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!

hdubowitz@peds.umaryland.edu