Addressing Social Determinants of Mental Health in Pediatrics During the Coronavirus Disease 2019 Pandemic

What's New.

The negative impact of poverty and adverse social determinants of health, including racism, on child mental health has grown clearer and more important than ever to address as part of health care in the context of the coronavirus disease 2019 pandemic.

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In our article published in June 2019, “The Relationship Between Social Risks and the Mental Health of School-Age Children in Primary Care,” we examined the association between social risks and mental health among children screened in primary care pediatrics at an urban safety-net hospital.¹ More social risks on the WE CARE screener (including caregiver education, childcare, employment, food security, heat, and housing) were associated with worse overall child mental health measured with the Pediatric Symptom Checklist. Individually, food insecurity and unemployment were associated with worse child mental health after adjusting for sociodemographic characteristics and other social risks.

Since our paper's publication, the coronavirus disease 2019 (COVID-19) pandemic worsened social risks and health disparities, increasing calls to improve health equity and address adverse social determinants of health (SDOH) as part of health care practice.² The pandemic also accelerated an already troubling downward trend in child mental health, paired with a deepening access crisis to pediatric psychiatric services, aggravated by adverse SDOH and racism.³

In this report, we discuss our study's findings in context of new events and research since June 2019 with particular attention to the impacts of both the pandemic and racism on SDOH, child mental health, and primary care-based screening efforts.

COVID-19 Pandemic

During the COVID-19 pandemic, families were disproportionately impacted by increased social risks.⁴ Rates of poverty, food insecurity, housing insecurity, difficulty meeting basic needs all increased during the pandemic and have not returned to baseline prepandemic levels.⁴ Simultaneously, child mental health problems have increased across the globe due to school closures, social isolation, increased screen and sedentary time, parent stress, worsening socioeconomic hardship, and increased social risks.^{3 , 5} Socioeconomic inequality in child mental health has been magnified by the pandemic, with children exposed to more social risks experiencing worse mental health than their peers.⁶ Among 8493 school-age children in the US-based Adolescent Brain Cognitive Development longitudinal study evaluated between May 2020 and March 2021, perceived stress, pandemic-related worry, and sadness were each associated with multiple social risks including food insecurity, with disproportionate impacts on the mental health of racial and ethnic minoritized children.⁶ In our survey study of 168 children aged 5 to 11 years in our urban safety-net hospital-based pediatric practice,⁵ almost all social risks measured rose dramatically during the pandemic, and children with at-risk overall mental health scores rose from 8% to 18%, mainly due to new internalizing symptoms. The correlation between number of social risks and child mental health problems was significantly stronger prepandemic than mid-pandemic, due to other pandemic stressors impacting children such as remote learning, increased screen time, and parent stress.

With increasing recognition of the social determinants of child mental health, the next question is whether addressing SDOH in pediatric primary care can prevent or improve mental health symptoms. Lay health worker-led interventions can improve access to needed mental health care,⁷ but in general, the evidence for SDOH interventions reducing mental health symptoms in youth is sparse. To improve mental health, primary care-based SDOH interventions may need to be tailored to specific populations of children, and more attention is needed on implementation strategies to ensure they apply across practice settings, mitigate double loss (ie, families disclosing needs but not having them addressed), and do not unintentionally worsen health disparities.

Racism

Racism is a critical SDOH that is intimately linked with social risks. Health inequities related to race and ethnicity are widening, further exacerbated by the COVID-19 pandemic.⁶ Racism at 3 levels—structural, interpersonal, and internalized—worsens and perpetuates social risks including access to education, employment, housing, basic needs, and health care.⁸ Racism also adversely impacts child development and mental health, in part via social risks.⁸ In a 2019 policy statement on racism and child health, the American Academy of Pediatrics suggested that beyond screening for unmet social needs, pediatric practices should integrate evidence-based screening tools for experiences of racism and evaluate the mental health of youth who have experienced racism.⁸ However, we do not know of studies evaluating the feasibility, acceptability, or effectiveness of universal screening for racism in pediatrics; this is an important area for future work.

In addition, racism—including implicit bias—may impact the results of screening for social risks and mental health. Families of color report hesitation to disclose social needs and mental health concerns to primary care providers due to fear of shame, judgment, being reported to child welfare, and not being taken seriously, all rooted in health care mistrust due racism, which can impact the accuracy of screening results.⁹ At the same time, we found that even after needs were disclosed in primary care, families of color were less likely to report their social needs were addressed than white families.¹⁰ Overall, children of color have worse access to mental health care than white children, a disparity that may be widening due to COVID-19.³ More work is needed to understand how racism, discrimination and bias impact primary care-based screening and to develop equitable, culturally appropriate implementation strategies to avoid inadvertently perpetuating health inequities.

Future Work: Focus on Community

The COVID-19 pandemic has magnified concerns about mental health and social risks for this generation of youth, and with this spotlight, there is opportunity. Primary care-based SDOH screening programs could help identify at-risk children and connect them to social and mental health supports, but their effectiveness will vary widely based on implementation success. Most importantly, health care-based interventions that connect families with resources require intimate partnerships with community-based mental health and social programs to which families are referred, and these entities must have the needed resources and staff to help all families with needs. Thus, we must advocate for policies that fund and protect social and mental health programs that are currently understaffed and underfunded. The data on the impact of poverty, adverse SDOH, racism, and now the added stressor of COVID-19 on child mental health could not be clearer; the political will to value and invest in children and families is far less consistent and evident.