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Within the medical home, understanding the family and community context in which children live is critical to optimally promoting children’s health and development. How to best identify psychosocial issues likely to have an impact on children’s development is uncertain. Professional guidelines encourage pediatricians to incorporate family psychosocial screening within the context of primary care, yet few providers routinely screen for these issues. We propose applying the core principles of surveillance and screening, as applied to children’s development and behavior, to also address family psychosocial issues during health supervision services. Integrating psychosocial surveillance and screening into the medical home requires changes in professional training, provider practice, and public policy. The potential of family psychosocial surveillance and screening to promote children’s optimal development justifies such changes.
Family psychosocial issues have a major influence on children’s development.1 Certain factors contribute to children’s resiliency and healthy development, while other factors place children at increased risk of delayed or disordered development. In fact, many developmental and behavioral problems of young children correlate with the psychosocial status of their families.2
The term “family psychosocial issue,” as previously defined by Kelleher and Kemper, refers broadly to any “family factor that affects children’s health.”1,3 Family psychosocial issues can range from social needs (e.g., food insecurity, housing instability) to parent psychosocial problems (e.g., depression, intimate partner violence). Numerous studies have demonstrated the myriad of family psychosocial issues that place children at developmental risk (Table 1).4–13 Furthermore, the impact of these issues has been shown to be both cumulative and influenced by the age and developmental stage of the child.14–16
The American Academy of Pediatrics (AAP) states that a family-centered medical home exists within a “community-based system.”17 Professional guidelines have encouraged providers to identify and intervene with various family issues, given their potential negative impact on child health and development.18–21 As stated in the AAP’s policy statement on the medical home, a key service for pediatricians is to interact with “community agencies to be certain that the special needs of the child and family are addressed.”22
Pediatricians, regardless of their practice setting and patient population, provide care to children who are exposed to family psychosocial issues and are in a unique position to develop partnerships with families.23 Yet studies suggest that providers are not effective in detecting many psychosocial issues.24,25 Providers most often cite barriers, including a lack of time, training, and knowledge of available resources.26,27 Child health providers may also question whether it is their prerogative to initiate discussion of parents’ psychosocial problems and whether they will offend parents by raising sensitive issues that are not solely child-directed topics.28,29 Finally, there are challenges to incorporating psychosocial screening within the current medical home structure.
Pediatric care models have focused on screening for specific family issues, such as parental smoking,30–32 intimate partner violence,33–35 and maternal depression36–40. To date, however, little guidance is available on how to best detect and intervene with the wide range of family psychosocial issues that influence children’s development. A new paradigm is needed to better address family psychosocial issues within the medical home.
Expert opinion and research evidence support surveillance and screening as the process by which pediatric providers should monitor infants and young children for developmental delays.41 Surveillance is defined as “a flexible, longitudinal, and continuous process whereby knowledgeable professionals perform skilled observations during the provision of health care.”42 In contrast, screening involves the use of standardized tools, such as parent-completed questionnaires and professionally administered tests, at select ages. Surveillance and screening are guided by the developmental stage of the child and the concerns of the family and are used to monitor children’s development, provide anticipatory guidance, and initiate appropriate referrals. Both the Council on Children with Disabilities of the AAP and the Bright Futures Steering Committee have endorsed surveillance and screening as best practice.18,41
In contrast, there is currently no consensus on how best detect family psychosocial issues. We propose that the core components of surveillance and screening can also be effectively applied to family psychosocial issues to enhance the effectiveness of child health services.
The AAP recognizes that parental concerns warrant prompt attention and recommends that providers elicit parental observations, experiences, and concerns by posing simple questions related to children’s development, learning, and behavior.18 A similar approach can be used to elicit and attend to parents’ concerns regarding family psychosocial issues. General queries could be posed at all well-child care visits, such as, “Tell me about your living situation,” and “How are your resources for caring for your baby?”18 The pediatrician may also ask, “Do you or your family have any needs with which I can help you?”
A family psychosocial history should be a key component of the well-child visit. The mnemonic, IHELLP, is one example of a strategy to assist providers with addressing family issues such as income, housing, education, legal status/immigration, literacy, and personal safety.43 Health information technology (e.g., templates) may also be useful. Like a developmental history, this history should be continually updated. This may be accomplished by asking, “Have there been any changes with your or your family’s needs since our last visit?”
Multiple, concurrent family problems increase a child’s risk for poor development and suggest the need for early intervention and close follow-up.15 Recognizing protective factors is also crucial to enable the provision of strength-based care to support the positive attributes of families.18,44
The medical record should document all family psychosocial surveillance and screening activities to ensure proper follow-up. The electronic medical record offers opportunities to develop templates specifically tailored to facilitate the documentation of family psychosocial issues and compile registries of families with common psychosocial issues. Of note, documentation of sensitive topics such as maternal depression and intimate partner violence may have medical-legal implications and require processes to ensure confidentiality and secure management.
Bi-directional communication between pediatric providers and community social service agencies is important to promote a comprehensive, multidisciplinary approach to family psychosocial issues. Recent innovations in pediatric training acknowledge the importance of promoting collaboration and communication between child health providers and community-based organizations.45
The AAP recommends the use of standardized screening tests at periodic well-child visits and when surveillance elicits concerns. Research has documented the efficacy of screening tests in the detection of family psychosocial issues.46 More than a decade ago, Kemper and Kelleher recommended incorporating global family psychosocial screening into pediatric practice.1 The authors concluded that doing so would legitimize these topics for discussion, enrich the clinical experience, and, ultimately, lead to more comprehensive pediatric care.
Achieving consensus on the importance of screening to strengthen longitudinal surveillance requires the resolution of such issues as which psychosocial issues should be the target of such screening. Certain guiding principles can inform pediatricians and their practices. Screening should be tailored to the most commonly identified issues in the community served by the medical home. For example, screening for public housing needs makes little sense in a practice that serves an upper middle class, suburban community. Screening should also be linked to the stages of a family’s development. Screening for childcare needs, for example, may no longer be as important once a child begins school. Relying on parents’ opinions and concerns to inform and, ultimately, determine the issues that are deemed important for screening is consistent with family-centered care and may promote families’ adherence to providers’ recommendations and referrals. Family psychosocial issues should be a target for screening when community resources are available to address these needs, since detection without referral to resources is only likely to increase frustration and may undermine the parent-provider relationship.47 This requires the medical home to be aware of available community resources prior to initiating routine screening.
Family psychosocial screening may consist of global screening, as well as more focused screening for certain, specific family psychosocial issues. While there are a variety of validated screening tools designed to detect such specific family psychosocial needs as maternal depression, intimate partner violence, etc. (Table 1), few global screening tools have been developed with demonstrated applicability to pediatric practice. Kemper’s original family psychosocial screening tool, since adopted for use by Bright Futures, screens for substance abuse, depression, intimate partner violence, parental history of abuse, social support, housing instability, low parental education, and unemployment.46
To date, two studies have demonstrated the impact of global screening for multiple family psychosocial problems at pediatric visits.46,48 Kemper found the use of a self-administered questionnaire increased the identification of family psychosocial problems among mothers attending a pediatric clinic.46 In the WE CARE project, conducted in an urban clinic, we found that parents completing a self-report screener for ten family psychosocial needs prior to the visit, along with providers’ access to family resource books containing information sheets listing available community resources (see Table 2), significantly increased identification and referrals to community agencies for basic needs such as food, employment, education, and housing.48 This model extended the provider’s role beyond surveillance and screening to include referring families to community-based services. Of note, this global screener identified relatively few sensitive family psychosocial problems to which our families were likely exposed, such as intimate partner violence and substance abuse.
In contrast, studies have shown the impact of using specific screening tools for such sensitive family psychosocial issues as maternal depression,36–38 substance abuse,30–32 and intimate partner violence33–35. For example, Olson, et al., demonstrated that screening for maternal depression at well-child care visits using the Patient Health Questionnaire (PHQ-2) significantly increased the identification of mothers with major depressive disorder and pediatric interventions, including counseling and referral to community supports.38
Thus, research findings support the use of global screening tools to identify basic family issues, in combination with specific screening tools for sensitive problems, to enhance the effectiveness of longitudinal surveillance for psychosocial issues. We suggest that family psychosocial screening should occur: when surveillance detects a family psychosocial problem; during initial intake with any new family; with a newborn within the first six months of life; and periodically (e.g., annually) during well-child care visits, since family needs can change over time. Frequency of screening should be determined by the prevalence of psychosocial issues in the community and the capacity of the medical home staff.
We acknowledge the challenges to incorporating psychosocial surveillance and screening in pediatric practice. The range of potential issues is extremely broad and families’ specific needs may vary by and within practice settings. Furthermore, resources are highly variable in their availability and require interaction with different service sectors. For example, certain basic issues such as housing, food, or employment are typically addressed by social service agencies, while other issues, such as maternal depression and substance abuse are typically treated by mental health professionals. Recommendations and strategies regarding the implementation of psychosocial surveillance and screening must, therefore, be sufficiently generic to accommodate the broad range of issues confronting families in different communities, while sufficiently substantive and specific to enable practices to better identify such issues and ensure the effective linkage of families to appropriate community resources.
Barriers to establishing family psychosocial surveillance and screening as the standard of care for child health care providers are similar to those impeding the widespread implementation of developmental surveillance and screening.26,49 Providers are expected to perform a litany of tasks during the well-child visit and adding another expectation to their busy agenda may seem unfeasible. For example, Holtrop and colleagues demonstrated that intimate partner violence (IPV) screening increased identification of women with IPV. To adequately address this issue with at-risk mothers, pediatricians must also have the capacity to make referrals to community resources and develop a safety plan. The effort required may well be daunting, given the time constraints of the typical well-child visit. This suggests that the current medical home model must be redesigned. Lack of reimbursement for such activities may make the costs of staffing and processes prohibitive. We suggest the following strategies for child health providers, professional organizations, and advocacy groups to facilitate the incorporation of surveillance and screening for family psychosocial issues within the medical home.
Although pediatric professional guidelines recommend discussion of family psychosocial issues at well-child visits,19–21 pediatricians may view these topics as beyond the scope of their implicit contract with families27,28. Professional organizations can take a leadership role in promoting this message nationally and locally, by emphasizing the correlation between family psychosocial issues and child health and the role of the pediatrician. Doing so may help promote acceptance of the detection of psychosocial issues as a core component of pediatric care.
Providers must also promote the message that parents can receive assistance and appropriate referrals to community resources within their child’s medical home. Parental awareness that these issues are a priority will encourage their participation in psychosocial surveillance and screening and increase their comfort with discussing sensitive issues. The longitudinal, therapeutic relationship between providers and parents should also enable discussions of difficult, sensitive issues.
Schor has recommended using time before the health supervision visit to perform screening tests.50 In our experience, parents were willing and able to complete a ten-item, written family psychosocial questionnaire in the waiting room.48 Currently, all parents accompanying their child for a well-child visit to the Harriet Lane Clinic of the Johns Hopkins Hospital complete a family psychosocial questionnaire that screens for basic needs and safety needs while awaiting their child’s pediatric provider. In addition to written surveys, newer technologies such as computer kiosks in the waiting room or administering surveys via telephone or the internet have also been shown to be useful.51–53
Without adequate reimbursement, universal adoption of family psychosocial surveillance and screening will not be feasible. Such reimbursement has facilitated the implementation of developmental surveillance and screening in a number of states.54 The AAP Committee on Psychosocial Aspects of Child and Family Health has suggested using the Current Procedural Terminology (CPT) code 99420 to support screening for post-partum depression as a measure of risk in the infant’s environment.55 Effective advocacy by pediatricians and organizations is critical to secure such policy change.
The Institute of Medicine has identified care coordination as a key factor in improving the quality of health care.56 Pediatric care coordination is defined as a “patient- and family-centered, assessment driven, team-based activity designed to meet the needs of children and youth while enhancing the care-giving capabilities of families.”57 Experience with developmental surveillance and screening has documented the importance of care coordination in ensuring successful referrals. Even when at-risk children are successfully detected and community-based resources are identified, an average of 7 contacts may be required to successfully link children and families to services.58
Family psychosocial issues are likely to demand similar care coordination efforts. Parents report a disconnect between their child’s health provider and community-based services.59 In our experience in an inner-city pediatric clinic, we were impressed by the number of community resources that are available, free of charge, to families in need.48 When available, care coordinators can help to identify available community resources, along with monitoring adherence to recommendations and referrals, care planning (e.g., scheduling appointments), and providing feedback to parents, providers, and community resources.57 This team-based model of care allows busy providers to assist parents in connecting to resources, while not eroding clinical capacity. Unfortunately, few medical homes currently have care coordinators as members of their practice team and such functions are often assumed, when performed at all, by untrained and very busy support staff. In other practices, such functions are assumed by trained staff, such as social workers and nurses, often at the expense of their substantive clinical duties.
System change is necessary to fully enhance linkages between medical homes and community-based resources. Successful models of care coordination are currently being implemented, evaluated, and replicated in a variety of practice settings.60 Carolina Collaborative Community Care partners with other non-profit organizations to inform providers and families about resources and encourage referrals.61 Help Me Grow, a state-wide program in Connecticut currently being replicated in other states, assists with identifying children from birth to eight who are at increased risk for developmental and behavioral problems and connects them and their families to appropriate community resources.62,63 Key components include a free and confidential telephone access point which links families to existing services and a continually updated inventory of community-based programs and services (Table 3). Such models can likely be extended to the identification and referral of family psychosocial issues. Currently, 47 states maintain toll-free telephone numbers (e.g., 2-1-1 Infoline) that enable families to be linked to available human service resources such as food banks, job training, Head Start, substance abuse counseling, and support groups. Nationally, over 16 million calls were received by 2-1-1 in 2009.64 In addition, state-run maternal and child health (MCH) toll-free telephone hotlines are also available to assist families with such issues as health insurance, parenting and child rearing topics, and children with mental health needs.65 Pediatric medical homes should become familiar with existing community resource hotlines.
An integrated system of care could, for example, have pediatric providers identify families with psychosocial problems and refer them to a toll-free Infoline. Parents or care coordinators within the medical home could initiate the telephone call. Infoline personnel would provide contact information on available community resources. The care coordinator would help families access resources and update providers on families’ use of services. Feedback on the specific community resource’s ability to effectively address the family’s needs would inform the maintenance and updating of the Infoline resource inventory (Figure 1).
The development of an integrated system for care coordination will require thoughtful responses to a variety of important issues. For example, how is the quality of services ensured? Will the system be prepared to manage large volumes of referrals? Cross-sector collaboration and partnerships are critical to ensure families’ access to a comprehensive array of programs and services.
Implementing family psychosocial surveillance and screening into pediatric primary care has implications for education, research, and public policy.
Educating pediatricians on family psychosocial surveillance and screening should occur across the medical education continuum. Training curriculum should target providers’ knowledge of the impact of family psychosocial issues on child health and development, surveillance and screening skills, and awareness of available community resources.
Increasing providers’ knowledge should begin in medical school and continue during residency training. Exposure to community resources may be integrated within pediatric training. Many residency programs have advocacy rotations that offer this type of experience.66–68 This allows future pediatricians to gain a better understanding of how community services operate and the procedures (and paperwork) required of parents to access resources. Educating providers in practice about the social determinants of health and available community resources is an important priority for continuing medical education.
Educational initiatives aimed at increasing providers’ knowledge are necessary but insufficient to ensure practice change. Pediatric residents need “hands-on” training in family psychosocial surveillance and screening. This could be incorporated within mandatory child development rotations and practiced in primary care rotations. Residents typically provide care to low-income children in continuity clinic,69 thereby providing a robust opportunity to practice surveillance and screening and making referrals for an at-risk population. Reviewing quality measurement data on the identification of needs, referrals, utilization of resources, and correlation with child outcomes will allow providers to assess the impact of these endeavors.
Research is needed to evaluate the feasibility and effectiveness of family psychosocial surveillance and screening within the medical home. Screening tools that broadly assess multiple family psychosocial issues need to be further developed. Different screening delivery systems (e.g., kiosks, internet-based, telephone, etc.) should also be evaluated in diverse patient populations. Prospective, longitudinal cohort studies and randomized controlled trials should evaluate the impact of surveillance and screening on short- and long-term child health and developmental outcomes. Finally, research grounded in diffusion of innovation theory will be important to identify key attributes for the dissemination into practice of novel surveillance/screening models.70,71
Qualitative and quantitative studies should evaluate strategies to overcome barriers to accessing community resources.72 We found that only one-third of urban families with identified basic needs such as food and childcare accessed community resources.73 Similarly, evaluation of the Help Me Grow model found that only 43% of referred children at risk for developmental delay successfully accessed services.63
The requirement for quality improvement projects by the American Board of Pediatrics for maintenance of certification, as well as such activities as The National Committee for Quality Assurance Patient-Centered Medical Home recognition program,74,75 may create incentives to evaluate efforts that incorporate family psychosocial surveillance and screening into routine pediatric practice. Advances in health information technology will enhance data collection capabilities and better enable the monitoring of quality indicators.
Incorporating family psychosocial surveillance and screening into the medical home and creating linkages to community resources has important public policy implications. Family psychosocial surveillance and screening and care coordination activities must be a valued and therefore, reimbursed component of pediatric primary care. Policies that enable and encourage cross-sector (and inter-agency) collaboration and partnerships are critical to ensure families’ access to a comprehensive array of programs and services. In Connecticut, Help Me Grow is a partnership among five state agencies, demonstrating the feasibility and benefits of this type of integrated model.62 Developing and implementing an integrated model of care will require strong leadership and advocacy from pediatric and community leaders and organizations both at the state and national levels.
As the early identification of developmental disorders is crucial to the well-being of children, so is early detection and intervention for family psychosocial issues. The core principles of surveillance and screening can be readily applied to the detection and referral of psychosocial issues by child health providers within the medical home. Integrating family psychosocial surveillance and screening into well-child care services requires changes in professional training, provider practice, and public policy. We believe that the potential of psychosocial surveillance and screening to enhance the effectiveness of child health supervision services to promote children’s optimal development justifies efforts to promote such changes.
This work was begun while Arvin Garg was at the Floating Hospital for Children at Tufts Medical Center. Arvin Garg was supported by Award Numbers K99HD056160 and R00HD056160 from the Eunice Kennedy Shriver National Institute for Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health & Human Development or the National Institutes of Health. We would like to thank Howard Bauchner MD, Kathi Kemper, MD, MPH, Ellen Perrin, MD, Ed Schor, MD, Chris Sheldrick, PhD and the two anonymous reviewers for their feedback and comments on the manuscript draft.
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