Sarah comes to your office for the first time. The 12-year-old has significant developmental delay and is nonverbal and wheelchair bound. She also is vastly underweight. Her mother — the sole caregiver — notes major transportation and housing difficulties and appears stressed. When you ask how her daughter is doing, the mother says, “She’s just unhappy all the time.”
Housing, school, poverty, racism and other social determinants of health are increasingly understood to impact the health, wellness, growth and development of children. However, such psychosocial factors of health have a disproportionate impact on certain children and youths. Among the more vulnerable are those with special health care needs, who comprise almost one-fifth of children, according to the 2016 National Survey of Children’s Health. These children have a range of chronic health conditions such as asthma, diabetes and spina bifida, and are increasing not only in number but also in medical complexity.
The role of psychosocial factors of health, and how they can positively and negatively impact children with special needs, is the focus of a new AAP clinical report, Psychosocial Factors in Children and Youth With Special Health Care Needs and Their Families. The report, from the Committee on Psychosocial Aspects of Child and Family Health and the Council on Children with Disabilities, is available at https://doi.org/10.1542/peds.2018-3171 and will be published in the January issue of Pediatrics.
The report outlines research advances that describe how chronic conditions and medical treatments can affect social and emotional development and how unrecognized stress and mental health concerns can exacerbate chronic physical health conditions. For example, housing, food insecurity and transportation limitations may impact access to health care, health status, and child and family stress. In turn, family stressors can negatively affect the health of children with special needs.
It is important for pediatricians to recognize the psychosocial factors that impact health and wellness for these patients.
Mitigate risk, promote protective factors
The report reviews strategies for pediatricians to help with surveillance, screening and identification of psychosocial factors for health and wellness. Risk and protective factors are internal (i.e., biological, emotional and behavioral) and external (i.e., interpersonal, financial, housing, educational). Thus, mitigation of risk factors and promotion of protective factors, such as healthy parenting techniques, stress reduction and social services, can increase resiliency.
Pediatric providers are encouraged to develop competencies in mental health for patient care and in coordination of community resources. Co-located and integrated behavioral health providers also can assist.
AAP toolkits address psychosocial factors for all children, including those with special needs. Bright Futures recommendations suggest a psychosocial and behavioral assessment at every well-child visit that is family-centered and may include an assessment of child social-emotional health, caregiver depression and social determinants. The AAP Mental Health Initiatives site features tools; other tips and trainings are available via the Screening Technical Assistance & Resource (STAR) Center (see resources).
Key recommendations
- Provide routine psychosocial screening, including for housing, service needs and co-morbid mental health conditions for all children, especially those with special health care needs.
- Promote resources that support developmental skills and abilities and positive coping for patients and their families.
- Link families to supportive and coordinated early intervention systems, schools and community services. This may involve pediatric providers, schools and families addressing individualized plans in child care or school to support medical and psychosocial needs.
- Utilize and promote community support services, including home visiting, respite and palliative care.
Drs. Mattson and Kuo are lead authors of the clinical report. Dr. Mattson, a former member of the Committee on Psychosocial Aspects of Child and Family Health, is co-chair of the Prevention and Public Health Special Interest Group of the Council on Community Pediatrics. Dr. Kuo is chair of the Council on Children with Disabilities Executive Committee.
