AAP Takes Aim at Poverty

Diana Swift

March 11, 2016

In a policy statement published online March 9 in Pediatrics, the American Academy of Pediatrics (AAP) committed itself to eliminating child poverty and called on US pediatricians to improve the health and standard of living of the many US children currently living at or below the poverty line.

The academy referred to research showing that poverty-related determinants of health have lifelong adverse consequences "negatively affecting physical health, socioemotional development, and educational achievement."

Pediatricians are uniquely positioned to screen for poverty-related disorders in the very young, and they can help match needy families with community resources. "With improved understanding of the root causes and distal effects of poverty, pediatricians can apply interventions in practice to help address the toxic effects of poverty on children and families," the statement says.

Urging concerted action from its state chapters and governments, as well as faith-based, charitable, and advocacy organizations, the academy's Council on Community Pediatrics endorsed a sweeping range of proactive recommendations. Among these are:

  • expanding support for Medicaid, the Children's Health Insurance Plan, and Maternal, Infant and Early Child Home Visiting;

  • restructuring healthcare to improve delivery to low-income children;

  • creating "medical homes" attuned to the needs of low-income families;

  • encouraging even nonresident fathers to engage in their children's lives and medical care;

  • funding high-quality early childhood development initiatives such as Early Head Start and Head Start;

  • supporting food programs such as the Supplemental Nutrition Program and school meal plans;

  • streamlining enrolment in public benefits programs;

  • boosting family income through higher minimum wages and job training, as well as tax policies such as the earned income tax credit for low-income families, the child tax credit, and the child and dependent care tax credit; and

  • bolstering community infrastructure with affordable housing and safe public spaces and play areas.

"In 1935, the US Congress passed the Social Security Act and in 1965 enacted Medicare. Together, these 2 pieces of legislation have greatly reduced and nearly eliminated poverty in the elderly," the statement reads. "It is time to enact similar reforms to eliminate child poverty."

The statement was supported by a technical report by John M. Pascoe, MD, MPH, and colleagues, compiled in conjunction with the AAP's Committee on Psychological Aspects of Child and Family Health. The technical report analyzed data from a variety of fields, including physiology, sociology, psychology, economics, and epidemiology, to identify specific mediators of the pathophysiology of poverty, from chronic stress and poor nutrition to limited developmental opportunities.

According to the report, in 2014, almost 10% of children lived in extreme poverty in families earning less than 50% of the federal poverty level. "Children inherit not only their parents' genes but also the family ecology and its social milieu," the report authors write.

These detrimental effects were highlighted in a study published online March 10 in Pediatrics that tested the connection between adverse childhood experiences (ACEs) and early adult well-being. Alison Giovanelli, MA, a doctoral student at the Institute of Child Development, University of Minnesota, Minneapolis, and colleagues analyzed data from 1142 predominantly black, low-income urban participants from the Chicago Longitudinal Study who had attended kindergarten in 1985 to 1986.

Associations emerged between high ACE exposure and poorer young adult (age 26 years) well-being across several domains, from depression and unhealthy behaviors to juvenile arrest and felony charges, regardless of classic demographic risk factors. As ACE exposure increased, economic indices such as educational and occupational success declined, with, for example, high-ACE subjects graduating from secondary school at 66% the rate of their zero-ACE counterparts.

Of nine ACEs, the most common was extended absence or a parent or parental divorce (32.1%), followed by death of a family member or close friend (29.2%). Other ACEs were parental substance abuse, being a victim of or witness to a violent crime, neglect, and physical or sexual abuse. Males reported significantly more negative events than females (parental absence, 38.8% vs 26.4%; witnessing a violent crime, 22.3% vs 6.1%; and being victimized by a violent crime, 9.0% vs. 3.4%).

By age 18 years, 62.4% of the sample had experienced at least one ACE. Participants with four or more ACEs had significantly reduced likelihood of high school graduation (odds ratio [OR], 0.37; P < .001). They also ran greater risks for depression (OR, 3.9; P < .001), unhealthy behaviors such as smoking and drinking (OR, 4.5; P < .001), juvenile arrest (OR, 3.1; P < .001), and felony charges (OR, 2.8; P < .001). The highest-ACE group was also less likely to enjoy occupational prestige (OR, 0.50; P = .001).

The study also asked whether preventive interventions could attenuate this ACE–outcomes association. Unlike other research, the researchers found that for this Chicago cohort, engagement in a child–parent center program of education and family support for children aged 3 to 9 years did little to help. In other studies, however, preventive interventions from a child's earliest years have improved well-being "by reducing family stress and adversity and promoting children's school readiness, achievement, and socioemotional learning," Giovanelli and colleagues write.

They call for more study to provide evidence that early childhood interventions during these early years can foster healthy development.

This study was supported by the National Institute of Child Health and Human Development and the National Science Foundation. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online March 9, 2016. Policy statement abstract, Technical report full text. Published online March 10, 2016. Article abstract


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