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Transcript of Poverty and Child Protection Implications for Practice and Policy Midwest Children’s Resource...
Poverty and Child ProtectionImplications for Practice and Policy
Midwest Children’s Resource Center Webinar
October 11, 2011
Howard Dubowitz, MD, MSUniversity of Maryland School of Medicine
Objectives
• To review poverty in the US
• To show the link between poverty and child maltreatment?
• To consider personal, professional, practice and policy dilemmas
• To demonstrate what can be done– In practice– In policy
What do we know about poverty in the USA?
Living in or near poverty has always a form of exile, of being cut off from the larger society. To be poor in America today, even more than in the past, is to be an outcast in your own country. And that, the neuroscientists tell us, is what poisons a child’s brain.
Paul Krugman,Nobel Prize – Economics, 2008
Poverty is Poison, New York Times, 2/18/08
Family Income Self-Sufficiency Measure
• To cover basic expenses: housing, food, healthcare, childcare, transportation
• Approximately 2 - 3x the Federal Poverty Level– Boston in 2006: $62,095– 2 adults, 2 school-aged children
What does it mean to experience poverty?
• Unable to achieve a minimum, decent standard of living for full participation in mainstream society.
• Material hardship - food, clothing, and shelter.
• The definition of basic material necessities varies by time and place.
• In the USA, running water, electricity, indoor plumbing, and telephone service are essential to 21st century living; not true 50 or 100 years ago.
Not All Poverty is Equal
Worth reading
What does it mean to experience poverty?
• The experiences of children and families in poverty vary greatly
– Brief spells chronic poverty
• Challenges
– insufficient income to meet daily expenses
– inadequate assets (savings, a home) to get ahead
– Compounded by social circumstances
• Consider the severity & depth of poverty & the effects on children
Impact of poverty on children’s health, development & safety
www.nccp.org
Poverty
Physical Health Cognitive Development
Social Development Emotional Health
Poverty: adverse outcomes for children
Effects of poverty on children’s health & development depend on its timing, duration, and intensity
Risks are greatest for children who:
experience poverty when they are young
experience persistent and deep poverty
Early experiences have lasting consequences
The “architecture” of a child’s brain - foundation for future learning, behavior, & health
Once the architecture is built, it cannot be changed, making it difficult, although not impossible, to change behavior
Stable and stimulating environments in the early years help create a sturdy foundation for later school achievement, economic productivity, and responsible citizenship
Poverty = Societal Neglect?????????????
What is the link between poverty and child maltreatment in the
USA?
The Myth of Classlessness
“Child abuse & neglect afflict all communities, regardless of race, religion or economic status.”
• Doesn't just run counter to research. It runs counter to common sense.
• It is well-known that child abuse is linked to stress.
• And, that poor families tend to be under more stress than rich families.
Pelton L. Am J Orthopsychiatry 1978;48(4):608-17
Poverty & maltreatment4th US National Incidence Study
– Household earning < $15,000/yr
– Parents’ educational level < high school– Household member participates in a
poverty program
– Abuse >3 x more common in poor families– Neglect >7 x more common in poor families
Sedlack et al, 2010
Are the increased numbers due to biased reporting to the child
welfare system?
Identification and Reporting of Abusive Fractures by Orthopedic Surgeons
Lane W, Dubowitz H. Clin Orthopedics Relat Res. 2007;461:219-25
Research QuestionResearch Question
What factors affect the diagnosis and reporting of child abuse?
– Race? – Social class?
Clinical Scenario – Example
• A 4 m.o. white infant is referred to your office from his private pediatrician / the local health department clinic
• He was brought in because of R arm swelling. Mother: “he rolled off the sofa when I went to get a diaper. He landed on the floor”
• X-ray: acute transverse fracture, mid-shaft of the humerus
Rating ScalesRating Scales
I think this injury is:
Almost Certain Accident
Likely Accident
Unsure Likely Abuse
Almost Certain Abuse
This child should be reported to CPS:Strong Disagree
Disagree Unsure Agree Strong Agree
Influence of Social ClassInfluence of Social Class
• 3 of 4 scenarios: significant differences
– Over identification & reporting of lower SES
with non-inflicted injuries
– Under identification & reporting of higher SES with abusive injuries
Studies of Fatal Maltreatment
• Expect less bias
• Most deaths occur in context of poverty
Kaplun & Reich, Am J Psychiatr, 1976;133:909-813
Weston, In: The Battered Child, 1974
Link between poverty and child maltreatment (CM)
due to both ………………
Bias
Poverty contributing to CM
Practice Implication
Guard against possible bias
The Myth of Classlessness
• Does the myth persist?
• If yes, why?– Personal– Professional interests– Political interests
Worth reading
Does poverty cause child maltreatment?
Child
Parent
Family
Community/SocietyPoverty
Contributors to Child Maltreatment
Poverty Maltreatment
Direct EffectsEg, hunger
Parental StressProblems
No or Inferior Institutions
Summary
• CM occurs outside of poverty
• Most poor people do not maltreat their children
• Poverty and its associated burdens do contribute to CM
• Poverty = societal neglect (or abuse?)
If poverty contributes to CM, when is it appropriate to hold parents accountable?
• Ms. Smith is the 24 year old single mother of 5 year old Amy and 1 year old Paul
• She recently lost her job and health insurance, and has had trouble paying the rent. She’s been feeling “pretty down”
• Ms. Smith was unable to get Amy’s asthma medications, and Amy was recently hospitalized
How should we define child
neglect given the strong
link to poverty?
State Legal Definitions of Neglect
• Omissions in care
• By parent or caregiver
• Causing significant harm
• Or, risk of significant harm
State Legal Definitions of Neglect
• “The child's environment is injurious to his or her welfare” – Colorado
• “Is being permitted to live under conditions, circumstances, or associations injurious to the well-being of the child or youth” – Connecticut
• “Who lives in an environment injurious to his or her welfare” – North Carolina
www.childwelfare.gov
U.S. State Laws & Poverty
12 States and DC exclude poverty from their neglect definitions
– if circumstances primarily due to poverty
• “It is not considered neglect when the parent's failure to provide for the child's needs is due to financial inability, and no services or relief have been offered” - Arkansas
www.childwelfare.gov
Why do we want to define child neglect?
To protect children & ensure their health and safety
NOT
to blame parents
Child neglect: Proposed definition
• Child neglect occurs when a child’s basic need is not adequately met, resulting in actual or potential harm
• Basic needs include:
adequate food, clothing, health care, supervision, protection, education,
nurturance, and a home
Advantages of a Child-focused, Broad Definition
• Moves us beyond the narrow focus on parents to consider other contributors, and other interventions
• A more constructive, less blaming approach
• Fits with our broad interest in the health, safety & well-being of children
Community
Alternative Response Systems
CPS
Legal System
Possible Solutions
National Center for Children in Povertywww.nccp.org
Poverty is not inevitable
To escape poverty, and neglect
• To achieve a minimum but decent standard of living, families need more than material resources
• “Human and social capital.” Education, basic life skills, employment, social networks and access to civic institutions
• Helps families get by and get ahead
• Helps families improve their earning potential & accumulate assets, access safe neighborhoods and quality services, such as medical care, schooling, & expand their networks & social connections Zolotar & Runyan, Pediatrics, 2006
Practice Implications
• Avoid bias
• Help families obtain basic resources– TANF– Food benefit programs– Health insurance
• Consider ways to lift families out of poverty– Work opportunities– Child care– Schooling
Costs of Poverty
• In addition to the harmful consequences for children, poverty exacts a serious toll on the US economy.
• Economists estimate that child poverty costs $500 billion a year – lost productivity– health care – crime
How can we afford to tackle this problem?
How can we afford not to?
An integrated policy approach
Make work pay
Support parenting, not just work
Ensure access to high-quality early care and learning opportunities for children
Ensure access to health & mental health services - for children and parents
Promote & protect savings & asset development
State initiatives to fight poverty
• Connecticut Child Poverty & Prevention Council– Cut child poverty by 50% by 2014
• A Minnesota Without Poverty– End poverty by 2020
• Illinois Commission on Poverty Elimination– Cut extreme poverty by 50% by 2015
Q: “We want a new commitment …. like cutting poverty in half in 10 years. Would you commit to such a goal?”
Obama: “I absolutely will make that commitment”
Child
ParentsFamily
Community
Society
Advocacy
Summary
• Poverty affects many Americans
• Poverty is clearly linked to CM
– It is a form of CM
• Preventing CM involves preventing poverty
• There are things we can do in practice
• There are policies that would help
• We can make a difference
“Overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right, the right to dignity and a decent life.”
Nelson MandelaNobel Peace Prize
G8 summit, July 2005
Thank you!