Screening for Both Child Behavior and Social Determinants of Health in Pediatric Primary Care

Abstract

Objective: To implement comprehensive screening for child behavior and social determinants of health in an urban pediatric practice and explore rates of referrals and follow-up for positive screens.

Method: Quality improvement methodology was used to implement routine screening using an adapted version of the Survey of Well Being of Young Children, a child behavior and social screen, for all children aged 6 months to 10 years. Rates of screen administration and documentation were assessed for 18 months. Medical records of a convenience sample (N = 349) were reviewed to track referrals and follow-up for positive screens. A secondary analysis explored associations between reported parental concern for their child's behavior and both child behavior symptoms and social stressors.

Results: Over 18 months, 2028 screens were administered. Screening rates reached 90% after introducing a tablet for screening. Provider documentation of screens averaged 62%. In the convenience sample, 28% scored positive for a behavioral problem, and 25% reported at least 1 social stressor. Of those with positive child behavior or social stressor screens, approximately 80% followed up with their primary medical doctor, and approximately 50% completed referrals to the clinic social worker. Further analysis indicated that referral and follow-up rates varied depending on whether the family identified child behavior or social issues. Logistic regression revealed that parental concern was independently associated with child behavior symptoms (p = 0.001) and social stressors (p = 0.002).

Conclusion: Implementing a comprehensive psychosocial screen is feasible in pediatric primary care and may help target referrals to address psychosocial health needs.

Figure 1.

Study design flowchart including referrals and follow-up. *Denominators are less than all of those patients whose medical records were reviewed (N 5 349) because of missing data, i.e., total scores could not be created because of missing items on the scales. aRepresents those who scored positive on the subscale shown (behavior 5 gray, social stressor 5 white). Families may have scored positive on only 1 of the subscales or both of the subscales. Referral and follow-up rates for those families who had overlap and scored positive on both subscales (N 5 18%) are included but not shown separately here. bRepresent percentage of those with behavior (gray) or social (white) issues that were documented in the medical records before the screening.

Figure 2.

Data measured using 1 random week per month. Run chart (A) numerator equals number of screens collected, and denominator equals number of well visits over corresponding time period. Run chart (B) numerator equals number of screens documented in the electronic medical record and denominator equals number of screens collected over corresponding time period. *Numbers correspond to various plan-do-study-act cycles conducted as part of quality improvement. See Table 1.