PolicyLab

Kevin* is a sweet, smiling, chubby one-year-old male I’ve cared for since birth. I consider his family to be one of my most vulnerable. Kevin’s mother, Maria*, immigrated to the U.S. from the Dominican Republic nine years ago. Both of her children were born in the U.S. and have citizenship and health insurance. Unfortunately, Maria has neither—she is uninsured and undocumented. Maria never finished high school. She struggles with reading and despite me connecting her to many resources, she has never made it “across the finish line” to any of the services. She has very limited English proficiency, and I consider my ability to connect with her in her preferred language of Spanish one of the key reasons we have such deep and meaningful conversations.

Kevin’s older brother, Jesus*, has had high lead levels in the past, and this was something on her mind during Kevin’s recent visit to see me. Maria’s tenuous relationship with her landlord has made repairs tricky due to her fear of retaliation or eviction. During the pandemic, things have gotten much worse for her. Our months of open dialogue and frank conversations have allowed me to come to know these stressors well.

When asked about food insecurity through our well-child social need screening tool, Maria always timidly answered “No. Estoy bien.” But, when I asked in our most recent visit “¿Hay algo más por lo que estés preocupada? (Is there anything else that worries you?)” Maria broke down, tears in her eyes, telling me that her home is infested with rats and cockroaches. She is scared that her infant son will be bitten by the rodents. She does not have enough formula at home for Kevin, and she worries constantly about food. About housing. About her lack of health insurance. About not having enough to pay the bills.

According to this Washington Post piece, nearly 12 million renters will owe an average of $5,850 in back rent and utilities this month as a result of job loss during the COVID-19 pandemic. Last month, 9 million renters said they were behind on rent, according to a U.S. Census Bureau survey.

Would Maria have disclosed these worries on a tablet-based screening questionnaire? Would texting her a link to a housing resource have helped? Would she need more intensive services, like a home visitor or community health worker who is bilingual, someone she can trust? These are the questions we need to answer with further research if we truly want to meaningfully address social needs for children and families.

It is becoming more prevalent for pediatric primary care centers to screen for family social needs using tablet- or paper-based screeners, but research is lagging behind practice as to the most effective way to determine needs and priorities. We know that the upstream social determinants of health are a direct result of oppression, racism and structural inequality. What we do NOT understand is the best “recipe” to “diagnose” the individual needs a family may have. How frequently should we assess this? How can we assess strength and resilience? How can we help families who may feel like they are drowning prioritize what’s most important today, and honor their autonomy in deciding which issues they think the health care system can support?

Pediatric primary care providers are the trusted resource for family-centered care, and we want to be a sanctuary, refuge, and loving medical home for our children and their families. However, unless they are young infants, pediatric providers only see our patients one, maybe two, times a year. We also know that there are significant disparities in access to well-child care and opportunities for screening. Some of our highest risk and highest need families may not be in front of us even annually. If we truly want to make an impact on connections, we must provide our families with the tools they need to manage stress and social needs when they are not in front of us.

We review this complicated issue and how to address it in the brief, “Screening for Social Needs in Pediatrics: How Can We Ensure it is Family-Centered and Effective?” that a collaborative, interdisciplinary group of Children’s Hospital of Philadelphia pediatricians and social workers released this week. The brief offers guidance on strategies that health care systems and providers can adopt to effectively meet families’ needs, as well as recommendations to follow to avoid unintended consequences. This issue brief does not provide all of the answers, but we hope it will be a starting point for a much needed conversation about giving families—families like Maria’s—choices, honoring their incredible strength and resilience, and considering their preferences and priorities when addressing their social needs.

*Name changed to protect patient privacy.