer is currently yes, based on experience, common sense garnered from several pediatric practices beginning to screen for social determinants, and the Adverse Childhood Experiences Study, which is now gaining wider recognition and acceptance.
In this study, families were excluded if the mothers were <18 years old. That is a fair exclusion criterion because younger mothers bring additional risk factors that can differ from those older than 18. However, because younger mother’s youthfulness is, in itself, a serious threat to optimal development of their infants, an opportunity now presents itself for a study limited to younger mothers. The research questionnaire assessed only a few social issues rather than a more comprehensive social history including referral services.
The authors present their data and conclude that systematic screening leads to greater community resources. This is an admirable beginning, but if we back up to consider our current and rapidly expanding awareness of neurosciences, particularly the adverse effects of continuous, unabated and unmitigated stress, often referred to as “toxic stress,” it is evident that more exploration of a family’s situation is needed to fully address and improve the situation in which a child will develop. There is an urgent need to recognize the importance of toxic stress, childhood adversities, and other social factors as we provide pediatric care to children. What good is providing routine care exemplified perhaps by giving an immunization, if a child leaves the office to continue living in poverty, with food insecurity, maternal depression, lack of affordable child care, violence in the home, drug abuse, and other adversities?
Recognition of social factors affecting a child and the family is easy. Providing care requires close affiliations with community resources (assuming the resources even exist), and a willingness to address these issues in the midst of a busy practice where time is both precious and tied to payments. The American Academy of Pediatrics is in the midst of launching its new Center on Healthy, Resilient Children to address ways to provide pediatricians with education and knowledge about adversities and social determinants, to provide access to care for children and families, to dialogue with payers about the importance and value of time spent addressing social determinants, developing pathways toward resilience, and partnering with many other individuals and organizations sharing similar goals and objectives. The AAP includes early brain and child development, epigenetics, and the health effects of poverty on its national agenda. As pediatric practices develop through the current decade and as training in pediatrics increases attention to brain health and social determinants of health, pediatricians are now, and will increasingly become, able to provide attention to the social translations of neuroscience in their practices. For families, communities, and for pediatricians, this will be an important achievement.
- Accepted November 17, 2014.
- Address correspondence to Robert W. Block, MD, FAAP, 256 E 27th St, Tulsa, OK 74114. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page e296, online at www.pediatrics.org/cgi/doi/10.1542/peds.2014-2888.
- Copyright © 2015 by the American Academy of Pediatrics