Issue Brief 74: Screening for Social Determinants of Health: A Promising Step for Improving Children’s Behavioral Health

July 28, 2020

Screening for Social Determinants of Health:

A Promising Step for Improving Children's Behavioral Health

Many families struggle to meet basic needs such as food, stable and healthy living conditions, and access to health care. Commonly referred to as social determinants of health (SDOH), these factors – which are present for many children starting at birth – are estimated to account for 80-90% of modifiable contributors to health outcomes.² Research has shown that SDOH, including socioeconomic inequalities,³ food insecurity,⁴ and poor housing quality⁵ are associated with mental health concerns among children, suggesting that meeting social needs will have an impact on mental health. There are also disparities in SDOH, with racial and ethnic inequities seen in poverty rates,⁶ housing,⁶ education,⁶ and food insecurity.⁷ Better integration of clinical and social services has the potential to improve children’s overall well-being and close longstanding gaps between populations.

What are the Social Determinants of Health? SDOH are defined as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”1 SDOH comprise five domains:  Economic stability (e.g., employment and poverty) Neighborhood and built environment (e.g., housing quality and environmental conditions)  Education (e.g., language and literacy, and enrollment in higher education) Social and community context (e.g., discrimination, racism, and social cohesion) Health and health care (e.g., access to health care and health literacy)1

Several service sectors currently screen for SDOH and connect families to community services to meet their specific needs. Pediatric practices have significantly increased their use of SDOH screening over the last decade in an effort to increase early detection and linkage to intervention for unmet social needs.⁸ However, SDOH screening remains underutilized in other child-serving settings, such as schools and behavioral health.⁸

The COVID-19 pandemic has illuminated the presence of health disparities across the nation stemming from decades of inequities. It has also highlighted the importance of SDOH, as unemployment, food insecurity, and health concerns have increased, particularly among low-income individuals and communities of color. As Connecticut’s children return to schools, childcare, and other community settings, providers of children’s services, including behavioral health providers, have opportunities to significantly improve children’s overall health and well-being by identifying families with SDOH needs and connecting them to available services. This Issue Brief explores screening for SDOH by children’s behavioral health providers as a promising strategy for improving children’s behavioral health and wellness.

Connecticut is Addressing Social Determinants of Health in an Effort to Improve Population Health 

In 2014, Connecticut’s first State Health Improvement Plan (SHIP) outlined a roadmap to improve population   health and health equity through partnerships between state agencies and key stakeholders. The plan included seven wide-ranging focus areas such as maternal, infant, and child health (e.g., reproductive health, pregnancy care, and child well being), environmental risk factors (e.g., air quality and healthy communities), and injury and violence prevention (e.g., unintentional injury, suicide, and community violence). The state’s SHIP 2.0 is a five-year plan that is currently under development, but anticipated to use the SDOH as the central focus of an integrated framework for achieving population health and health equity.⁹ 

Additionally, the Unite Connecticut initiative led by the Connecticut Hospital Association is a multi-year campaign to build a network of hospital, health system, and social service providers to coordinate SDOH screening and referrals.¹⁰ This network links hospital, health system, and social service provider data systems via a web portal and allows for tracking the completion of SDOH screens, the completion of referrals, and the initiation of follow-up services. Although the Unite Connecticut system may benefit people who receive care through hospitals, many children do not frequently access care through hospitals, making it important to also screen for SDOH in other settings.

Behavioral Health Care Providers are Well Positioned to Identify Children’s SDOH Needs

Behavioral health services are ideal for SDOH screening given the strong connection between SDOH and behavioral health. Though standardized SDOH screening is less common in behavioral health settings,⁸ they are optimal settings for coordinating care and addressing, or connecting families to services that address unmet basic needs. For example, through the Care Coordination Program and Intensive Care Coordination Program of WrapCT, the Integrated Care for Kids model, and the Connecticut Network of Care Transformation (CONNECT), behavioral health providers aim to address client-identified needs, particularly basic needs, such as housing and food. Screening for and identifying basic needs helps to address the most critical barriers in moving the family toward their goals. By invoking family strengths, the plan of care helps to prioritize meeting basic needs first so that families can attend to behavioral and health needs with more successful and sustainable outcomes.  

Screening for SDOH is Beneficial for Children and Families, Despite Current Challenges 

As SDOH screening and linkage to services becomes part of routine practice in clinical settings, several issues have been highlighted: 

• Low number of validated SDOH measures for children. Only three validated SDOH screens are currently available for children (see Table 1 on page 3). None of these screens have been validated in a behavioral health setting or measure all five domains of SDOH, and none of the measures assess the domain of social and community context, which includes factors such as discrimination and racism.⁸
• Concerns about the appropriateness of SDOH screening measures for use with diverse populations. Validated SDOH screens for children are currently only available in English and Spanish. Other measures (e.g., FAMNEEDS) may be offered in more languages, but have not yet been validated.⁸ Further, when caregivers who are undocumented or have limited English language proficiency are screened, they are less likely to be located after screening for follow-up service coordination¹¹ and these individuals may be most in need of services.
• Inconsistent linkage of screening results to family engagement, referral, and connection to care. In a recent systematic review of 17 studies of SDOH screening for children, only three studies reported that SDOH screens were completed and discussed with caregivers, and that referrals and interventions were delivered. Nearly a quarter of the studies reported no follow-up procedures after screening.⁸ Screening is of little benefit to families if it is not accompanied by a collaborative review of findings, appropriate referrals, and linkage to needed services.

Despite challenges with screening and follow up, SDOH screening has shown a number of benefits. Specifically, research has shown that screening can result in increased discussions with families regarding their needs, referrals to address these needs, and the receipt of interventions targeting these needs.⁸ Further, recent research in pediatric practices shows that screening for SDOH in these settings, and subsequent referrals to address needs, results in improved behavioral and physical health for children.¹² In order to make SDOH screening most useful, providers should consider other factors including a family’s current circumstances, strengths, and preferences for referrals, as well as the availability of resources to meet mutually identified needs.¹³

Recommendations for Advancing SDOH Screening and Referral in Children’s Behavioral Health 

Connecticut is well-positioned to support SDOH screening by child behavioral health providers. Behavioral health organizations typically include a strong cadre of well-trained care coordinators working alongside behavioral health providers, and both disciplines have long histories of collaboration and extensive experience with screening and referral to services. The presence of many existing partnerships and collaboratives in children’s behavioral health has built significant capacity for disseminating new innovations. The state’s focus on SDOH in the SHIP 2.0 provides a policy platform for supporting and monitoring this work. The following recommendations can enhance Connecticut’s efforts to meet the basic needs of families:

1. Create partnerships between researchers and behavioral health providers to adapt and validate a standardized SDOH screening measure for use with children and families. The screening measure should be developed for a racially, ethnically, and linguistically diverse population; validated in behavioral health settings; and address all five domains of SDOH. 
2. Incorporate a validated SDOH screening measure as a routine element of behavioral health care with children and families. 
3. Train networks of behavioral health providers and care coordinators together on the use of the validated SDOH screening measure.
4. Ensure that public and private payers reimburse for SDOH screening. Public and private payers should consider incorporating SDOH screening, as well as improvement in identified areas of concern, within emerging value-based payment methodologies.
5. Address clinical and SDOH needs more holistically by establishing and supporting integrated networks of clinical and social service providers, such as behavioral health organizations, primary care providers, school-based health centers, care coordination services, hospital systems, and SDOH providers.

• Expand existing systems that bring together clinical and SDOH information and resources, such as the Unite Connecticut and United Way 2-1-1 systems. 
• Build the capacity within these networks to consistently track and share data and information on SDOH screening administration, results, referrals, linkages to services, and outcomes with a particular focus on reducing health disparities.

REFERENCES

1. Office of Disease Prevention and Health Promotion. Social determinants of health. 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health 
2. Magnan S. Social determinants of health 101 for health care: Five plus five. NAM Perspectives 2017.
3. Reiss F. Socioeconomic inequalities and mental health problems in children and adolescents: A systematic review. Social Science & Medicine 2013; 90: 24-31.
4. Shankar P, Chung R, Frank DA. Association of food insecurity with children’s behavioral, emotional, and academic outcomes: A systematic review. Journal of Developmental & Behavioral Pediatrics 2017; 38(2): 135-50.
5. Rollings KA, Wells NM, Evans GW, Bednarz A, Yang Y. Housing and neighborhood physical quality: Children’s mental health and motivation. Journal of Environmental Psychology 2017; 50: 17-23.
6. Stanford Center of Poverty and Inequality. State of the Union: The poverty and inequality report, 2017.
7. Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household food security in the United States in 2018, 2019.
8. Sokol R, Austin A, Chandler C, et al. Screening children for social determinants of health: A systematic review. Pediatrics 2019; 144(4): e20191622.
9. Connecticut Department of Public Health. Healthy Connecticut 2025. n.d. https://portal.ct.gov/DPH/State-Health-Planning/Healthy-Connecticut/Healthy-Connecticut-2025.
10. Unite Us. Unite Connecticut: Building connections for healthier communities. n.d. https://www.uniteus.com/join-unite-connecticut/.
11. Uwemedimo OT, May H. Disparities in utilization of social determinants of health referrals among children in immigrant families. Frontiers in Pediatrics 2018; 6: 207.
12. Gottlieb LM, Hessler D, Long D, et al. Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial. JAMA Pediatrics 2016; 170(11): e162521-e.
13. Dworkin PH, Garg A. Considering approaches to screening for social determinants of health. Pediatrics 2019; 144(4): e20192395.
14. Colvin JD, Bettenhausen JL, Anderson-Carpenter KD, et al. Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals. Academic Pediatrics 2016; 16(2): 168-74.
15. Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK) Model. Pediatrics 2009; 123(3): 858-64.
16. Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR. Improving the management of family psychosocial problems at low-income children’s well-child care visits: The WE CARE Project. Pediatrics 2007; 120(3): 547-58.

This Issue Brief was prepared by Brittany Lange, DPhil, MPH, Senior Project Coordinator; Jack Lu, PhD, Director of Implementation; and Jason Lang, PhD, Vice President for Mental Health Initiatives. For more information, contact Brittany Lange at blange@chdi.org.

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