When I heard the American Academy of Pediatrics call for pediatricians to address poverty and social determinants of health, I – and maybe you, too – thought, “Great idea. But how am I, as a practicing pediatrician, supposed to help with such overwhelming and socially determined factors?”
It seems that the best way to reduce poverty, homelessness, and inadequate education is to advocate and vote to maintain or expand proven social programs. But there are also more proximal “relational” (relationship) factors we can address. The Adverse Childhood Experiences (ACE) study showed that the number of ACEs reported in their pasts by adults has a nearly linear relationship to long-term morbidities, including suicide, depression, obesity, smoking, substance abuse, heart disease, and early death. The ACE events during childhood – besides lack of food – came from the child’s relationships: abuse (emotional, physical, or sexual) and family dysfunction (mother abused; loss of a caregiver through divorce, separation, or death; household members with alcohol or substance abuse, mental illness, or time in prison).
Dr. Barbara J. Howard
The most important step you can take to prevent your patients from ACEs is detection. You have to ask parents, either verbally or with a screening tool about current factors that could be harmful to the child. You may think, “My patients don’t have these problems,” but abuse, intimate partner violence (IPV), depression, substance use, and loss occur in families of all kinds and means. Even the presence of food insecurity and imprisonment in some of my “put together” families has surprised me.
There are a number of tools available to screen for individual factors such as parental depression (Edinburgh Postnatal Screening, Patient Health Questionnaire-2 and -4), IPV, substance use (CRAFFT, which stands for Car, Relax, Alone, Forget, Friends, Trouble), and food insecurity. Tools covering multiple risk factors also are available on paper (Safe Environment for Every Kid [SEEK], Survey of Well-being of Young Children [SWYC]) or online (CHADIS). Rather than being overly intrusive, parents report accepting these questions as representing your caring about them as well as their child.
Coverage for screening and counseling for depression and IPV is mandated by the Affordable Care Act. As of July 2016, screening for maternal depression by pediatricians is paid for by Medicaid and many other insurers, often as part of the well-child visit, according to the Center for Medicaid and CHIP Services’ Informational Bulletin of May 11, 2016. For patient-centered medical homes, there is a mandate for referral and care coordination (AHRQ Publication No.11-M005-EF, December 2010). New value-based payment mechanisms are likely to pay you based on such screening and referral processes (e.g. New York), so we had best prepare (“Value-Based Payment Models for Medicaid Child Health Services,” Report to the Schuyler Center for Analysis and Advocacy and the United Hospital Fund, July 13, 2016).
But what to do when the screen or questions reveal a problem? Your first impulse is likely to be to refer. But unlike referrals for a physical health issue such as severe anemia for which the parent calls the hematologist immediately, in the case of these touchy, embarrassing, or emotionally charged problems, accepting help may not be so easy. It may be the financially critical partner who is the substance user or the mother herself who is too depressed to move towards help. For problems such as lack of food or the need to get a GED (general education development), the referral may be successful by supplying phone numbers. Referrals for IPV, one of the most common (greater than 29%) and damaging ACEs to the child, who is exposed to violence and often abused, have been found to mainly fail from simply making a referral.
Just as for a positive blood screen, for a referral to be effective more information is needed. In the case of a family stressor, you need to find out the nature and extent of the problem, the immediacy of the danger, and what has been done so far to reduce it. Research now shows that the most effective way to collect this information is using motivational interviewing (MI) techniques that nonjudgmentally determine not just the facts, but engage parents in weighing the pros and cons of changing the status quo, their readiness to change, the types of interventions that might be acceptable, and what would tell them that it was time to act. When using MI, you are actually doing more than making a referral, you are beginning to address the problem you uncovered.
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