Fighting Childhood Poverty
SCOPE OF THE PROBLEM
One in five children lives below the federal poverty level (FPL) in the United States and almost one in two are poor or near poor. Children are the poorest members of our society, a society that knows how to use policies and programs to raise its citizens out of poverty. Thirty-five percent of seniors lived below the FPL in 1959, but due to programs like social security expansion and Medicare, only 9% of seniors are poor today. What the US does for seniors is clearly good; so why do we not also protect children from the life-altering effects of poverty?
The effects of poverty on children's health and well-being are well documented. Poor children have increased infant mortality, higher rates of low birth weight and subsequent health and developmental problems, increased frequency and severity of chronic diseases such as asthma, greater food insecurity with poorer nutrition and growth, poorer access to quality health care, increased unintentional injury and mortality, poorer oral health, lower immunization rates, and increased rates of obesity and its complications. There is also increasing evidence that poverty in childhood creates a significant health burden in adulthood that is independent of adult - level risk factors and is associated with low birth weight and increased exposure to toxic stress (causing structural alterations in the brain, long-term epigenetic changes, and increased inflammatory markers). The consequences of poverty for child and adolescent well-being are perhaps even more critical than those for health. These are the consequences that may change their life trajectories, lead to unproductive adult lives, and trap them in intergenerational poverty. Children growing up in poverty have poorer educational outcomes with poor academic achieve ment and lower rates of high school graduation; they have less positive social and emotional development which, in turn, often leads to life "trajectory altering events" such as early unprotected sex with increased teen pregnancy, drug and alcohol abuse, and increased criminal behavior as adolescents and adults; and they are more likely to be poor adults with low productivity and low earnings.
At present, there is not a consistent and unified pediatric voice speaking out about childhood poverty, the most important problem facing children in the United States today. The Academic Pediatric Association (APA), the American Academy of Pediatrics (AAP) and the Pediatric Policy Council (PPC) all advocate for individual issues (such as Medicaid, Child Health Plus, and food supplementation) that are important programs related to childhood poverty. There is, however, no sustained focus on childhood poverty itself, which underlies many of the ills of children, and which needs to be addressed in a comprehensive manner.
GUIDING PRINCIPLES
Therefore, the APA Task Force on Childhood Poverty has as its mission to pursue an agenda to address childhood poverty. The Task Force has these guiding principles:
Pediatricians are among the most trusted experts on children's health and safety, which makes us potentially powerful advocates for the most vulnerable children and families.
Pediatricians, child health nurses and early childhood educators have extensive contact with children before age three, prior to preschool, and there fore, have the opportunity to work with children and their families to maximize health and development during this critical period.
We will focus on both lifting children out of poverty and alleviating the effects of poverty on children.
Poor children live in poor families. Any solutions to childhood poverty will focus on family poverty and the factors that strengthen the resiliency of families living in poverty.
Childhood poverty is not without solutions. Other developed countries, including the United Kingdom, have devised long-term national efforts to dramatically decrease childhood poverty and have succeeded. Where there is a serious public intention and effort to tackle childhood poverty, substantial reductions can in fact be achieved. We will treat childhood poverty as an issue with a pathway to resolution and focus on specific policies, programs and actions.
There are serious inequities in childhood poverty, disproportionately affecting very young children, racial/ethnic minorities, Native Americans, and children in immigrant families. Special attention will be paid to these groups of children, including addressing their cultural and linguistic needs.
Poor and low-income families are more likely to have children with special health care needs and at the same time have less access to quality health care, and fewer resources to address the health and emotional well-being of their children. The health care delivery system will need to address the special needs of these children and families.
Childhood poverty is a long-term problem. Despite the urgency, solutions can only be implemented over time. We cannot wait any longer and are beginning a long-term effort to address poverty in children. Any solutions that are found will also need to be sustained and protected from retrenchment.
Key indicators of child health and well-being should be monitored systematically. Analysis of existing data sources (such as US Census data, the National Survey of Children's Health, UNICEF Reports on Child Well-Being internationally) at both the national and state levels will need to be performed and publicized. New methods of collection or collation of key data will be considered. Data regarding social determinants of health in addition to income level (e.g., discrimination, education, marital status, place of residence, crowding conditions, the built environment, adequate nutrition, access to quality health care, insurance status) needs to be consistently and systematically collected by our health care system and as part of national datasets.
Neighborhood characteristics (such as poverty, crime, residential turnover, availability of quality child and family institutions, poor social control and interaction, negative normative expectations, and low employment and marriage rates) all have negative impacts on poor children's health and well-being. Model "place-based" programs to address these issues should be explored.
We plan to communicate the issues of childhood poverty with effective and coherent messaging and with terminology that doesn't "trigger" partisan and non-productive responses. We will frame these issues in ways that appeal, as much as possible, across the political spectrum. We will endeavor to collaborate with business and social science professionals skilled in messaging. This is not about "welfare" but about the future of our country. This is about half the children in the US, everyone's children. Child well-being is a public good that benefits us all.
The APA Standing Committees (Public Policy and Advocacy, Health Care Delivery, Education, and Research), Regions and Special Interest Groups will be involved in the efforts of the Task Force. AAP Councils, Committees and Initiatives, such as the Council on Community Pediatrics, the Committee on Psychosocial Aspects of Child and Family Health, the Committee on Early Childhood, the Committee on Pediatric Research, and the Early Brain and Child Development Initiative, will also be involved.
We intend both to lead and to collaborate. We want especially to collaborate with all other pediatric organizations (including the AAP and the other members of the PPC, as well as the National Medical Association and the National Hispanic Medical Association), with university-based institutes on poverty, with our colleagues in economics and social sciences, with non-profit organizations advocating for poor children and families, and with private corporations and public agencies. The AAP has recently made "Child Health and Poverty" a strategic agenda plank and we intend to closely align the efforts of both organizations.
A STRATEGIC ROAD-MAP
The Task Force will focus on specific strategies involving public policy and advocacy, health care delivery, medical education, and research. These strategic priorities are a first step in a "war on childhood poverty".
Public Policy and Advocacy
In addition to existing, ongoing policy and advocacy activities (such as support for Medicaid and CHIP), the Task Force will focus on four strategic priorities:
1. Raising families out of poverty: Scientific evidence shows that income matters. We support making work pay through raising the minimum wage so that families with at least one full-time wage-earner will no longer live below the FPL, through improvements in the Child Tax Credit to make it refundable to poor families, especially those with the youngest children, and by further strengthening the Earned Income Tax Credit, which provides more targeted benefits to poor families. We also support strengthening and improving access to Temporary Assistance for Needy Families to better help parents receive benefits and find and keep jobs. Efforts will be needed at both the federal and state levels.
2. Providing high quality early childhood programs and high quality affordable child care to poor families: The clearest evidence for interventions that alleviate the effects of poverty on children and give them a chance at productive lives is in early childhood. We support free high quality pre-Kindergarten for all 3-and 4-year-old poor and near poor children; improving and expanding Head Start and Early Head Start, as well as other innovative models starting at birth; evidence-based home visiting programs for all poor children; and evidence-based interventions in pediatric primary care. We also support high quality affordable child care. Availability of high quality affordable child care will improve early childhood development, decrease the significant economic burden of child care on poor families (thus decreasing poverty), and allow parents to work (further decreasing poverty). One tool to make child care affordable is to modify the Child and Dependent Care Tax Credit by substantially raising reimbursements of qualifying child care expenses for poor families. Increasing the availability of high quality child care to poor families will require working with Congress, federal agencies such as the DHHS Administration for Children and Families, and state legislatures and agencies regarding local funding and implementation.
3. Promoting a White House Conference on Children and Youth: From 1909 to 1970, seven White House Conferences on Children and Youth, roughly every ten years, took place in Washington, D.C. There has not been a Conference since 1970. These Conferences were devoted to improving the lives of children across the nation. They were one or two-year long endeavors, involving the executive branch, Congress, voluntary agencies and state level activities. They produced many important outcomes, including a commitment to ending the institutionalization of dependent children, ending child labor, the first significant report on child health and welfare standards, the creation of the US Children's Bureau (now part of the DHHS Administration for Children and Families), the development of a national Children's Charter, funding for maternal and child health programs, improvements in education, and legitimacy given to the benefits of creative freedom and healthy personality development on children's well-being. Legislation to convene a new White House Conference on Children and Youth has been promoted in Congress, and non-profit advocacy groups have focused on getting support from the White House. The time has come to refocus the nation on the needs of children and develop a vision for the welfare of children and youth in the 21st Century.
4. Neighborhood Revitalization Initiatives ("place-based" initiatives): The White House has committed the federal government to develop effective initiatives to improve neighborhoods, including: improving school quality and access to high-quality early childhood care; improving the built environment with better streetscapes, more fresh food stores and better transportation; providing more local job training; and increasing funding to address crime. We have great experience in partnering with families and communities though decades of experience in community pediatrics and community-based participatory research. We plan to work with the Department of Health and Human Services (especially MCHB and ACF), the Department of Education, and the Department of Justice to bring pediatric expertise to these initiatives.
Health Care Delivery
The Task Force will work, in collaboration with the AAP, to support pediatric practitioners in their efforts to care for children in poor and near poor families. These efforts will include:
1. Developing elements of a Patient-Centered Medical Home for Children (PCMHC) that addresses the needs of poor and near-poor families
a. Identification of children living in poor and near poor families and determination of the specific needs of those children and families
b. Systems that facilitate connecting families with community and government resources and benefits, including maximizing utilization of the ACA home visiting programs.
c. Establishment of appropriate roles within the health care team for the above activities
d. Screening and evaluation for speech and language, school function, child mental health, maternal depression, and parental adverse childhood events.
e. Evidence-based, primary care program located strategies that disproportionately help children in poor families, e.g.:
i. Reach Out and Read
ii. Other parenting strategies in primary care
iii. Obesity reduction programs
iv. Medical-Legal Partnerships
v. Health Leads
2. Support for the development of payment systems and structures to support pediatric practices that devote time and resources to reducing the negative impacts of poverty on populations they serve.
a. Identification of resources for care coordination
b. Meaningful linkages with community resources
3. Adapting health care systems to address the specific challenges faced for poor and low-income families with children with special health care needs.
a. Coordination with services provided by child care, schools, Title V, housing, nutrition and other publicly-funded agencies
b. Work within systems to provide new services identified in ACA (e.g., ABA-therapies for children with ASD)
4. Support for the developmental of collocation programs including two generation programs for mothers and children, and collocation of behavioral health programs with medical programs.
5. Enhancements to Bright Futures: Integrating the issues of poor families more strongly into Bright Futures with appropriate screening tools and tool-kits that help practitioners:
a. Identify needs of poor and near-poor families
b. Identify community and government resources for those children and families
c. Assist families in accessing those resources
6. Developing non-partisan programs to encourage families to vote on children's issues.
7. Establishing a framework for evaluation of the impact of the expanded PCMHC upon child and family well-being.
Education
The Task Force has set up a subcommittee to develop educational products and activities regarding childhood poverty for medical students, residents, fellows, faculty, practitioners, and other child health providers. These efforts will promote:
1. Understanding the impact of poverty and other social determinants of health on well-being over the life course and across generations.
2. Development of the knowledge, skills, and attitudes necessary to implement the elements of the PCMHC.
3. Advocacy training toward poverty reduction in conjunction with the AAP Community Training and Advocacy Initiative (CPTI), and models of advocacy training from residency training programs across the US. We will work to build statewide and regional collaboratives uniting the pediatric voice across the nearly 200 pediatric training programs in the US. Collaboration with other organizations of fering advocacy training may also be important, including efforts of the American Academy of Family Physicians, the American Medical Student Association, Physicians for a National Health Program, and others.
Research
The Task Force will work with the APA Research Committee and the AAP Committee on Pediatric Research to create a research agenda to develop better evidence regarding childhood poverty, especially the effectiveness and implementation of policies and programs to improve the health and well-being of poor children. While we will await the deliberations of these committees for a thoughtful and detailed agenda, areas of focus may include:
1. Continued research into early brain development and the effect of toxic stress on adaptive self-regulation, executive functioning, social-emotional and cognitive development, and resiliency. In addition, further research on the impact of epigenetics on brain functioning and its relationship to toxic stressors in poverty
2. Further research on developing the evidence base for interventions
3. Further research to determine how policies, programs and other interventions lift children out of poverty and how they alleviate the effects of poverty on children: filling in the gaps of previous research.
4. Taking evidence-based practice to scale (implementation and dissemination)
5. Community-based participatory research
6. Development of valid and reliable measures of important outcomes and determinants related to childhood poverty.
7. A life course approach to research on childhood poverty.