Screening for Toxic Stress Risk Factors at Well-Child Visits: The Addressing Social Key Questions for Health Study

Kavitha Selvaraj*, Melissa J. Ruiz, Jean Aschkenasy, Jan D. Chang, Anthony Heard, Mark Minier, Amanda D. Osta, Melissa Pavelack, Monica Samelson, Alan Schwartz, Margaret A. Scotellaro, Alisa Seo-Lee, Stan Sonu, Audrey Stillerman, Barbara W. Bayldon

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


Objectives: To determine the prevalence of and demographic characteristics associated with toxic stress risk factors by universal screening, the impact of screening on referral rates to community resources, and the feasibility and acceptability of screening in a medical home setting. Study design: We developed the Addressing Social Key Questions for Health Questionnaire, a 13-question screen of adverse childhood experiences (ACEs) and unmet social needs. Parents/guardians of children 0-17 years of age received this questionnaire at well-child visits at 4 academic clinics from August 1, 2016 to February 28, 2017. Providers reviewed the tool and referred to community resources as needed. A subset of families completed demographic and satisfaction surveys. Prevalence of ACEs and unmet social needs, community referral rates at 1 site with available data, and family acceptability data were collected. Analyses included frequency distributions, χ2 tests, and Poisson regression. Results: Of 2569 families completing an Addressing Social Key Questions for Health Questionnaire, 49% reported ≥1 stressor; 6% had ≥1 ACE; 47% had ≥1 unmet social need. At 1 site, community referral rates increased from 2.0% to 13.3% (P <.0001) after screening implementation. Risk factors for having a stressor include male sex and African American or Hispanic race. 86% of 446 families want clinics to continue screening. Conclusions: Universal screening for toxic stress risk factors in pediatric primary care improved identification and management of family needs. Screening was feasible and acceptable to families. Prevalence of unmet social needs but not ACEs was comparable with prior studies. Further evaluation and modification of the screening protocol is needed to increase screening and identification.

Original languageEnglish (US)
Pages (from-to)244-249.e4
JournalJournal of Pediatrics
StatePublished - Feb 2019


  • adverse childhood experiences
  • social determinants of health
  • toxic stress
  • universal screening

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health


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