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Poverty and Child Protection Implications for Practice and Policy Midwest Children’s Resource Center Webinar October 11, 2011 Howard Dubowitz, MD, MS University.

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Presentation on theme: "Poverty and Child Protection Implications for Practice and Policy Midwest Children’s Resource Center Webinar October 11, 2011 Howard Dubowitz, MD, MS University."— Presentation transcript:

1 Poverty and Child Protection Implications for Practice and Policy Midwest Children’s Resource Center Webinar October 11, 2011 Howard Dubowitz, MD, MS University of Maryland School of Medicine

2 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

3 What do we know about poverty in the USA?

4 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


6 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








14 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.

15 Not All Poverty is Equal

16 Worth reading

17 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

18 Impact of poverty on children’s health, development & safety

19 Poverty Physical Health Cognitive Development Social Development Emotional Health

20 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

21 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

22 Poverty = Societal Neglect ?????????????

23 What is the link between poverty and child maltreatment in the USA?

24 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

25 Poverty & maltreatment 4 th 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

26 Are the increased numbers due to biased reporting to the child welfare system?

27 Identification and Reporting of Abusive Fractures by Orthopedic Surgeons Lane W, Dubowitz H. Clin Orthopedics Relat Res. 2007;461:219-25

28 Research Question What factors affect the diagnosis and reporting of child abuse? – Race? – Social class?

29 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

30 Rating Scales I think this injury is: Almost Certain Accident Likely Accident UnsureLikely Abuse Almost Certain Abuse This child should be reported to CPS: Strong Disagree DisagreeUnsureAgreeStrong Agree

31 Influence 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

32 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

33 Link between poverty and child maltreatment (CM) due to both ………………  Bias  Poverty contributing to CM

34 Practice Implication Guard against possible bias

35 The Myth of Classlessness Does the myth persist? If yes, why? –Personal –Professional interests –Political interests

36 Worth reading

37 Does poverty cause child maltreatment?

38 Child Parent Family Community/Society Poverty Contributors to Child Maltreatment

39 Violence Substance abuse Poverty Adult mental health problems Poverty associated with ………. Major stress

40 Poverty Maltreatment Direct Effects Eg, hunger Parental Stress Problems No or Inferior Institutions

41 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?)

42 If poverty contributes to CM, when is it appropriate to hold parents accountable?

43 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

44 How should we define child neglect given the strong link to poverty?

45 State Legal Definitions of Neglect Omissions in care By parent or caregiver Causing significant harm Or, risk of significant harm

46 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

47 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

48 Why do we want to define child neglect? To protect children & ensure their health and safety NOT to blame parents

49 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

50 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

51 Community Alternative Response Systems CPS Legal System

52 Possible Solutions National Center for Children in Poverty

53 Poverty is not inevitable

54 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

55 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

56 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

57 How can we afford to tackle this problem? How can we afford not to?

58 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

59 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

60 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”

61 Child Parents Family Community Society Advocacy

62 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

63 “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 Mandela Nobel Peace Prize G8 summit, July 2005

64 Thank you!

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