The social environment of a child is a key determinant of the child’s current and future health. Factors in a child’s family environment, both protective and harmful, have a profound impact on a child’s long-term health, brain development, and mortality. The social history may be the best all-around tool available for promoting a child’s future health and well-being. It is a key first step in identifying social needs of a child and family so that they may benefit from intervention. This article focuses on key social history elements known to increase a child’s risk of maltreatment and provides case examples.
Key points
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The social history plays a key role in determining a child’s current and future health.
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A useful social history involves asking about key elements of a child’s environment, including the circumstances in which the child is being raised, adults involved in the child’s life, presence of key factors associated with increased risk, and, most importantly, caregiver-child relationship and attachment.
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The social history should be obtained starting at the first well-child visit and at each visit thereafter. Children at highest risk often live in dynamic, often chaotic, environments, with frequent changes in their living situations and household compositions, increasing the importance of obtaining a social history at each visit.
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Child maltreatment (abuse or neglect) can have devastating health consequences that last for life and diminish emotional health and intellectual ability.
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Understanding each child’s familial psychosocial risk and protective factors through the social history is an important link to preventing harmful parenting tactics, other threats to healthy development, and even potentially preventing child maltreatment.
Why the social history matters
A child’s family environment is one of the most important and critical determinants of the child’s health (current and future) and it is integral to the child’s well-being and development. A robust body of research has shown the role that this environment plays in brain and emotional development. These environmental influences also have an impact on a child’s physical health and play a significant role in determining future health and disease. Thus, a social history not only is useful in identifying risk for child injury and maltreatment but also in identifying factors that might contribute to children’s health problems. Strengthening families and supporting parents also promote children’s health, development, and safety and help prevent child maltreatment.
A large body of research highlights the importance of environmental influences in the prenatal to early childhood period (ie, before age 2). Therefore, obtaining a social history focused on the important aspects of the child’s family environment is a critical component of early well-child care. The social history should be obtained at every visit because the family environment is frequently changing, and it influences child development in a dynamic way. The information obtained from social histories has the potential to contribute to a lifetime of health and well-being.
The ill effects of maltreatment can last a lifetime
Adverse childhood experiences, especially child maltreatment, are linked to risk factors for ill health as adults and early death. Child maltreatment occurs in many forms (physical, sexual, or emotional abuse or neglect). It is not uncommon for a child to suffer from multiple forms of maltreatment at the same time. Maltreatment is known to confer myriad deleterious health effects, both physical and mental. In some instances, the effects of maltreatment are so severe that life ends in infancy or early childhood. In fact, 70% of deaths from maltreatment occur in children under 3 years of age.
Child maltreatment prevention begins with primary care
Problems in the family environment are often contributors to child maltreatment and indicate risk for a variety of negative outcomes (discussed previously). A social history that identifies families at risk for maltreatment has the potential to identify problems before they escalate to these most serious outcomes, in addition to helping families and children function better.
This type of prevention strategy is in line with the biopsychosocial model proposed by Engel, which provides a broad view of child health and includes the psychosocial aspect when assessing children. This concept is well stated by Flaherty and colleagues : “A comprehensive assessment of children’s health should include a careful history of their past exposure to adverse conditions and maltreatment. Interventions aimed at reducing these exposures may result in better child health.”
Goals of the social history
The goal of the social history is to assess the strengths and weaknesses in a child’s environment to identify aspects of family life that can be reinforced and encouraged as well as identify potential sources of harm to the child that must be addressed. A comprehensive social history may also identify opportunities for parental education regarding parental expectations and age- and health-appropriate developmental milestones. The social history provides insight into a child’s environment, which includes the circumstances in which the child is being raised, a comprehensive listing of the adults involved in the child’s life, disciplinary practices, presence of key factors associated with increased risk for maltreatment, and, most importantly, caregiver-child relationship and attachment. Assessing the nature of the caregiver-child relationship is important. A healthy, secure attachment between parents and children strongly predicts healthy child outcomes. The children at highest risk experience frequent changes in both their housing situations and household compositions, increasing the importance of obtaining a social history at each visit. Strengths, such as family supportiveness and concern for each other, are often ignored when focusing risk, but such strengths can buffer against even significant family risk. Making a comprehensive social history an integral part of every visit also allows the primary care provider to follow-up on prior issues and identify any new stressors that may have arisen since the last visit.
The social history also helps develop rapport; the authors have often found that thoughtfully asked questions assessing attachment have resulted in otherwise distant or suspicious parents opening up. This aspect of history taking conveys interest in the parent and family and gives the parent an opportunity to feel listened to. Thus, it strengthens the relationships between the primary care provider, parent/caregiver, and child.
Insight into family dynamics—functions and malfunctions—can be gained through a set of social history questions and should include a listing of each adult in contact with the child (including paramours, babysitters, nannies, and daycare workers as well as other adults in the home). This listing should include the ages of each adult, their relationship (to the child), and their role in the home. There is often a temptation in a social history to assume a given family structure and to focus on only the adults who are related, but unrelated adults living in the home are often associated with a higher risk for children. The social history also provides a great opportunity to understand the parents’ developmental expectations for their children and to educate parents about the child’s needs and capabilities so that parental expectations are appropriately aligned with their child’s developmental stage.
Both current and past social histories are relevant. The past history has the potential to reveal a risk for a recurrence of past problems as well as unresolved issues for the parent. The current history informs the health care provider of immediate issues. Specific questions regarding these risk factors can help identify problems to address and create opportunities to provide resources and education. Because child maltreatment entails a problem in the caregiver-child relationship, early identification of parenting problems or attachment issues is paramount. Occasionally, serious or severe problems are unearthed. By addressing the problems directly, a host of negative outcomes, including child maltreatment, can be prevented or curtailed. For example, there is a burgeoning body of research demonstrating that helping parents with mental illness get appropriate treatment can have long-term benefits for their children’s health. Also, the Safe Environment for Every Kid (SEEK) model, which includes training for providers on how to assess the family environment and brief screening for common psychosocial problems together with parent education resources, has been demonstrated to reduce risk of child maltreatment. Structured social history assessments in the primary care setting are an important component in the prevention of child maltreatment.
As part of a research study of children and their families presenting to an emergency department, the authors’ research team of physicians, social workers, and a psychologist developed a set of questions to assess social history. These questions, some of which are presented in Table 1 , are typically part of social work assessments when a family is identified as at risk, but the authors have found them useful to identify risk in all families. Such social histories are useful in building rapport quickly with parents and understanding the issues that parents see as key to their child’s well-being (see Table 1 ). The authors’ approach to the social history is somewhat expanded in that not only are the past and current social circumstances included but also key aspects of the parent-child relationship and the approach to parenting. This is but one sample of questions that could facilitate a discussion of family risk factors. The SEEK model is another ( Appendix 1 ). Also, the American Academy of Pediatrics (AAP) has a brief set of recommended questions for beginning a discussion about children’s exposure to violence ( Box 1 ).
| Topics | Sample Questions |
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| Child’s contacts and household |
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| Parental thoughts about child’s personality and disposition |
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| Parental expectations |
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| Understanding child’s actions and parent-child interactions |
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| Disciplinary practices |
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| Child care |
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| Child and parental literacy and education |
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| Household environment |
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| Risk factors |
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Violence overview
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Are there any behavior problems with the child at home and/or school?
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Has anyone come or gone from the household lately?
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Are there any problems with sleep and enuresis?
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Has your child ever witnessed anyone being harmed at home or in the community?
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Bullying and cyberbullying
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Sometimes kids get picked on at school. Does this happen to you/your child? Has the child heard of or seen incidences of this?
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Have there been any problems at school with behavior?
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Community violence
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Has the child had stomach pains, headaches, and other somatic complaints that seem to have no source?
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Has the child’s behavior changed dramatically, seemingly without cause (eg, difficulty sleeping, avoiding people, or performance in school)?
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Has anything violence-related or frightening happened in the child’s school or neighborhood since the last time you saw the child?
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Child abuse and neglect
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Are there other signs or symptoms that are concerning for abuse or neglect?
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Domestic and intimate partner violence
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Are you safe at home?
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Does anyone hit you or call you names?
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Sexual abuse
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Has child disclosed being sexually abused?
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Has child had stomach pains, headaches, and other somatic complaints that seem to have no source?
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Has child’s behavior changed dramatically, seemingly without cause (eg, difficulty sleeping, avoiding people, or performance in school)?
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Are there other signs or symptoms that are concerning for sexual abuse?
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Teen dating violence
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Have there been any new boyfriends/girlfriends? How has that changed life for you? Do you feel safe with that person?
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The following AAP Web site has a list of diagnostic, decision-support, and screening tools to identify children exposed to violence: .
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