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Improving the Management of Family Psychosocial Problems at Low-Income Children's Well-Child Care Visits

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In the Literature

Many of the 28 million U.S. children who live in low-income families grow up exposed to a host of psychosocial problems. Housing insecurity, inadequate parental education, and parental substance abuse have all been shown to be associated with higher rates of behavioral, developmental, and learning problems. Still, few pediatricians routinely address these important issues during well-child visits.

According to a new Commonwealth Fund-supported study, the use of a simple screening tool during pediatric visits not only can increase discussion of such topics between parents and providers, but can also increase the number of referrals to vital community resources like graduate equivalency diploma programs, job training, and food pantries.

As part of the WE CARE (well-child visit, evaluation, community resources, advocacy, referral, education) project, a research team led by Arvin Garg, M.D., M.P.H., of the Johns Hopkins School of Medicine developed a self-administered family psychosocial screening tool. Results of their trial use of this tool are available in "Improving the Management of Family Psychosocial Problems at Low-Income Children's Well-Child Care Visits: The WE CARE Project" (Pediatrics, Sept. 2007).

Developing the Screening Tools

The researchers developed the screening tool collaboratively, using the American Academy of Pediatrics' Bright Futures pediatric intake form as an initial guide. Other problems were identified from the professional literature and from discussion with clinic staff members. Ultimately, only psychosocial problems for which community resources were available were included in the survey.

The study, which took place in the pediatric clinic of a large urban teaching hospital, involved 200 randomly selected parents of children between two months and 10 years old. Parents in the control group were given a self-report survey to fill out while in the waiting room before their pediatric visit. The survey asked parents if they experienced the se-lected problems (e.g., "Do you smoke cigarettes?") and about their willingness to ad-dress them (e.g., "If yes, would you like help to quit?"). The researchers also developed a family resource book, which listed community resources offering help for each of the problems. The book was placed in all the exam rooms, and pediatric residents in both groups were made aware of it. Parents in both groups were interviewed immediately after and one month after the visit.

Survey Tools Helps Prompt Conversations, Referrals

The parents in the intervention group discussed more family psychosocial topics than did those in the control group, say the authors, and had fewer unmet desires to discuss psychosocial topics. In addition, 51 percent of parents in the intervention group received at least one referral—most often for employment (22%), obtaining a graduate equivalent degree (15%), and smoking-cessation classes (15%)—compared with 12 percent of the control-group parents. The survey likely served as a prompt to initiate discussion and referral, say the authors.

In the subset of parents who received a referral, 69 percent of parents in the intervention group, compared with 20 percent in the control group, recalled receiving a referral when they were interviewed one month after the visit. This suggests, say the authors, that the intervention had a more meaningful and lasting effect. "If a parent does not recall receiving a referral than he/she is unlikely to have contacted community resources for assistance," they say. In fact, 20 percent of the parents in the intervention group reported contacting a referred community resource, compared with only 2 percent of parents in the control group.

The screening tool did not appear to present an undue burden for providers. Seventy-seven percent of providers reported that the survey did not slow down the visit: 91 percent said it added less than five minutes to the visit, and 54 percent said it added less than two minutes.


A vital component of the intervention, say the authors, was the identification of available community resources, which was the result of an interdisciplinary collaborative approach among pediatricians, social workers, a lawyer advocate, and primary care providers. "We were surprised with the number of resources, most of which were free of charge, that were available in our community," they say.

The most common reason cited for parents not contacting a resource was lack of time. Additional research is needed, the authors say, to address this barrier and help low-income parents take advantage of available resources.

Finally, the authors note that very few referrals were made for sensitive topics like depression and intimate-partner violence. Residents may be less comfortable addressing these subjects, which may require additional, structured clinical training.

Percent of Referrals for Family Psychosocial Problems at Well-Child Care Visits

Parents who received a referral 51% 12%
Referral type
   GED 20   1
   Job training 26   5
   Food pantries; food stamps/WIC 12   1
   Smoking-cessation classes 16   4
   Alcohol/drug outpatient treatment programs  6   2
Recalled referral one month later 41   7
Contacted community resource 20   2
GED = graduate equivalency diploma, WIC = Supplemental Nutrition Program for Women, Infants, and Children.
Source: Adapted from A. Garg, A. M. Butz, P. H. Dworkin et al., "Improving the Management of Family Psychosocial Problems at Low-Income Children's Well-Child Care Visits: The WE CARE Project," Pediatrics, Sept. 2007 120(3):547-58.

Publication Details



A. Garg, A. M. Butz, P. H. Dworkin et al., Improving the Management of Family Psychosocial Problems at Low-Income Children's Well-Child Care Visits, Pediatrics September 2007 120(3):547–58