Profound advances in our understanding of the importance of the biology of adversity, including social determinants of health (SDoHs) and adverse childhood experiences, have led to an important reexamination of deterrents and promoters of children’s optimal health, development, and wellbeing. The critical impact of these social, environmental, and behavioral determinants has informed the development of SDoH screening tools as well as the debate on the utility of such an approach.1 

In a timely and well-written article, Sokol et al2  and a team of interdisciplinary colleagues cite the interest in addressing SDoHs but appropriately lament the “…deficit in understanding the present state of the science.” They undertake a systematic review of SDoH screening tools and examine their psychometric properties, their efficacy in detecting early indicators of risk, and the extent to which they are shown to inform care. Their comprehensive search yields only 17 studies encompassing 11 screeners and highlights the disappointing but perhaps not surprising limitations in assessing psychometric properties and the inability to answer the question as to whether referrals and interventions after screening address SDoHs and, most importantly, improve child wellbeing. The authors’ conclusions and implications add to growing literature on the caveats and nuances associated with screening for SDoHs, suggesting important implications for research, clinical practice, and policy.

As authors of several commentaries citing the potential risks and dangers of unrequited reliance on screening tools, we commend the authors for anchoring the science gap in the proper context and for raising key questions. We have previously stressed the imperatives that the screening process for SDoHs be patient-and family-centered in emphasizing shared decision-making and respect for family autonomy; that screening results be interpreted in the context of all that is known of the family and their circumstances; that screening employs a universal and strength-based approach; that tools be embedded within a comprehensive, integrated process of ongoing and timely assessments through surveillance and screening; and that early detection and screening include the capacity to refer and link families to community-based programs and services to address their priorities and needs.35 

Sokol et al’s2  findings, including the limited attention to psychometric properties of screeners; the lack of a clearly defined referent period; limited emphasis on protective factors and family and community strengths; and sparse attention to discussion of screening results, referrals, and intervention, reinforce the need for continued emphasis on our screening imperatives. They also suggest the need to carefully consider slowing the well-intentioned drive by policymakers, health care institutions, and professional organizations to implement screening in practices despite limited consideration of its context, process, and impact. Many state affiliates of the Help Me Grow National Affiliate Network (founding director, P.H.D.), which focus on the early detection, referral, and linkage of vulnerable children and families to community-based programs and services, are eager to consider the merits of SDoH screening.6  Our discussions invariably reinforce the importance of considering the efficacy and validity of SDoH screening tools and the extent to which screening is but 1 element in a comprehensive, integrated approach to family and patient engagement, early detection, and referral and linkage in response to families’ priorities and needs. In fact, the deployment of such screening tools in the context of such an integrated, comprehensive approach assuages the implications of the limited evidence for their psychometric soundness. In several of the studies cited by the authors (eg, WE CARE project; lead researcher, A.G.), the tools are not employed as simple “screen-and-refer” measures but rather are used to initiate a discussion with families to solicit their priorities and concerns and connect them to community resources to meet their needs.7  This is analogous to the use of developmental screening tools as 1 component of the early detection process of surveillance and screening and linkage to early intervention services.8 

Despite Sokol et al’s2  call for greater attention to screening tools’ reliability and validity, screening for SDoHs is unlikely to ideally fulfill the well-established criteria by which conditions are judged amenable to the screening process and tools are considered psychometrically sound.9  We have, for example, noted that positive scores on SDoH screening tools reflect different degrees of absolute risk for specific problems depending on their prevalence in the population and, therefore, are inherently fallible.10  Furthermore, a family’s positive screen result on a psychometrically validated tool for such issues as food insecurity may be discordant with the family’s desire for assistance.11  Developmental concerns pose comparable challenges to early detection. However, despite their inherent limitations, developmental screening tools are endorsed as best practice for the early detection of developmentally vulnerable children.8  Similarly, the well-described and acknowledged limitations of SDoH screening tools should not ultimately undermine their value or discourage their application. Rather, Sokol et al’s2  findings strengthen the call for ensuring that detection of SDoH is embedded within a comprehensive, integrated approach to early detection, referral, and linkage, all in the context of respecting families’ needs, priorities, and autonomy.

The authors thank Lisa Honigfeld, PhD, for her review of the article.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1622.

SDoH

social determinant of health

1
Krist
AH
,
Davidson
KW
,
Ngo-Metzger
Q
.
What evidence do we need before recommending routine screening for social determinants of health?
Am Fam Physician
.
2019
;
99
(
10
):
602
605
2
Sokol
R
,
Austin
A
,
Chandler
C
, et al
.
Screening children for social determinants of health: a systematic review
.
Pediatrics
.
2019
;
144
(
4
):
e20191622
3
Garg
A
,
Dworkin
PH
.
Surveillance and screening for social determinants of health: the medical home and beyond
.
JAMA Pediatr
.
2016
;
170
(
3
):
189
190
4
Garg
A
,
Boynton-Jarrett
R
,
Dworkin
PH
.
Avoiding the unintended consequences of screening for social determinants of health
.
JAMA
.
2016
;
316
(
8
):
813
814
5
Garg
A
,
Homer
CJ
,
Dworkin
PH
.
Addressing social determinants of health: challenges and opportunities in a value-based model
.
Pediatrics
.
2019
;
143
(
4
):
e20182355
6
Help Me Grow National Center
.
Leading a national network that ensures all children reach their full potential. Available at: https://helpmegrownational.org/. Accessed July 2, 2019
7
Garg
A
,
Butz
AM
,
Dworkin
PH
, et al
.
Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project
.
Pediatrics
.
2007
;
120
(
3
):
547
558
8
Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee
.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in
Pediatrics
. 2006;118(4):1808–1809]
.
Pediatrics
.
2006
;
118
(
1
):
405
420
9
Dworkin
PH
.
British and American recommendations for developmental monitoring: the role of surveillance
.
Pediatrics
.
1989
;
84
(
6
):
1000
1010
10
Garg
A
,
Sheldrick
RC
,
Dworkin
PH
.
The inherent fallibility of validated screening tools for social determinants of health
.
Acad Pediatr
.
2018
;
18
(
2
):
123
124
11
Bottino
CJ
,
Rhodes
ET
,
Kreatsoulas
C
,
Cox
JE
,
Fleegler
EW
.
Food insecurity screening in pediatric primary care: can offering referrals help identify families in need?
Acad Pediatr
.
2017
;
17
(
5
):
497
503

Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Dworkin is founding director of the Help Me Grow National Center; Dr Garg is lead researcher of the WE CARE project.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.