When Marsha D. Raulerson, M.D., FAAP, asked a patient his three greatest wishes, his first was to be in the NBA. His second and third were to help his family and for things to get better.
“Most 16-year-old boys don’t say that,” said Dr. Raulerson, who practices in rural Alabama. She often uses the wish question to root out problems faced by her patients, many living in or near poverty. She may find out a family has housing insecurity or not enough to eat. In the case of the teen, Dr. Raulerson learned the boy was acting out at school because of stress at home. She referred him to a counselor and, as she does with every patient at every visit, she gave him a book.
“That’s my biggest poverty prevention program,” she said.
Dr. Raulerson’s ease at uncovering problems associated with poverty and then offering support is not uncommon in pediatrics. With almost half of young children in the U.S. living in or near poverty, pediatricians nationwide have firsthand experience helping families, said AAP President Benard P. Dreyer, M.D., FAAP.
“We know these issues impact a child’s health, other than immunizations, more than a lot of other things we’re doing,” Dr. Dreyer said.
As a result, the Academy has released a new policy statement and technical report that demonstrate a commitment to help end child poverty and outline ways individual pediatricians can offer support. The policy Poverty and Child Health in the United States is available at http://pediatrics.aappublications.org/content/early/2016/03/07/peds.2016-0339 and will be published in the April issue of Pediatrics along with the technical report Mediators and Adverse Effects of Child Poverty in the United States, www.pediatrics.org/cgi/doi/10.1542/peds.2016-0340.
“The impact of growing up in a household that is poor can have really dramatic impacts on lots of different kinds of manifestations of health,” said Andrew D. Racine, M.D., Ph.D., FAAP, chair of the AAP Poverty and Child Health Leadership Work Group.
Poverty is linked to low birthweight, negative effects on early brain development through toxic stress, delayed growth and development, adolescent pregnancy, chronic conditions such as asthma, and later in life to conditions like hypertension. Other problems are related to mental health such as higher levels of depression and increased substance abuse.
“The impact that poverty has on physiology in childhood is pervasive,” Dr. Racine said.
Attacking the problem
Besides calling attention to the importance of addressing childhood poverty, the policy statement aims to provide pediatricians with concrete steps they can take to have positive impacts on the health of their patients.
“We know pediatricians are already doing a lot of these things,” Dr. Dreyer said. “They are dealing with poor kids. They are sensitive to these issues. We want to help them with resources.”
First is understanding what issues poverty creates in the community. Second is understanding what issues individual families face. And third is recognizing strengths families already possess and connecting them with community resources, Dr. Dreyer said.
Screening — either by asking questions or using written questionnaires — is important to uncover problems and barriers for impoverished families. Aid can be as easy as an information sheet with resources, or help can be more direct. In the Bronx, a large pediatric health care system has psychiatrists and dentists co-located with its pediatric offices. Pediatricians are able to refer patients and families next door. Some New York schools have health care clinics located inside.
Meanwhile in rural Alabama where there is no public transportation, Dr. Raulerson uses a community van service to get children to specialists and a telemedicine service that allows her patients to confer with a psychiatrist 200 miles away. Dr. Raulerson also encouraged her community to take part in a summer lunch program for schoolchildren.
Both she and Dr. Racine say they know they can’t take on every aspect of poverty but have found ways to help their patients. Some are as simple as giving parents ideas about how to connect with their children through reading or taking walks.
On a more global level, Dr. Dreyer encourages pediatricians to speak out about issues like paid family leave and raising the minimum wage. “Pediatricians speaking out are a powerful voice in advocacy at the local, state and federal level,” he said.
The policy statement offers ways pediatricians in community practice can make a difference for their patients, such as the following:
- Creating a medical home that acknowledges and is sensitive to the needs of families in poverty. Practices can learn to recognize economic barriers families may face like difficult work schedules or competing financial issues.
- Screening for risk factors during patient encounters. Practices can use written screenings or ask families about basic needs like food, housing and heat. Patients then can be referred to a social worker or community program, or given contact information for places like food pantries.
- Implementing programs to help families build resilience in their children such as Healthy Steps, Reach Out and Read, Health Leads and the Video Interaction Project, along with mental health interventions like Incredible Years and Triple P. Also, the AAP Bright Futures guidelines provide screening tools, strategies and recommendations.
- Identifying and building on family strengths and protective factors such as support networks, skills, and spiritual and cultural beliefs.
- Collaborating with community organizations to help families with unmet basic needs and to assist with stressors. Pediatricians can tap into resources like public health departments, legal services, social work organizations, food pantries, faith-based organizations, community health services and parent support groups.
- Engaging with early intervention programs and schools to promote learning. Pediatricians can participate with education professionals in feeding programs, clothing drives, health screenings and after-school programs.
- Promoting the Maternal, Infant, and Early Childhood Home Visiting program (MIECHV). Pediatricians can connect families to home visiting programs and recommend successful programs for inclusion in MIECHV.
- Supporting programs enhancing the involvement of fathers in their children’s lives.
- Advancing strategies for family and child mental health and development by routinely screening for maternal depression among mothers of infant patients, advocating for increased resources for mental health and behavior issues in poor communities, and pushing for separate payment for screening for parental depression and care coordination.
- Advocating for public policies mitigating the effects of poverty on child health (see below). Pediatricians can reframe poverty as an evidence-based health concern with lifelong health, social and economic consequences.
Public policy efforts needed: AAP
The new policy statement recommends 11 strategies to protect the health of children affected by poverty and help families become more secure:
- Invest in young children. Funding quality early childhood programs, for example, can have a significant return on investment.
- Protect and expand funding for essential benefits programs that assist low-income and poor children. Evidence-based programs include Head Start, the Children’s Health Insurance Program, the Special Supplemental Nutrition Program for Women, Infants, and Children, and the Supplemental Nutrition Assistance Program.
- Support two-generation strategies to help children and parents simultaneously.
- Support and expand strategies that promote employment and increase parental income.
- Support policies that improve community infrastructure, including affordable housing.
- Support population health with the goal of reducing health disparities.
- Enhance health care financing to support comprehensive care for at-risk families.
- Fund home visiting programs for all children in low-income households.
- Support primary care models that promote effective parenting and school readiness such as Reach Out and Read and the Video Interaction Project.
- Improve national poverty definitions and measures.
- Support a comprehensive research agenda.
To read more about the Academy’s poverty policy and related initiatives, see "Letter from the President: We have solutions that can prevent, ameliorate poverty" and "New resource provides key messages about poverty, child health."