8.3 SDOH & Disease-Specific Screening

Domain II.D.3 is screening that is not a named developmental or mental-health questionnaire: social determinants of health, the Adverse Childhood Events (ACE) Questionnaire, and disease-specific biomedical screens. PNCB still expects the twelve named tools to be used correctly — ACE lives here as prevention/trauma history — and expects you to apply pediatric periodicity, not a copied adult USPSTF list.

Adverse Childhood Events (ACE) Questionnaire

The outline wording is Adverse Childhood Events; in practice this is the ACE (Adverse Childhood Experiences) questionnaire from the CDC–Kaiser work. Original items cluster in abuse (physical, emotional, sexual), neglect (physical, emotional), and household challenges (intimate partner violence, substance use, mental illness, separation/divorce, incarceration). The score is a count of categories endorsed, typically 0–10.

A score is not a diagnosis. It is not PTSD. It is not a required SSRI. It is not a courtroom document you print to "prove" maltreatment. At a population level, higher counts associate with later health risk. For this child, the clinical job is: ask, listen, provide trauma-informed care, screen function (school, sleep, mood, suicide, substances), and connect to safe, stable, nurturing relationships and concrete supports. Four ACEs plus a thriving child is not a psychotropic. Zero ACEs plus current abuse is still a child-protection emergency (maltreatment chapter).

Use ACEs as prevention and history. Do not tell a parent, "Four ACEs means your child will have heart disease." Do tell them that buffering relationships and treating caregiver depression, food insecurity, and violence risk change the trajectory more than a laminated score.

Clinic vignette. A caregiver circles four ACE categories and asks you to "put PTSD on the form for the IEP." The child is sleeping, attending, and has no trauma-related symptoms on history. You document adversity, offer supports, and you do not assign PTSD from a count.

SDOH: food, housing, transportation, utilities, education, safety

Social determinants of health are visit data, not a social-work-only afterthought. Screen, at minimum:

• Food — skipped meals, running out of food before money, WIC/SNAP gaps
• Housing — eviction, crowding, homelessness, mold, lead paint, unstable doubled-up housing
• Transportation — missed visits or pharmacy pickup because there is no ride
• Utilities — heat, electricity, water shutoff risk (also a safety and medical-equipment issue)
• Education — caregiver literacy/GED, child school enrollment, special-education access
• Safety — interpersonal violence, community violence, firearm storage, neighborhood play

WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) is a commonly taught pediatric SDOH screen: short yes/no items about education, employment, food, housing, childcare, and transportation, then refer to a resource rather than collecting misery for the chart. Bright Futures also builds SDOH questions into the health-supervision interview (family resources, neighborhood, caregiver mood, racism and discrimination, immigration stress). Either structured form or Bright Futures questions is acceptable; doing nothing because "we don't have a social worker today" is not.

A positive SDOH screen is an action: WIC, SNAP outreach, housing/legal aid, medical-legal partnership, transportation vouchers, utility hardship programs, Head Start, intimate-partner-violence resources, and a follow-up plan. Writing "SDOH+" in the EHR without an offer of help is incomplete screening.

Confidentiality: adolescents may disclose housing or safety issues the caregiver does not know. Intimate-partner or caregiver violence needs a private moment and a safety plan. You still operate within reporting laws for child maltreatment — SDOH screening does not create a loophole around mandated reporting.

Newborn metabolic and hearing screening

Newborn dried-blood-spot metabolic/endocrine/hemoglobinopathy panels are state-specific. Your job is not to recite every analyte. Your job is: confirm the screen was done and resulted, know how your state reports, and act on out-of-range results immediately — same-day contact, confirmatory testing, and specialty (endocrinology, metabolism, hematology) as indicated. "Repeat at the 6-month visit" is how congenital hypothyroidism and metabolic crises are missed.

Newborn hearing is universal (OAE and/or ABR) before discharge or by the 1-month point of the 1-3-6 (or 1-2-3) early-hearing-detection path: screen by 1 month, diagnose by 3 months, intervention by 6 months (many programs now aim earlier). A missed or failed screen is not "wait for speech to declare itself." NICU graduates, meningitis, ototoxic drugs, and caregiver concern are reasons to rescreen even after a passed newborn test.

Critical congenital heart disease pulse-oximetry is a newborn screen too; failed CCHD screening is cardiology now, not a 2-month murmur recheck as the only plan.

Hemoglobin, lead, and TB

Hemoglobin / anemia: Bright Futures/AAP universal screening at 12 months. Risk-based earlier (preterm, low birth weight) and later (restrictive diet, heavy menses, chronic disease). Do not skip the 12-month hemoglobin because the toddler "looks pink."

Lead: Medicaid EPSDT requires blood lead tests at 12 and 24 months. In non-Medicaid children, AAP/CDC use risk assessment (pre-1978 housing, renovation, immigrant/refugee, sibling with lead poisoning, occupational take-home exposures) and blood testing if risk is present or the community prevalence is high. A capillary elevated result is confirmed with venous blood. CDC's current blood lead reference value is 3.5 µg/dL — that is a public-health action level, not a "safe until 10" story. Detailed chelation lives in the environmental/toxicology chapter; this chapter's job is when to draw the level.

Tuberculosis: risk-based, not universal annual TST or IGRA on every well child. Ask about birth or travel in high-prevalence regions, household contact with TB, incarceration/homelessness/congregate settings, and immunocompromise. Screen the risk; test when the risk is real. A universal TST on a U.S.-born child with no risk is not Bright Futures.

Vision and hearing after the newborn period

Vision. Instrument-based screening (photoscreeners, autorefractors) is for preverbal and early preschool children who cannot do a chart. Age-appropriate visual acuity charts (LEA, HOTV, then Snellen-type) start when the child can cooperate, typically 3–5 years, then at later Bright Futures ages. Refer failed screens, suspected amblyopia, strabismus, an abnormal red reflex, or a caregiver who says the child tilts and squints. Instrument-based screening does not replace a chart forever; charts do not work in a 12-month-old.

Hearing. After the newborn screen, Bright Futures places audiometry at selected school-age visits (commonly 4, 5, 6, 8, and 10 years) plus risk-based testing any time (speech delay, recurrent otitis with effusion, NICU graduate, caregiver concern). Language delay without a hearing test is an incomplete workup.

Lipids, cervical cancer, STIs, oral health — keep it pediatric

Lipids. Bright Futures/NHLBI pediatric guidance: universal lipid screening once at 9–11 years and once at 17–21 years, plus risk-based screening earlier or more often (diabetes, obesity, strong family history of early atherosclerotic disease, smoking). This is not adult every-5-year cholesterol starting at 40, and it is not "only if obese."

Cervical cancer screening. Adolescents generally do not get a Pap smear in the early teens. Cytology starts at 21 years in average-risk people, aligned with obstetric-gynecology and USPSTF adult timing — not at sexual debut. Do not dump adult cervical, breast, or colon schedules into a 14-year-old well visit. A sexually active 16-year-old needs STI screening, contraception counseling, and HPV immunization catch-up — not a speculum "because she is sexually active" as a Pap indication.

STI screening. Sexually active adolescents: chlamydia and gonorrhea (urine or swab NAAT) at least annually for sexually active females under 25, and for males based on site of exposure and risk; HIV at least once in adolescence (Bright Futures includes a universal HIV screen in later adolescence) and more often if risk; syphilis and others by risk and local epidemiology. Ask about sites of contact (genital, rectal, pharyngeal) so you do not test only urine after rectal exposure. Confidential care follows state minor-consent law; do not invent a statute.

Oral health. Oral-health risk assessment is a Bright Futures screen: bottle/sippy caries risk, fluoride exposure (water and toothpaste), visible plaque or white-spot lesions, and whether a dental home exists (first dental visit by age 1). Fluoride varnish in primary care from tooth eruption through the preschool years is prevention attached to that screen. A 2-year-old with no dental home and bottles in bed is a positive oral-health screen, not a "teeth are the dentist's problem in kindergarten" delay.

What you must not import from adult USPSTF

Pediatric screening is not a miniature physical for grown-ups. Do not order average-risk mammography, colonoscopy, or cervical cytology at 16. Do not skip pediatric lead and 12-month hemoglobin because "USPSTF doesn't emphasize them in adults." Do not treat ACE scores as adult coronary-risk calculators. Use Bright Futures periodicity, EPSDT rules for Medicaid lead, and the named ACE tool as history.

Clinic vignettes and traps

A 12-month Medicaid-enrolled toddler is in for vaccines. You draw hemoglobin and blood lead. Waiting until pica appears is the trap.

A 10-year-old has a normal BMI and no family history you have asked about. You still perform the 9–11 year universal lipid screen once in that window.

A 16-year-old is sexually active. You screen for STIs and HIV as indicated. You do not perform a Pap "to be complete."

A family screens positive on WE CARE for food and utilities. You offer WIC/SNAP and a utility hardship referral the same visit. Documenting "poor" without a resource is not screening completed.

Exam traps. Equating ACE count with PTSD. Universal TB skin tests. Skipping Medicaid 12- and 24-month lead. Pap at sexual debut in early teens. Adult colonoscopy logic. Treating SDOH as optional. Missing newborn-screen follow-up because the baby "looks well."

Close Domain II.D by matching the outline: named developmental-behavioral tools, named mental-health and CRAFFT tools, ACE as history, SDOH as action, and pediatric disease-specific screens on pediatric timing.