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Abstract

Introduction/Objectives:

Social determinants of health (SDOH) have the potential to differentially impact child developmental outcomes. This study examined whether scores on the Environmental Screening Questionnaire (ESQ), a newly developed SDOH screening tool, were associated with scores on the Brigance and Ages & Stages Questionnaires-Social-Emotional (ASQ:SE-2) child development assessments.

Methods:

Brigance, ASQ:SE-2, and ESQ scores from children enrolled in a Head Start Program in Northeast Iowa were collected during the 2021 to 2022 and 2022 to 2023 school years. Associations between scores in each ESQ domain and Brigance and ASQ:SE-2 scores were assessed.

Results:

Education-Employment and Community concerns on the ESQ were associated with reduced Brigance scores (r = −.21, P < .001; r = −.17, P = .001). Concerns related to Housing, Child and Family Health, and Community were associated with more concerning ASQ:SE-2 scores (r = .14, P = .005; r = .18, P < .001; r = 0.27, P < .001). In multivariable models controlling for sex and ethnicity, Education-Employment concerns were significant predictors of lower Brigance scores, while Child and Family Health and Community concerns were significant predictors of ASQ:SE-2 scores.

Conclusions:

ESQ scores in certain SDOH domains correlate significantly with child developmental outcomes. The ESQ domains of Child and Family Health and Community appear to be particularly important for appropriate child socio-emotional development. Interventions should focus on addressing critical SDOH domains to promote child resilience and counteract the non-medical factors that can interfere with child developmental outcomes.

Keywords

child development socioemotional development head start environmental screening questionnaire social determinants of health

Introduction

Early childhood is a critical time of development that helps determine the trajectory of a child’s life.¹ Early relational health from positive, nurturing, and stimulating childhood relationships builds the foundations for a lifetime of relational health, emotional well-being, positive developmental outcomes, and resilience.^2
-4 It is critical to determine practical ways that organizations that care for young children can measure and intervene on factors that influence early relational health and subsequently improve child health outcomes.

One important domain of child development is that of social and emotional development, which relates to the development of child temperament as well as attachment to others.⁵ Social- and emotional-based skills allow children to build solid relationships and develop self-regulation, competencies that have been associated with school-based achievement, better adult physical health, higher adult income, and decreased criminality.⁶ Conversely, difficulties with emotional or behavioral regulation in early childhood have been associated with related problems in adolescence, including delinquency and dropping out of school.⁷

There is a critical need to understand the factors which can impact social and emotional development. While there are numerous factors that contribute to early-childhood socio-emotional and overall development, an important set of factors to understand is the social determinants of health (SDOH) – defined by the World Health Organization as “the non-medical factors that influence health outcomes” which include family income, education, food security, housing, and access to healthcare, among many others.⁸ Studies have found associations between several social determinants of health including adverse childhood experiences,⁹ lower family income,¹⁰ decreased parental education,¹¹ unsafe housing,^12,13 food insecurity,¹⁴ and a multitude of sub-optimal child development outcomes.

Screening for SDOH and providing appropriate intervention is linked to improved childhood health outcomes.¹⁵ There is evidence from clinical contexts that screening for SDOH is a feasible and acceptable way to assess the social needs of children and their families.¹⁶ However, less is known about the feasibility of screening for SDOH in families with young children and in community settings. Moreover, there is no one universally accepted best screening practice for SDOH in either clinical or community settings.¹⁷

The Environmental Screening Questionnaire (ESQ) is one of many available screening tools to assess the social determinants of health among children.^18
-20 Despite there being a body of evidence associating any one social determinant of health with child development outcomes, few studies have examined how a comprehensive measure of various SDOH, such as through the ESQ, correlates with any one aspect of child development, and specifically, socioemotional development. One study found that in an online sample of predominantly Caucasian caregivers, higher ESQ scores were associated with worse child socioemotional development at 6 and 48 months as assessed by the Ages and Stages Questionnaires – Social-Emotional (ASQ:SE) screen.¹⁹ Notably, 60% of the sample had an income level over $40 000. In a smaller sample of 72 caregivers from at-risk families, of which 60% had an income <$12 000, ASQ:SE and ESQ scores were not correlated.¹⁹ It therefore remains unclear what the relationship is between ESQ scores and socioemotional development among larger low-income populations.

Head Start programs may represent a unique opportunity to study SDOH in a low-income population.²⁰ Head Start is a pre-school program developed to provide integrated classroom-based education services, in addition to health, nutrition, social, and literacy support for children between the ages of 3 to 5 years who come from low-income households and/or have a disability.²⁰ Thus, participants in Head Start represent a uniquely vulnerable community-based population.

This study aims to correlate scores from the ESQ to overall development as assessed by Brigance III 3 to 5 Year Early Childhood Screen (Brigance) and socioemotional development as assessed by the Ages and Stages Questionnaires – Social-Emotional – Second Edition (ASQ:SE-2) among children enrolled in a Head Start program in Northeast Iowa. We hypothesized that children in environments where there were greater concerns with SDOH would have worse developmental outcomes.

Methods

This was a retrospective cross-sectional observational study of de-identified data. Participants included children enrolled in a Head Start program in Northeast Iowa during the 2021 to 2022 and/or 2022 to 2023 school year and their respective parent(s). All children enrolled in the Head Start program were included in the study. There were no exclusion criteria including gender, race/ethnicity, or underlying medical conditions. Head Start staff collected all study data as part of their routine procedures. All participant information was de-identified by Head Start staff before being transferred to the study team and participant consent was not required. This study received ethical approval as a minimal risk study from both the Mayo Clinic IRB and the Luther College IRB.

Participants came from 7 counties across Northeast Iowa and 15 unique Head Start sites. There were 231 children enrolled in the 2021 to 2022 school year, and 225 children enrolled in the 2022 to 2023 school year. Several children were enrolled in both school years. Data were available from either year for a total of 363 unique participants, and this was our overall study cohort. This cohort included 231 children from 2021 to 2022 and 132 from 2022 to 2023. There were 260 children who were the only child from their household enrolled, whereas there were 100 children who were enrolled with one other child from their household. There were three children who were enrolled with two other children from their same household. Overall, 92% of the sample was Caucasian (23% Hispanic), 7% was biracial, and 1% was Black/African American. During 2021 to 2022, 48% of the study population utilized the Program for Women, Infants, and Children (WIC) and 50% used Supplemental Nutritional Assistance Program (SNAP). During 2022 to 2023, 47% used WIC and 47% used SNAP.

The primary predictive variable was scores on the ESQ, a 10- to 15-min, parent-completed screening tool which asks questions related to six key SDOH areas including: Education & Employment; Child & Family Health; Economics & Finances; Housing; Family Life; and Community.^19,21 There are 5 questions in each domain with potential answers of “Yes,” “No,” or “Concern.” If the “Yes/No” answer describes a potential need for intervention, a score of 10 is given. If, in addition, the family marks “Concern” with this, then an extra 5 points are given. Each domain ends with the following question: “If you checked CONCERN, what kind of help do you need?” Follow up is recommended for any parent concern with scores of 30 or higher in any specific SDOH domain, although NE Iowa Head Start staff typically completed referrals if any concerns were identified on the ESQ. The form provides options for “Resource Need” and “Action Taken.” Different options for resource needs are provided, including examples such as “Job training,” “SNAP,” and “Respite Care.” Few studies have formally assessed the validity of the ESQ; however, one study found that in an online sample of caregivers, ESQ scores were highly convergent with the Parenting Stress Index-Short Form (i.e., caregivers with higher ESQ scores had higher stress levels).¹⁹

Outcome measures for our study included Brigance²² and ASQ:SE-2 scores.²³ The Brigance is an age-specific assessment for children between ages 3 years and 0 months to 5 years and 11 months which aims to assess child development according to various domains including academic and cognitive development, language development, and physical development.²² Higher scores on the Brigance indicate more optimal development. The ASQ:SE-2 is a parent-completed screening questionnaire that can identify social, emotional, and behavioral challenges in young children between ages 1 and 72 months of age.²⁴ In a sample representative of the US population of children, the ASQ:SE-2 was determined to have excellent reliability (test-retest = 0.89), internal consistency (0.84), validity (0.83), sensitivity (0.81), and specificity (0.83).²⁴ Higher scores on the ASQ:SE-2 indicate more concerns for sub-optimal socioemotional development. For example, a normal score for the 36-month ASQ:SE-2 test is under 105 and for the 48-month ASQ:SE-2, a normal score is under 85. For the Brigance, a score of <42 on the 3-year screen for children ages 3 to 3.25 years and <49 for children 3.75 to 4 years is considered abnormal.

The ESQ was completed by parents of Head Start participants as part of the family’s pre-enrollment paperwork. The ESQ was typically taken by families on their own via a paper survey; however, on occasion a Family Service Specialist would complete the questionnaire verbally if there were concerns about literacy. Both English and Spanish version of the ESQ were available to families. Family service specialists assigned to each family conducted at least monthly check-ins with families to refer them to any relevant supports and/or services, and results from the ESQ were used to inform these referrals.

The ASQ:SE-2 screening questionnaire was completed by parents in the summer (June or July), prior to the child starting a given school year which begins at the end of August. Both English and Spanish versions of the ASQ:SE-2 were available to families. The Brigance assessments were completed by Head Start staff within the first 45 days of the school year.

Descriptive statistics included means and standard deviations. We examined bivariate Pearson correlations between ESQ scores and child development, and we constructed multivariable models examining multiple social determinants as simultaneous predictors of child development. All variables and model residuals met requirements for parametric statistical analyses. Statistical significance was set at P < .05.

We anticipated that SDOH health variables would be a specific sub-class of all the possible variables likely associated with Brigance and ASQ:SE-2 scores. Consequently, we conservatively estimated an anticipated bivariate correlation effect size of .15. Using a two-tailed test with an alpha level of .05, an N = 363, and an effect size of .15, the power of the Pearson correlation tests run for this study equaled .82. Likewise, when we conservatively estimated an R² = .05 with an effect size of .05, alpha = .05, and an N = 363, the power of the multivariable models was .92. In sum, both bivariate and multivariable analyses were sufficiently powered.

Results

Means and standard deviations are provided in Table 1. ESQ variables have a minimum of 0 and maximum of 300. Brigance and ASQ:SE-2 score range from 0 to 100 and 0 to 370, depending on the age of the child, respectively.

Table 1.

Descriptive Statistics for Study Variables (n = 363).

Variable	M or %	SD
Female	47%	—
Male	53%	—
2021-2022 cohort (age in months; range)	48.0 (36-61)	7.0
2022-2023 cohort (age in months; range)	48.8 (36-62)	6.5
Hispanic	23%	—
Non-Hispanic	77%	—
Free/reduced lunch	100%	—
Education-employment concern	11.76	11.62
Housing concern	3.42	6.37
Child/family health concern	12.62	10.50
Economic concern	14.57	9.43
Family life concern	6.78	7.97
Community concern	5.43	8.14
Brigance score	28.17	19.23
ASQ score	59.92	42.47

Pearson correlations were examined to determine bivariate associations between SDOH and Brigance and ASQ:SE-2 variables in Table 2. Scatterplots of the Brigance scores and SDOH domains (Figure 1) and ASQ:SE-2 scores and SDOH domains (Figure 2) display the relationships between these variables. Education and employment concerns, as well as community concerns, were associated with worse (lower) Brigance scores. Housing concerns, child and family health concerns, and community concerns were associated with worse (higher) ASQ:SE-2 scores.

Table 2.

Bivariate Associations Between ESQ Domain Scores and Brigance and ASQ Scores, Using Pearson Correlations (n = 363).

Correlations	Brigance		ASQ:SE-2
Correlations	r	P	r	P
Education-employment concern	−.21	<.001*	.05	.34
Housing concern	−.07	.165	.14	.005*
Child/family health concern	−.08	.156	.18	<.001*
Economic concern	−.08	.149	.06	.25
Family life concern	−.10	.065	.06	.28
Community concern	−.17	.001*	.27	<.001*

Statistically significant to a level of P < 0.05.

Figure 1.

Scatterplot associations between ESQ domain scores and Brigance scores.

Figure 2.

Scatterplot associations between ESQ domain scores and ASQ:SE-2 scores.

Multivariable models were used to examine simultaneous associations of the social determinants with each of the developmental outcomes (i.e., Brigance, ASQ:SE-2) while controlling biological sex and ethnicity (i.e., Hispanic vs non-Hispanic). In the model predicting Brigance scores, only education and employment concerns (B = −0.22, β = −.14, P = .02) uniquely predicted the outcome. In the model predicting ASQ:SE-2 scores, child and family health concerns (B = 0.57, β = .14, P = .01) and community concerns (B = 1.26, β = .24, P < .001) were the only significant predictors of the outcome. Social determinants accounted for 4 % of the variance in Brigance scores and 9% of the variance in ASQ scores, above and beyond variance accounted for by socio-demographic variables.

Discussion

Overall, this study demonstrates that certain ESQ domains are significantly associated with child developmental and socioemotional outcomes during the early childhood period. This study found that concerns with the ESQ domain of Education and Employment were associated with worse child development as determined by the Brigance scores. Additionally, Child & Family Health and Community concerns were associated with more socioemotional concerns in children.

The findings that Education/Employment concerns were predictive of Brigance outcomes are consistent with the previous literature. Previous studies have documented associations between lower-quality parental employment and/or lower parental educational attainment and suboptimal child school performance and education outcomes^25,26 and our study demonstrates that these detrimental effects may start during early childhood. Education and Employment concerns were not significantly associated with more concerning ASQ:SE-2 scores, however, despite some evidence demonstrating that greater familial/parental employment is associated with improved behaviors and socioemotional functioning.^27
-29

Likewise, the findings that Child and Family Health and Community concerns were predictive of socioemotional development are also consistent with the literature. For example, in the Child & Family Health domain, evidence demonstrates that improved public health insurance access is associated with improved child behavioral outcomes.³⁰ Conversely, parental mental health concerns, including substance use concerns, are associated with increased risk of mental health issues and internalizing and externalizing behavioral problems among children.^31,32 In terms of the Community domain, improved neighborhood conditions, engagement in community activities, and increased perceived parental social support are all associated with reduced behavioral problems among children.^33
-35

While housing was not associated with improved child developmental outcomes in multivariate models, it was significantly correlated with improved ASQ:SE-2 scores in bivariate analyses. This is consistent with the literature, which demonstrates that higher housing cost burden and exposure to violence in the home or community (one of the components of this domain) are both associated with behavioral disturbance among children.^36
-38 Furthermore, housing insecurity may increase the risk of child maltreatment, which can, in turn, influence socioemotional outcomes such as defiance, aggression, and mental health symptoms.³⁹

In contrast to the ESQ domains discussed above, this study did not demonstrate any significant associations between the ESQ domains of Economics and Family Life with child developmental outcomes on the Brigance screen or socio-emotional outcomes on the ASQ:SE-2 screen. These domains both have demonstrated impact on child development, affecting outcomes including: internalizing and externalizing behaviors, cognitive development, academic performance, and psychosocial functioning.^14,29,40
-47 The lack of significant findings in our study may be explained by a failure to self-report these concerns. Alternatively, another explanation could be that all families that qualify for Head Start are of low-income.

For example, questions under the Economics domain included “Do you worry about having enough food for your family?” and “Do you have credit problems?” It is known that food insecurity and financial distress are associated with feelings of shame, embarrassment, and stigma,^48,49 which may lead to underreporting. Likewise, Family Life questions included “Do you have frequent spouse/partner conflicts?” and “Are you in a relationship where you have been physically hurt, felt threatened or been controlled by someone else?” Stigmatization, fear of partner retaliation and fear of child protective services involvement are all factors which may contribute to reduced disclosure of intimate partner violence among survivors.^50
-53

This study provides further evidence that screening for family-related SDOH in clinical and community settings is vital to improving child health outcomes. The ESQ is one of many SDOH screening instruments that is feasible to use in clinical or community settings. Overall, we found results consistent with previous studies that have evaluated the association of SDOH with child developmental and social-emotional outcomes. The ESQ can direct referrals to appropriate community agencies and shows promise in potentially predicting which children could be at risk for developmental or socio-emotional delays. Ultimately, larger, prospective studies examining the impact of different SDOH concerns on the risk for child developmental and socio-emotional delays in different populations and settings are needed. Although further validation studies of the ESQ and other SDOH screening tools are warranted, these tools are demonstrating utility, and clinical and community organizations who care for families should prioritize incorporating them into their screening activities.

This study has several strengths. The use of a community-based sample from a rural, vulnerable population allowed for a unique examination of the ESQ in an at-risk population. Furthermore, the use of objective indicators of child development (i.e., Brigance and ASQ:SE-2 scores) is a strength. However, our study has several limitations. The cross-sectional nature of the data limits the ability to understand changes in child development over time or evaluate for causation. Furthermore, the ESQ is not well-validated and due to concerns discussed above including stigma and fear of reporting vulnerabilities to perceived “authorities,” there exists a possibility for self-report and/or social desirability bias in terms of parent-reported concerns on the screening instrument. Nevertheless, it is worth noting that families develop close relationships with Head Start staff and they may be more comfortable sharing sensitive family SDOH information in this setting as opposed to a clinical setting.⁵⁴ Finally, the predominantly Caucasian sample from a region in Iowa limits the generalizability of these findings to other contexts.

Conclusions

In conclusion, among a community-based sample of Head Start participants in Northeast Iowa, the ESQ domains of Education and Employment, Child and Family Health, and Community were significantly associated with child development, with Child and Family Health and Community concerns being predictive of socio-emotional concerns. Future research should examine the relationship between ESQ scores and child health outcomes in other settings. These results could also inform future studies that could assess whether the ESQ, when combined with appropriate intervention, could ultimately improve the socioemotional development of affected children. Such interventions should focus on addressing critical SDOH domains to promote child resilience and counteract the non-medical factors that can interfere with child developmental outcomes.

Footnotes

Acknowledgements

The authors wish to thank Sharon Burke, Missy Holohan, Wendy Larson, Denise Tapscott, and Kim Jasper (Northeast Iowa Community Action Corporation) for their assistance with study design and data collection. The authors would also like to thank Ann Mansfield and Haleisa Johnson (Northeast Iowa Food and Fitness Initiative). Lastly, they wish to thank the children and families enrolled in the NE Iowa Head Start Program.

Author Note

Elizabeth K. Farkouh is now affiliated to Mayo Clinic Alix School of Medicine, Rochester, MN, USA.

ORCID iDs

Elizabeth K. Farkouh

Loren L. Toussaint

Brian A. Lynch

Ethical Considerations

This study received ethical approval as a minimal risk study from both the Mayo Clinic IRB and the Luther College IRB (approval #1.2324 on June 20, 2023). This is an IRB-approved retrospective study, all participant information was de-identified and participant consent was not required.

Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data is not available to protect subject confidentiality as per request by Northeast Iowa Community Action Corporation.

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