POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Poverty and Child Health in the United States COUNCIL ON COMMUNITY PEDIATRICS

Almost half of young children in the United States live in poverty or near abstract poverty. The American Academy of Pediatrics is committed to reducing and ultimately eliminating child poverty in the United States. Poverty and related social determinants of health can lead to adverse health outcomes in childhood and across the life course, negatively affecting physical health, socioemotional development, and educational achievement. The American Academy of Pediatrics advocates for programs and policies that have been shown to improve the quality of life and health outcomes for children and families living in poverty. With an awareness and understanding of the effects of poverty on children, pediatricians and other pediatric health practitioners in a family-centered medical home can assess the fi nancial stability of families, link families to resources, and coordinate care with community partners. Further research, advocacy, and continuing education This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have will improve the ability of pediatricians to address the social determinants fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process of health when caring for children who live in poverty. Accompanying this approved by the Board of Directors. The American Academy of policy statement is a technical report that describes current knowledge on Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. child poverty and the mechanisms by which poverty infl uences the health Policy statements from the American Academy of Pediatrics benefi t and well-being of children. from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course STATEMENT OF THE PROBLEM of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Poverty is an important social determinant of health and contributes to All policy statements from the American Academy of Pediatrics child health disparities. Children who experience poverty, particularly automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. during early life or for an extended period, are at risk of a host of adverse health and developmental outcomes through their life course.1 Poverty DOI: 10.1542/peds.2016-0339 has a profound effect on specific circumstances, such as birth weight, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). infant mortality, language development, chronic illness, environmental Copyright © 2016 by the American Academy of Pediatrics exposure, nutrition, and injury. Child poverty also influences genomic function and brain development by exposure to toxic stress, 2 a condition characterized by “excessive or prolonged activation of the physiologic To cite: AAP COUNCIL ON COMMUNITY PEDIATRICS. Poverty stress response systems in the absence of the buffering protection and Child Health in the United States. Pediatrics. 2016; 137(4):e20160339 afforded by stable, responsive relationships.”3 Children living in poverty

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 137 , number 4 , April 2016 :e 20160339 FROM THE AMERICAN ACADEMY OF PEDIATRICS are at increased risk of difficulties poverty during and immediately American Indian/Alaska Native with self-regulation and executive after the Great Recession of children are 3 times more likely to function, such as inattention, 2007–2009. A later 2014 report live in poverty than are white and impulsivity, defiance, and poor peer from the Organization for Economic Asian children.15 Infants and toddlers relationships.4 Poverty can make Cooperation and Development10 more commonly live in poverty than parenting difficult, especially in the ranked the United States 35th of 40 do older children. context of concerns about inadequate nations, only above Chile, Mexico, Children may be born into poverty, food, energy, transportation, and Romania, Turkey, and Israel. remain in a poor household housing. This policy statement specifically throughout childhood, or, most addresses child poverty in the United Child poverty is associated commonly, rotate in and out of States but reflects the 2015 United with lifelong hardship. Poor poverty over time. Approximately Nations’ Sustainability Goal to end developmental and psychosocial 37% of all children live in poverty poverty in all its forms everywhere.11 outcomes are accompanied by a for some period during their significant financial burden, not just According to 2014 Census data, an childhood.16 Children who are born for the children and families who estimated 21.1% of all US children into poverty and live persistently in experience them but also for the younger than 18 years (15.5 million) poor conditions are at greatest risk rest of society. Children who do not lived in households designated as of adverse outcomes. However, even complete high school, for example, “poor” (ie, in 2014, incomes below short-term spells of poverty can are more likely to become teenage 100% of the federal poverty level expose children to hardships, such as parents, to be unemployed, and to [FPL] of $24 230 for a family of food insecurity, housing insecurity/ be incarcerated, all of which exact 4*) and 42.9% (over 31.5 million) homelessness, loss of health care, and heavy social and economic costs.5 lived in households designated as school disruptions. A growing body of research shows “poor, near poor, or low income” Equality of opportunity is central to that child poverty is associated with (ie, incomes up to 200% of the FPL). the American dream and is reflected neuroendocrine dysregulation that Nearly 9.3% (6.8 million) lived in by social mobility or the potential may alter brain function and may households of deep poverty (ie, of intergenerational economic contribute to the development of incomes below 50% of the FPL).12 betterment. However, social mobility chronic cardiovascular, immune, and In 2014, an estimated 16 million is difficult to measure, because the psychiatric disorders.6 The economic children lived in families who usual method compares incomes cost of child poverty to society can received Supplemental Nutrition of 30-year-old persons against the be estimated by anticipating future Assistance Program (SNAP) incomes of their parents. Despite the lost productivity and increased benefits.13 Between 2007 and 2010, difficulties, most researchers agree social expenditure. A study compiled foreclosures affected 5.3 million that social mobility in the United before 2008 projected a total cost children.14 States has faltered as the wealth of approximately $500 billion each Demographics have a profound and opportunity gaps between year through decreased productivity influence on the likelihood that a rich and poor have widened in and increased costs of crime and family or community will experience the past decade. In comparison health care, 7 nearly 4% of the gross poverty or low income. For example, with European and other wealthy domestic product. Other studies of African American, Hispanic, and industrialized countries, social “opportunity youth,” young people mobility in the United States ranks 16 to 24 years of age who are neither * The FPL is determined by comparing a among the lowest.17 A 2015 Pew employed nor in school, derived family’s pretax cash income to an income Charitable Trusts report documented similar results, generating cohort poverty threshold that is 3 times the cost of that the effect of parental income aggregate lifetime costs in the a minimum food diet. This measure does not take into account government benefi ts (eg, advantage is persistent over all trillions.8 SNAP), income tax credits, or family expenses levels of parental income but is Child poverty is greater in the United (eg, child care, income taxes) and has not especially strong for children born to fundamentally changed since 1969 except for States than in most countries with annual adjustments for food price infl ation. In wealthy families. Persistent parental comparable resources. In a 2012 2010, the SPM was instituted to provide a more economic advantage means that a report from the United Nations comprehensive measure of a family’s fi nancial son’s income is strongly influenced Children’s Fund, 9 the United States circumstances. The SPM includes the value by his father’s, indicating low social ranked 34th of 35 member nations of certain federal in-kind benefi ts, federal tax mobility. The result is a dramatic benefi ts, and family expenses. For additional of the Organization for Economic details on these measures, see the accompanying decline of the possibility of economic 18 Cooperation and Development, technical report, “Mediators and Adverse Effects improvement for the poor. Poor a reflection of the rate of child of Child Poverty in the United States.” children tend to remain poor and live

Downloaded from www.aappublications.org/news by guest on October 3, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS in neighborhoods of low opportunity. improved understanding of the root effect of safety net programs Wealthy children continue to be causes and distal effects of poverty, has been demonstrably positive. wealthy as adults and enjoy academic pediatricians can apply interventions Longitudinal studies from 1967 to and employment advantages. in practice to help address the toxic 2012 that used the Supplemental The drag on social mobility resulting effects of poverty on children and Poverty Measure (SPM) revealed that from income and opportunity families. They also can advocate for government programs have had a inequality is even more striking for programs and policies to ameliorate significant effect on family poverty. people of color. During the recovery early childhood adverse events Without these programs, the rate of of the Great Recession, income related to poverty. Pediatricians child poverty would have increased inequality in the United States have the opportunity to screen to 31% in 2012, 13 percentage points accelerated, with 91% of the gains for risk factors for adversity, to more than the actual SPM child going to the top 1% of families.19 identify family strengths that are poverty rate of 18%. Therefore, the Left out of the recovery were African protective against toxic stress, and income supports and direct benefits American families who, during the to provide referrals to community provided by these government downturn, lost an average of 35% of organizations that support and programs have cut family poverty their accumulated wealth.20 African assist families in economic stress. almost in half, from an estimated 29 American unemployment increased, This policy statement builds on 31% to approximately 16%. home ownership decreased, and child previous policies related to child 26 Tax Policies and Direct Financial Aid poverty deepened to approximately health equity, housing insecurity, 27 3 46% of children younger than 6 and early childhood adversity. The earned income tax credit (EITC) years.21 Because social mobility The accompanying technical report is a refundable federal tax credit that is lowest for people in the lowest from the American Academy of helps low-income families. The EITC income quartile, half of African Pediatrics (AAP), “Mediators and helps reduce poverty by incentivizing American children who are poor as Adverse Effects of Child Poverty in employment and supplementing 28 young children will remain poor as the United States,” supports this income for low-wage workers. In adults, approximately twice as many statement by describing current 2012, 25 states had established as white adults similarly exposed to knowledge on childhood poverty and their own state-level credits to poverty as children.22 the mechanisms by which poverty supplement the federal credit.30 influences the health and well-being The Center on Budget and Policy Although legacy residential of children. Priorities estimates that the federal segregation and environmental EITC lifted 3.1 million children out racism persist as regions of deep of poverty in 2011.31 The EITC has poverty in mostly urban areas, 23 been shown to increase workforce the epidemiology of poverty has WHAT WORKS TO AMELIORATE THE EFFECTS OF CHILD POVERTY participation among single women shifted over the past decade, in part with children and help families pay because of the housing crisis and Programs that help poor families for basic essentials.32 Additional the Great Recession. Since 2008, and children take many forms and research also has connected the EITC suburbs have experienced larger often involve stakeholders from to improvements in infant health. and faster increases in poverty multiple communities, including An analysis of families who received than either urban or rural areas.24 governmental, private nonprofit, the largest EITC under the 1990s This significant shift in the location faith-based, business, and other expansions of the credit showed and demographics of children and philanthropic organizations. The lower rates of low birth weight families dealing with financial stress following paragraphs describe children, fewer preterm births, and makes necessary a reevaluation of several antipoverty and safety net increased prenatal care among these the current engagement and service programs that are particularly families.33 delivery systems that may not meet important for child health and this emerging need.25 well-being. These programs help The child tax credit provides tax Because pediatricians work to families by increasing access to cash, refunds to low-income working prevent childhood diseases during providing “near-cash” benefits, and families who pay payroll taxes health supervision visits and with investing in child development. but who might not owe federal anticipatory guidance, the early income tax. Although only partially detection and management of Individual program outcomes, refundable, this direct cash benefit poverty-related disorders is an including financial cost-benefit in 2012 helped approximately 1.6 important, emerging component estimates, are documented where million children and their families of pediatric scope of practice. With possible. However, the cumulative maintain an income above the FPL.34

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 137 , number 4 , April 2016 3 Taken together, the EITC and child of children are sensitive to family not able to realize this support for tax credit represent tax policies that income. In a 1999 analysis by the their children, because the credit is reduce childhood poverty and its Brookings Institute, statistically not refundable or paid to families effects. significant increases in math and before taxation.44 Therefore, some reading performance were associated of the most at-risk children who Temporary Assistance for Needy with only a $1000 increase in family might benefit from high-quality early Families (TANF) is a block grant annual income.38 A retrospective childhood education are not eligible program by which the federal review of population data drawn for financial support. government provides money from the Panel Study of Economic for states to fund work and Dynamics and covering the years Access to Comprehensive Health family support programs with 1968 to 2005 correlated the date Care specific goals and time limits. The of birth and family income during Personal Responsibility and Work Children in poverty who otherwise early childhood with eventual Reconciliation Act of 1996 (often would not have access to health care adult educational and economic referred to as welfare reform) have greatly benefited from Medicaid attainment. The results suggest created TANF to replace Aid to and the Children’s Health Insurance that an increase in annual family Families with Dependent Children, Program (CHIP) and many provisions income of only $3000 during early thereby creating block grants and protections of the Patient childhood may result in significant for state administration, work Protection and Affordable Care Act. improvements on both SAT scores requirements for eligibility, and From 1984 through 2013, the rate of and adult labor market success lifetime limits on receipt of federal uninsured poor children decreased measured by an earnings increase support. Because of unchanging by 70%, from approximately 29% of almost 20%. The association federal funding levels and limits to just over 8%. During the first 3 is strongest at the low end of the of the amount of time individuals months of 2014, the uninsured rate family income scale and becomes can access benefits, the number for poor children dropped further statistically nonsignificant for of families receiving TANF has to 6.6%.45 As a measure of benefit wealthy families.39 decreased, despite the increased from expanded coverage, children need since the Great Recession. enrolled in Medicaid or CHIP are Work requirements for cash and National TANF caseloads, especially more likely to access preventive other benefits have been advanced, those receiving cash benefits, have care than are uninsured children.46, especially since welfare reform in declined by 50% since 1996, with 47 In addition, CHIP has resulted in the 1990s, as a way to promote self- state caseload reductions varying a 9.8% increase in the coverage of sufficiency and reduce welfare rolls. from 25% to 80% despite the steadily children with chronic illness and a However, as a consequence of young increasing numbers of families in 6.4% decrease in uninsured children mothers being required to work, poverty and deep poverty.35 The in the general population.48 In 2009, infants may be placed in child care at latitude that states have to designate CHIP programs expanded access a very early age, and mothers often how the funds are used adds to the to comprehensive care by covering require a patchwork of solutions, limitation of TANF as a national dental, mental health, and substance some of which may be substandard.40 safety net program. abuse services in addition to medical Quality child care and early childhood and surgical care for all eligible near- Income stagnation in recent decades education are extremely important poor children.49 and the erosion of purchasing for the promotion of cognitive and power have contributed to the socioemotional development of Early Childhood Education financial instability of working poor infants and toddlers.41 Yet, child families.36 Raising the minimum care may cost as much as housing Early Head Start and Head Start are wage has been shown to help some in most areas of the United States, federally funded, community-based low-income families reach 200% of 25% of the budget of a family with programs for low-income families the FPL and to be considered out of 2 children, and infant care can cost with young children. Early Head poverty.37 The benefit to children of as much as college.42 Many working Start serves pregnant women and improved family income stability is families benefit from the dependent families with infants and toddlers both general and specific. Financial care tax credit for the cost of child up to 3 years of age; Head Start stability means that basic needs, care, allowing those families to place serves families with preschool- such as housing and transportation, their children in a certified or higher- aged children 3 to 5 years of age. are more dependable and family quality environment.43 However, In fiscal year 2011, the programs stress may be reduced. School working families who do not have served more than 900 000 children readiness and academic performance sufficient income to pay taxes are nationally, with a budget of $7

Downloaded from www.aappublications.org/news by guest on October 3, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS billion. These programs provide children. WIC provides nutrition depth of poverty for children in the educational, nutritional, health, and education, growth monitoring, and poorest of poor families.60 social services. In addition to child breastfeeding promotion and The National School Lunch Program care and preschool services, Early support in addition to food for is a federally funded program Head Start and Head Start offer pregnant and postpartum women, that provides low-cost and free prenatal education, job-training and infants, and children younger than breakfasts, lunches, and, on a limited adult education, and assistance in 5 years with incomes less than 185% basis, summer food to school-aged accessing housing and insurance.50 of the FPL.55 children. The federal program However, Early Head Start presently WIC is associated with improved supplies both public and private serves only approximately 3% of outcomes in pregnancy and early nonprofit schools with food and cash low-income families.51 The Child Care childhood development. A series incentives. The meals are produced Development Block Grants Act of of reports from the US Department in accordance with the Dietary 2014 and subsequent appropriations of Agriculture has shown that WIC Guidelines for Americans. In 2012, also provide child care subsidies for participation for low-income women 31.6 million children each day were low-income working families and decreased the rates of prematurity served low-cost and free lunches at a funds to improve child care quality, and infant mortality and increased total cost of $11.6 billion.61 Students in addition to new and needed involvement in prenatal care.56 The from families with an income less protections to keep children safe and promotion of breastfeeding has than 130% of the FPL are eligible healthy when they are being cared resulted in significant improvements to receive free meals, and those for outside the home.52 in the rate and duration of from families with an income less Early childhood interventions exclusive breastfeeding among than 185% of the FPL are eligible have been found to have a high WIC participants.57 Studies of the for reduced-price meals. A recent rate of return in both human and postinfancy period also have shown analysis estimated that, using these financial terms. Early interventions that WIC increases the quality of guidelines, more than half of all US in high-risk situations have the children’s diets, with increases in public school students are eligible to 62 highest return, presumably through micronutrient intake and resulting receive free or reduced-price meals. mitigating the effects of toxic stress decreases in iron-deficiency anemia. Nutrition support, such as WIC and by providing nurturance, stimulation, Children participating in WIC have SNAP, address undernutrition, but and nutrition. Child benefits include scored higher on assessments of other forms of malnutrition, such improved cognitive functioning, mental development at 2 years of as obesity, also may be responsive improved self-regulation, and age than similar children who were to supplemental programs. For advancement of development in all not participating in the program. In instance, a recent study in preschool- domains. Research as early as 2005 addition, children whose mothers aged children found that those who by the Rand Corporation found a participated in WIC when they participated in Head Start had a range of return on investment from were in utero have also been shown healthier BMI at school entry than $1.80 to $17 for each dollar spent on to perform better on reading did children who did not have the early childhood interventions.53 More assessments than similar children benefit of food provided by federal recent studies of preschool (birth of mothers who did not use the subsidy.63 to age 5 years) education estimate a program.58 Home Visiting return on investment as high as 14% SNAP, formerly referred to as per year on the basis of improved “food stamps,” uses an electronic The Maternal, Infant, and Early academic and occupation outcomes, benefits card to provide nutrition Child Home Visiting (MIECHV) in addition to lowered costs of assistance to low-income individuals Program was established as part remedial education and juvenile and families. As with other federal of the Affordable Care Act in 2010. 54 justice involvement. programs, eligibility depends It provides support for federal, on income, age, family size, and state, and community governments Nutrition Support citizenship. More than 45 million to implement established and The Supplemental Nutrition Program Americans currently receive SNAP proven home visiting programs for for Women, Infants, and Children benefits each month, including at-risk children. The stated goals of (WIC) is a federal assistance program approximately 20 million children.59 MIECHV are to improve maternal of the US Department of Agriculture Using the SPM, SNAP benefits reduce and newborn health; prevent that was first established in 1974 both the rate (decrease of 4.4% child injuries, abuse, neglect, or with the aim of improving the health attributable to SNAP from 2000 to maltreatment; reduce emergency of low-income women, infants, and 2009) and, more importantly, the department visits; improve school

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 137 , number 4 , April 2016 5 readiness and achievement; reduce into primary care, have been shown Early Identifi cation of Families in crime or domestic violence; improve to promote responsive parenting Need of Services family economic self-sufficiency; and and address common behavioral and To link families to services as improve coordination and referrals developmental concerns.69–73 Early early as possible, pediatricians for other community resources and literacy promotion in the medical can use screening tools that have 64 supports. home with programs such as Reach high sensitivity and specificity. Out and Read advances reading MIECHV has identified 19 evidence- The WE CARE survey78 is a brief readiness by approximately 6 months based interventions that target set of questions that alerts the when compared with controls.74 In families with pregnant mothers and pediatrician to families experiencing addition, parents in Reach Out and children younger than 5 years.65, 66 stress related to poverty. In the Read practices are 4 times as likely to One example of an MIECHV program policy statement “Promoting Food read to their children and more likely with evidence of success is the Security for All Children,” the AAP to spend time with their children in Nurse-Family Partnership. First-time, recommends the use of a 2-question interactive play75 than are families low-income mothers are enrolled survey that has a high sensitivity to who are not in Reach Out and during the prenatal period and detect food insecurity.79, 80 A single Read. Another program, the Video visited weekly by nurses trained in a question, “Do you have difficulty Interaction Project (VIP), combines validated curriculum beginning in the making ends meet at the end of early literacy with guided parent- second trimester. The benefit-cost the month?” may be enough to child interactions that support family ratio for high-risk mothers has been alert the pediatrician with 98% relationships and social development calculated at 5.68 to 1.67 sensitivity to a need for linking of children.70 families to community resources.81 Family and Parenting Support in the The AAP has promoted the Inquiring whether families have Medical Home National Center for Medical-Legal moved frequently in the past year or Programs designed for the pediatric Partnerships model, which provides have lived with another family for medical home provide opportunities legal aid collocated with health financial reasons will reveal housing 82 for low-cost, population-based services, especially to families in insecurity. poverty. A pilot study of medical- preventive intervention with low- Effective early identification of legal partnerships found that income families. An awareness families in need may facilitate addressing the social determinants of the protective factors that are prevention services, including of health by providing legal present in children and families can nutritional supplements for services and helping families help pediatricians to build on their young children, preventive health negotiate safety net organizations strengths during health promotion services, age-appropriate learning improves child health outcomes, conversations. A commonly used opportunities, and socioemotional reduces unnecessary urgent instrument to assess protective support of parents. Program visits, and raises overall child factors in high-risk families is evaluation has supported this well-being.76 available through the FRIENDS multifaceted approach in multiple 68 National Resource Center. The Care coordination, a fundamental countries and settings.83 Analyses Protective Factor Survey is used service of the medical home model, by Nobel Prize–winning economist to assess current status as well as can link families with community James Heckman reveal that early change over time in family resiliency, resources and support interagency prevention activities targeted toward social connectedness, quality of coordination to address basic disadvantaged children have high attachment, and knowledge of child concerns such as food and energy rates of economic returns, much development. insecurity. An example of a robust higher than remediation efforts In a medical home adapted to the case management initiative is later in childhood or adult life.84 needs of families in poverty, parents Health Leads,77 an enhanced For example, the Perry Preschool have the opportunities and resources primary care strategy that uses Program showed an average to promote resilience in their young college volunteers as advocates and rate of return of $8.74 for every children, giving them the capacity advanced resource management dollar invested in early childhood to adapt to adversity and buffering techniques, which has improved education.85 Targeted interventions the effects of stress. Healthy Steps coordination of care and utilization foster protective factors, including for Young Children, a manual-based of collocated social services by low- responsive, nurturing, cognitively primary care strategy, and programs income families with the intent of stimulating, consistent, and stable such as Incredible Years and Triple reducing the social barriers to good parenting by either birth parents P, which integrate behavioral health health. or other consistent adults. Early

Downloaded from www.aappublications.org/news by guest on October 3, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS childhood experiences that promote there may be new opportunities to importantly, making healthy relational health lead to secure restructure the health care delivery development of young children a attachment, effective self-regulation system in ways that can improve care national priority while addressing and sleep, normal development of for children in low-income families. social determinants of health helps the neuroendocrine system, healthy Policy decisions in other countries, families and communities build a stress-response systems, and positive such as the United Kingdom, foundation for lifelong health. changes in the architecture of the 91 also may inform these efforts. • Protect and expand funding developing brain.86, 87 Perhaps the Incentivizing care coordination and for essential benefits programs most important protective factors are team-based care may help more that assist low-income and poor those that attenuate the toxic stress children access quality health care children. Invest in children’s health effects of childhood poverty on early through patient- and family-centered and development by appropriately brain and child development.3,5, 88 medical homes (FCMHs). Medical funding evidence-based programs, homes also can help families address including Early Head Start and Interventions for Adolescents and unmet social and economic needs by Head Start, Medicaid, CHIP, WIC, Parents of Young Children using partners, such as community home visiting, SNAP, school meal health workers, within the health In recent years, there has been a programs and other programs care team.92, 93 As previously noted, growing focus on “2-generation” that increase access to healthy home visiting is supported through strategies to reduce poverty and food, and Child Care Development the MIECHV. improve outcomes for low-income Block Grant–funded programs. families. Two-generation strategies State reforms and integrated Streamline enrollment and renewal focus on helping low-income children health delivery systems in some processes for public benefit and their parents simultaneously regions are providing incentives programs.95 through high-quality interventions.89 for population health approaches, • Support 2-generation strategies For example, a 2-generation program facilitating collaboration in that focus on helping children and may enroll parents into job training healthy neighborhood initiatives.94 parents simultaneously. Promote at the same time as children are Collaborators with health care the coordination and alignment of enrolled into quality child care. This organizations may include education adult- and child-focused programs, type of approach aims to improve a systems, social services, faith- policies, and systems. family’s earning potential as well as based groups, and community the child’s developmental outcomes. development organizations. Although • Support and expand strategies Improved coordination of programs all children may benefit from greater that promote employment and and services for low-income families collaboration between health care that increase parental income. is essential to a 2-generation organizations and community Programs that increase low-income strategy. resources, children and in poor and parents’ earnings have been low-income families may experience shown to improve child outcomes. Recent research suggests that even greater gains. Support policies that help parents noncognitive skills, such as increase family income, including perseverance, empathy, and self- higher minimum wages, education efficacy, remain malleable during Opportunities for Public Policy Advocacy and job-training programs, and the adolescence90 and build on the EITC, child tax credit, and child and cognitive skills developed during Public policy efforts are needed to dependent care tax credit. early childhood. Interventions protect the health of children affected such as adolescent mentoring, by poverty and to help families • Support policy measures that residential training (eg, Job Corps), become economically secure. The improve community infrastructure, and workplace-based apprenticeship specific recommendations made in including affordable housing and programs can increase academic this and the following section are public spaces. Ensure that all achievement, employment based on positive outcomes in peer- children have safe outdoor play success, and other nonacademic reviewed literature or preliminary areas as well as healthy, safe, and accomplishments over the life span.90 studies that show sufficient promise affordable housing. that rigorous long-term evaluations • Improve access to quality health are underway. care and create incentives to RECOMMENDATIONS • Invest in young children. Funding improve population health As the health care system quality early childhood programs with the goal of reducing health increasingly focuses on efforts to can have a significant financial disparities. Strategies to improve improve quality and contain costs, return on investment, but more quality and reduce costs should

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 137 , number 4 , April 2016 7 include care coordination and is necessary to quantify the extent maternal depression, is within the team-based care that help families of poverty in the United States and scope of practice for community address nonmedical health-related its effects on children and families pediatricians and that the effects concerns, such as food, housing, so that effective responses can be of toxic stress on children can be and utilities. Pediatricians and developed and promoted. ameliorated by supportive, secure health care systems should be relational health during early • Support a comprehensive encouraged to partner with childhood. research agenda to improve the other stakeholders to advance understanding of the effects • Screen for risk factors within social community-level strategies of poverty on children and to determinants of health during that improve health and reduce identify and refine interventions patient encounters. Practices disparities among populations of that improve child health can use a brief written screener varying income levels. outcomes. Research is needed to or verbally ask family members • Enhance health care financing identify better ways to measure questions about basic needs, to support comprehensive care how poverty affects children, such as food, housing, and heat. for at-risk families. All benefit what works to help families in Screening for basic needs can help plans should include coverage for poverty, and how to translate uncover not only obvious but also enhanced services in the medical the information gained into real less apparent economic difficulties home for families in poverty. Care solutions for the poor. experienced by families. As patient- coordination, team-delivered care, centered medical homes continue and coverage for mental health Opportunities for Community to develop, care coordinators will services provided by pediatricians Practice fulfill the role of community liaison are examples of these enhanced The following recommendations for families in poverty, connecting services. address how individual pediatricians them with needed resources. can support the health and well- • • Make a national commitment to Consider implementing integrated being of children living in poverty. fully fund home visiting programs medical home programs, such as Adaptations of the medical home to for all children living in low-income Healthy Steps, Reach Out and Read, acknowledge the complex challenges or poor households. The Bureau Health Leads, and VIP, in addition that confront poor families require of Maternal and Child Health has to primary care integration with surveillance on the part of the identified 19 programs, including mental health interventions practitioner of both risk and but not limited to Nurse-Family such as Incredible Years and protective factors that characterize Partnership, Early Head Start, Triple P. These programs help each family. Healthy Families America, and parents develop the capacity and Parents as Teachers, that target • Create a medical home that confidence to build resilience families with pregnant women or acknowledges and is sensitive in their children and improve children younger than 5 years. to the needs of families living the ability of the family to cope in poverty. Although every with adversity. Bright Futures • Support integrated models of family wants to provide the guidelines provide the most care in the medical home that best resources and care to their comprehensive recommendations promote effective parenting and children, economic barriers can for health supervision and are school readiness, such as Healthy stand in the way. All members of enhanced by strategies to advance Steps, Reach Out and Read, the care team and practice should behavioral health care into the VIP, Incredible Years, Medical become familiar with some of the pediatric medical home and to Legal Partnerships, and Positive common challenges faced by poor address the social determinants of Parenting Program. Both Medicaid families. Recognizing problems health. and education funding agencies such as transportation barriers, • Identify and build on family should provide support in the difficult work schedules, and strengths and protective factors. medical home for parenting and competing financial issues can help Although families in poverty face literacy promotion. practices effectively communicate many challenges, each family • Improve national poverty and partner with families. An has strengths, capabilities, and definitions and measures. The enhanced medical home providing protective factors. Pediatricians FPL underestimates the extent integrated care for families can strive to identify and build on and depth of poverty in the in poverty is informed by the protective factors within families, United States. The SPM is an understanding that emotional care such as cohesion, humor, support improvement, but more research of the family, including recognizing networks, skills, and spiritual and

Downloaded from www.aappublications.org/news by guest on October 3, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS cultural beliefs.96, 97 By approaching state and local levels. Pediatricians CONCLUSIONS families from a strengths-based and the AAP should be aware Poverty and other adverse social perspective, pediatricians can help that the MIECHV continually determinants have a detrimental build trust and identify the assets reviews home visiting programs effect on child health and are root on which a family can draw to for inclusion in the MIECHV and causes of child health inequity effectively address problems and can submit programs for review in the United States. Knowledge care for their children. that they have found successful. is expanding rapidly, especially Opportunities for enhanced • Collaborate with community regarding the neurobiological effects communication between the organizations to help families of poverty and related environmental FCMH and home-visiting programs address unmet basic needs and stressors on the developing human may be explored, including the assist with family stressors. When brain as well as the life course of possibility of collocation of visitors unmet basic needs and poverty- chronic illness. Understanding in the FCMH as an integrated associated risks are identified, the causative relation between service model. pediatricians can refer families to early childhood poverty and adult appropriate community services • Support community programs that health status should inform and and public programs. Key partners enhance the involvement of fathers influence the decisions of policy may include local and state public in the lives of their children. makers, researchers, and community health departments, legal services, Pediatricians can be an important pediatricians. The evidence strongly social work organizations, food support resource and advocate suggests that the FCMH with its pantries, faith-based organizations, for community-based fatherhood enhanced capabilities is an essential and community development initiatives. When possible, asset in efforts to ameliorate the organizations. Some communities nonresidential fathers should be adverse effects of poverty on also may have innovative financial involved in all aspects of pediatric children. literacy programs that are care. 98 The AAP considers child poverty in helpful. Practices may partner • Advance strategies to address with local home visiting programs, the United States unacceptable and family and child mental health detrimental to the health and well- community mental health services, and development. Pediatricians and parent support groups that can being of children and is committed are strongly encouraged to to its elimination. The AAP calls for help families address parenting include routine screening for challenges and other stressors. concerted action by its state maternal depression at every chapters as well as governmental, • Engage with early intervention health supervision visit during the private, nonprofit, faith-based, programs and schools to first year of life and to be able to philanthropic, and other advocacy promote learning and academic provide an appropriate referral organizations to reduce child poverty achievement. Education for treatment when depression by supporting and expanding professionals are often very is suspected. Pediatricians existing programs that have involved in efforts to help children can advocate for increased been shown to work and to make from low-income backgrounds resources to address mental efforts to develop, identify, and with academic achievement and health and behavioral issues in promote other potentially effective also may participate in initiatives poor communities, including policies and programs. In 1935, focused on basic needs, such separate payment for screening for the US Congress passed the Social as feeding programs, clothing parental depression and for care Security Act and in 1965 enacted drives, and health screenings. coordination activities. Medicare. Together, these 2 pieces Pediatricians can actively • Advocate for public policies that of legislation have greatly reduced participate with these efforts support all children and help and nearly eliminated poverty in the as well as early intervention mitigate the effects of poverty elderly. It is time to enact similar programs, after-school programs, on child health. Pediatricians can reforms to eliminate child poverty. tutoring programs, and social serve as important advocates for By embracing the policies and services provided through the policies that help children and enacting the recommendations in school district. families in poverty. Pediatricians this statement, the AAP joins with • Promote the MIECHV program. can add a unique voice to poverty- governmental, philanthropic, private, Pediatricians should be familiar related advocacy by reframing and other health care organizations with local MIECHV programs and poverty as an evidence-based in a concerted and dedicated effort to how to connect their patients with health concern with lifelong health, eliminate child poverty in the United home visiting programs on the social, and economic consequences. States.

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 137 , number 4 , April 2016 9 ACKNOWLEDGMENTS CONSULTANT REFERENCES We acknowledge the following Anne Brown Rodgers, Science Writer 1. Brooks-Gunn J, Duncan GJ. The effects of poverty on children. Future Child. University of California–Los Angeles STAFF 1997;7(2):55–71 pediatric and med-peds residents Camille Watson, MS for their research contributions to 2. Blair C, Granger DA, Willoughby M, this policy statement: Natalie Cerda, COMMITTEE ON PSYCHOSOCIAL ASPECTS et al; FLP Investigators. Salivary MD, Jeremy Lehman Fox, MD, Neil A. OF CHILD AND FAMILY HEALTH, 2015–2016 cortisol mediates effects of poverty Gholkar, MD, Lydia Soo-Hyun Kim, Michael Yogman, MD, FAAP, Chairperson and parenting on executive functions MD, MPH, Rachel J. Klein, MD, Ashley Nerissa Bauer, MD, MPH, FAAP in early childhood. Child Dev. 2011;82(6):1970–1984 E. Lewis Hunter, MD, Sarah J. Maufe, Thresia B. Gambon, MD, FAAP Arthur Lavin, MD, FAAP 3. Garner AS, Shonkoff JP; Committee MD, Colin L. Robinson, MD, MPH, Keith M. Lemmon, MD, FAAP on Psychosocial Aspects of Child and Joseph R. Rojas, MD, and Weiyi Tan, Gerri Mattson, MD, FAAP MD, MPH. Jason Richard Rafferty, MD, MPH, EdM Family Health; Committee on Early Lawrence Sagin Wissow, MD, MPH, FAAP Childhood, Adoption, and Dependent Care; Section on Developmental and LEAD AUTHORS LIAISONS Behavioral Pediatrics. Early childhood James H. Duffee, MD, MPH, FAAP Sharon Berry, PhD, LP – Society of Pediatric adversity, toxic stress, and the role Alice A. Kuo, MD, PhD, FAAP Psychology of the pediatrician: translating Benjamin A. Gitterman, MD, FAAP Terry Carmichael, MSW – National Association of developmental science into lifelong Social Workers health. Pediatrics. 2012;129(1). COUNCIL ON COMMUNITY PEDIATRICS Edward Christophersen, PhD, FAAP – Society of Available at: www.pediatrics. org/ cgi/ EXECUTIVE COMMITTEE, 2015–2016 Pediatric Psychology content/ full/ 129/ 1/ e224 Norah Johnson, PhD, RN, CPNP-BC – National Benjamin A. Gitterman, MD, FAAP, Chairperson 4. Boyle CA, Boulet S, Schieve LA, et Patricia J. Flanagan MD, FAAP, Vice-Chairperson Association of Pediatric Nurse Practitioners al. Trends in the prevalence of William H. Cotton, MD, FAAP Leonard Read Sulik, MD, FAAP – American Kimberley J. Dilley, MD, MPH, FAAP Academy of Child and Adolescent Psychiatry developmental disabilities in US James H. Duffee, MD, MPH, FAAP children, 1997-2008. Pediatrics. Andrea E. Green, MD, FAAP CONSULTANT 2011;127(6):1034–1042 Virginia A. Keane, MD, FAAP George J. Cohen, MD, FAAP 5. Belfi eld CR, Levin HM, eds. The Scott D. Krugman, MD, MS, FAAP Price We Pay: Economic and Social Julie M. Linton, MD, FAAP STAFF Carla D. McKelvey, MD, MPH, FAAP Consequences of Inadequate Jacqueline L. Nelson, MD, FAAP Stephanie Domain, MS, CHES Education. Washington, DC: Brookings Press; 2007 LIAISONS ABBREVIATIONS 6. Shonkoff JP, Garner AS; Committee Jacqueline R. Dougé, MD, MPH, FAAP – on Psychosocial Aspects of Child and Chairperson, Public Health Special Interest Group AAP: American Academy of Family Health; Committee on Early Janna Gewirtz O’Brien, MD – Section on Medical Pediatrics Childhood, Adoption, and Dependent Students, Residents, and Fellowship Trainees CHIP: Children’s Health Care; Section on Developmental and Insurance Program Behavioral Pediatrics. The lifelong FORMER EXECUTIVE COMMITTEE MEMBERS EITC: earned income tax credit effects of early childhood adversity and Lance A. Chilton, MD, FAAP FCMH: family-centered medical toxic stress. Pediatrics. 2012;129(1). Thresia B. Gambon, MD, FAAP home Available at: www.pediatrics. org/ cgi/ Alice A. Kuo, MD, PhD, FAAP content/ full/ 129/ 1/ e232 Gonzalo J. Paz-Soldan, MD, FAAP FPL: federal poverty level Barbara Zind, MD, FAAP MIECHV: Maternal, Infant, and 7. Holzer H, Schanzenbach DW, Duncan Early Child Home GJ, Ludwig J. The economic costs of FORMER LIAISONS Visiting childhood poverty in the United States. J Child Poverty. 2008;14(1):41–61 Toluwalase Ajayi, MD – Section on Medical SNAP: Supplemental Nutrition Students, Residents, and Fellowship Trainees Assistance Program 8. Belfi eld CR, Levin HM, Rosen R. The Ricky Y. Choi, MD, MPH, FAAP – Chairperson, SPM: Supplemental Poverty economic value of opportunity youth. Immigrant Health Special Interest Group Measure Washington, DC: Corporation for Frances J. Dunston, MD, MPH, FAAP – Commission National and Community Service; to End Health Care Disparities TANF: Temporary Assistance for 2012. Available at: www. serve. gov/ M. Edward Ivancic, MD, FAAP – Chairperson, Rural Needy Families new- images/ council/ pdf/ econ_ value_ Health Special Interest Group VIP: Video Interaction Project opportunity_ youth. pdf. Accessed WIC: Supplemental Nutrition CONTRIBUTORS January 11, 2016 Program for Women, John M. Pascoe, MD, MPH, FAAP Infants, and Children 9. UNICEF Innocenti Research Centre. David Wood, MD, MPH, FAAP Measuring child poverty: new league

Downloaded from www.aappublications.org/news by guest on October 3, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS tables of child poverty in the world’s Trusts, Russell Sage Foundation; 2015. 29. Fox L, Garfi nkel I, Kaushal N, Waldfogel rich countries. Florence, Italy: UNICEF Available at: www.pewtrusts. org/ ~/ J, Wimer C. Waging War on Poverty: Innocenti Research Centre; 2012. media/ assets/ 2015/ 07/ fsm- irs- report_ Historical Trends in Poverty Using Innocenti Report Card 10. Available at: artfi nal. pdf. Accessed December 27, the Supplemental Poverty Measure. www.unicef- irc. org/ publications/ pdf/ 2015 Cambridge, MA: National Bureau of rc10_ eng. pdf. Accessed January 11, 19. Saez E. Striking it richer: the evolution Economic Research; 2014. Working 2016 of top incomes in the United States. Paper 19789. Available at: www. nber. org/ papers/ w19789. Accessed July 31, 10. Organization for Economic Cooperation Berkeley, CA: University of California 2015 and Development. Child poverty. Berkeley; 2015. Available at: http:// Available at: www.oecd. org/ els/ soc/ eml. berkeley. edu/ ~saez/ saez- 30. Center on Budget and Policy Priorities. CO2_ 2_ ChildPoverty_ Jan2014. pdf. UStopincomes- 2013. pdf. Accessed Policy basics: the earned income tax Accessed January 11, 2016 December 27, 2015 credit. January 2014. Available at: www.cbpp. org/ fi les/policybasics- eitc. 11. United Nations. Sustainable 20. Stiglitz J. Inequality in America: a policy pdf. Accessed July 31, 2015 Development Goals. Goal 1: end poverty agenda for a stronger future. Ann Am in all its forms everywhere. Available Acad Pol Soc Sci. 2015;657(1):8–20 31. Center on Budget and Policy Priorities. Earned income tax credit promotes at: www.un. org/ sustainabledevelo pment/ 21. Economic Policy Institute. The state work, encourages children’s success poverty/ . Accessed January 11, 2016 of working America: key numbers. at school, research fi nds. April 2013. 12. DeNavas-Walt C, Proctor BD; US Census African Americans. Available at: http:// Available at: www.cbpp. org/ fi les/6- 26- Bureau. Current population reports, stateofworkingame rica. org/ fi les/ book/ 12tax. pdf\. Accessed July 31, 2015 P60-252, income and poverty in the factsheets/ african- americans. pdf. United States: 2014. Washington, DC: Accessed December 27, 2015 32. Leibman J. The impact of the earned income tax credit on incentives and US Government Printing Offi ce; 2015 22. Wagmiller RL, Adelman RM. Childhood income distribution. In: Poterba and intergenerational poverty. New 13. US Census Bureau. One in fi ve children JM, ed. Tax Policy and the Economy. York, NY: National Center for Children receive food stamps, Census Bureau Cambridge, MA: MIT Press; 1998: in Poverty; 2009. Available at: www. reports. Available at: www. census. gov/ 83–120 newsroom/ press- releases/ 2015/ cb15- nccp.org/ publications/ pub_ 909. html. 16. html. Accessed September 28, 2015 Accessed December 27, 2015 33. Hoynes HW, Miller DL, Simon D. The EITC: linking income to real health 23. Bolin B, Grineski S, Collins T. The 14. Kids Count Data Center. 2011 Kids outcomes [policy brief]. Davis, CA: geography of despair. Hum Ecol Rev. Count Data Book. Available at: http:// University of California Davis Center 2005;12(2):156–168 datacenter.kidscount. org. Accessed for Poverty Research; 2013. Available July 31, 2015 24. Kneebone B. Confronting Suburban at: http:// poverty.ucdavis. edu/ 15. The Annie E. Casey Foundation. 2013 Poverty in America. Washington, DC: research- paper/ policy- brief- linking- Kids Count Data Book. Available Brookings Press; 2013 eitc- income- real- health- outcomes. at: www.aecf. org/ MajorInitiatives/ 25. Joint Center’s Health Policy Institute. Accessed July 31, 2015 KIDSCOUNT.aspx? rules= 2. Accessed Building stronger communities for 34. Center on Budget and Policy Priorities. July 31, 2015 better health. 2004. Available at: www. Policy basics: the child tax credit. 16. Ratcliffe C, McKernan SM. Childhood racialequitytools . org/ resourcefi les/ January 2014. Available at: www. cbpp. poverty persistence: facts and jointcenter3. pdf. Accessed December org/fi les/policybasics- ctc. pdf. Accessed consequences. Urban Institute Brief. 28, 2015 July 31, 2015 June 2010. Available at: www. urban. 26. Council on Community Pediatrics and 35. Center on Budget and Policy Priorities. org/UploadedPDF/ 412126- child- poverty- Committee on Native American Child TANF weakening as a safety-net for persistence. pdf. Accessed July 31, 2015 Health. Policy statement—health poor families. March 2012. Available 17. Isaacs JB. International comparisons equity and children’s rights. Pediatrics. at: www.cbpp. org/ fi les/3- 13- 12tanf. pdf. of economic mobility. In: Isaacs JB, 2010;125(4):838–849 Accessed July 31, 2015 Sawhill IV, Haskins R, eds. Getting 27. Council on Community Pediatrics. 36. Hernandez DJ. Declining fortunes ahead or losing ground: economic Providing care for children and of children in middle-class families: mobility in America. Washington, DC: adolescents facing homelessness economic inequality and child well- The Brookings Institution; 2008:37–44. and housing insecurity. Pediatrics. being in the 21st century. New York, Available at: www.brookings. edu/ ~/ 2013;131(6):1206–1210 NY: Foundation for Child Development; media/ Research/ Files/ Reports/ 2008/ 28. Pascoe JM, Wood DL, Kuo A, Duffee JH; 2011. Available at: http:// fcd-us. 2/ economic%20 mobility%20 sawhill/ Committee on Psychosocial Aspects org/sites/ default/ fi les/2011%20 02_ economic_ mobility_ sawhill. pdf. of Child and Family Health; Council Declining%20 Fortunes_ 0. pdf. Accessed Accessed January 11, 2016 on Community Pediatrics. Mediators July 31, 2015 18. Mitnik PA, Grusky DB. Economic and adverse effects of child poverty 37. Dube A. Minimum wages and the mobility in the United States. 2015. in the United States. Pediatrics. distribution of family incomes. Philadelphia, PA: Pew Charitable 2016;137(4):e20160340 UMass Amherst Working Paper.

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 137 , number 4 , April 2016 11 2013. Available at: https:// dl. 46. Abdus S, Selden TM. Adherence with Available at: www.fns. usda. gov/ wic/ dropboxuserconten t. com/ u/ 15038936/ recommended well-child visits has howtoapply/ eligibilityrequir ements. Dube_ MinimumWagesFamil yIncomes. grown, but large gaps persist among htm. Accessed July 31, 2015 pdf. Accessed July 31, 2015 various socioeconomic groups. Health 56. Colman S, Nichols-Barrer IP, Redline Aff (Millwood). 2013;32(3):508–515 38. Issacs JB, Magnuson K. Income and JE, Devaney BL, Ansell SV, Joyce T. education as predictors of children’s 47. Perry CD, Kenney GM. Preventive care Effects of the Special Supplemental school readiness. Washington, DC: for children in low-income families: Nutrition Program for Women, Infants, Brookings Institute; 2011. Available at: how well do Medicaid and state and Children (WIC): a review of www.brookings. edu/ research/ reports/ children’s health insurance programs recent research. Alexandria, VA: US 2011/ 12/ 15- school- readiness- isaacs. do? Pediatrics. 2007;120(6). Available Department of Agriculture, Food and Accessed July 31, 2015 at: www.pediatrics. org/ cgi/ content/ Nutrition Service; 2012. Report WIC- 39. Duncan GJ, Ziol-Guest KM, Kalil A. full/ 120/ 6/ e1393 12-WM. Available at: www.mathematica- mpr.com/ ~/ media/ publications/ pdfs/ Early-childhood poverty and adult 48. Howell EM, Kenney GM. The impact nutrition/ wic_ research_ review. pdf. attainment, behavior, and health. Child of the Medicaid/CHIP expansions on Accessed January 11, 2016 Dev. 2010;81(1):306–325 children: a synthesis of the evidence. 40. Knox V, London A, Scoot E. Welfare Med Care Res Rev. 2012;69(4):372–396 57. Suchman A, Mendelson M, Patlan KL, Freeman B, Gotlieb R, Connor reform, work, and child care. MDRC 49. Racine AD, Long TF, Helm ME, et al; P. WIC Participant and Program policy brief. 2003. Available at: Committee on Child Health Financing. Characteristics 2012. Prepared by www.mdrc. org/ sites/ default/ fi les/ Children’s Health Insurance Program Insight Policy Research under contract policybrief_ 40. pdf. Accessed July 31, (CHIP): accomplishments, challenges, no. AG-3198-C-11-0010. Alexandria, 2015 and policy recommendations. VA: Food and Nutrition Service, US Pediatrics. 2014;133(3). Available at: 41. Cohen J, Ewen D. Infants and toddlers Department of Agriculture; 2013 in child care [policy brief]. Washington, www.pediatrics. org/ cgi/ content/ full/ DC: Zero to Three; 2008. Available 133/ 3/ e784 58. Jackson MI. Early childhood WIC participation, cognitive development at: http:// main. zerotothree. org/ site/ 50. Head Start Program. Head Start and academic achievement. Soc Sci DocServer/ Infants_ and_ Toddlers_ Program facts fi scal year 2011. Med. 2015;126:145–153 in_ Child_ Care_ Brief. pdf? docID= 6561. Available at: http:// eclkc. ohs. acf. hhs. Accessed July 31, 2015 gov/ hslc/ mr/ factsheets/ 2011- hs- 59. Executive Offi ce of the President of the 42. Allegretto S. Basic family budgets: program-factsheet. html. Accessed July United States. Long-term benefi ts of working families’ incomes often fail 31, 2015 the Supplemental Nutrition Assistance Program. December 2015. Available to meet living expenses around the 51. DiLaruro E. Learning, thriving and at: https:// www. whitehouse. gov/ sites/ U.S. Economic Policy Institute; 2005. ready to succeed. Zero to Three; 2009. whitehouse. gov/ fi les/ documents/ Available at: www.epi. org/ publication/ Available at: http:// main. zerotothree. SNAP_ report_ fi nal_ nonembargo. pdf. bp165/ . Accessed July 31, 2015 org/site/ DocServer/ EHSsinglesMar5. Accessed January 11, 2016 43. MacGillvary J, Lucia L. Economic pdf? docID= 7884. Accessed July 31, 2015 impacts of early care and education 60. US Department of Agriculture, 52. Administration for Children and in California. Berkley, CA: UC Berkley Economic Research Service. SNAP Families, Offi ce of Child Care. OCC Center for Labor Research and benefi ts alleviate the intensity and fact sheet. Available at: www.acf. hhs. Education; 2011. Available at: http:// incidence of poverty. Available at: www. gov/ programs/ occ/ fact- sheet- occ. laborcenter.berkeley. edu/ pdf/ 2011/ ers. usda. gov/ amber- waves/ 2012- june/ Accessed January 19, 2016 child_ care_ report0811. pdf. Accessed snap- benefi ts. aspx#. VolJcBHVStV. July 31, 2015 53. Karoly LA, Kilburn MR, Cannon JS. Accessed January 11, 2016 Proven benefi ts of early childhood 44. Tax Policy Center. Taxation and the 61. US Department of Agriculture, Food interventions [research brief]. Santa family. How does the tax system and Nutrition Service. National School Monica, CA: Rand Corporation; 2005. subsidize child care expenses? 2015. Lunch Program. Available at: www. Available at: www.rand. org/ content/ Available at: www. taxpolicycenter.org/ fns. usda. gov/ sites/ default/ fi les/ dam/rand/ pubs/ research_ briefs/ 2005/ briefi ng-book/ key- elements/ family/ NSLPFactSheet. pdf. Accessed July 31, RAND_ RB9145. pdf. Accessed July 31, child-care- subsidies. cfm. Accessed 2015 2015 July 31, 2015 62. Southern Education Foundation. A 54. Heckman JJ. The case for investing in 45. National Health Interview Survey Early New Majority Research Bulletin: low disadvantaged young children. In: Big Release Program. Health insurance income students now a majority in the Ideas for Children: Investing in Our coverage: early release of estimates nation’s public schools. Atlanta, GA: Nation’s Future. Washington, DC: First from the National Health Interview Southern Education Foundation; 2015. Focus; 2008:49–58 Survey, January–March 2014. Available at: www. southerneducation Available at: www.cdc. gov/ nchs/ data/ 55. Special Supplemental Nutrition .org/ Our- Strategies/ Research- nhis/ earlyrelease/ insur201409. pdf. Program for Women, Infants, and and- Publications/ New- Majority- Accessed January 11, 2016 Children. WIC eligibility requirements. Diverse- Majority- Report- Series/

Downloaded from www.aappublications.org/news by guest on October 3, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS A- New- Majority- 2015- Update- Low- Pediatrics. 2007;120(3). Available at: 81. Brcic V, Eberdt C, Kaczorowski J. Income- Students- Now. Accessed July www.pediatrics. org/ cgi/ content/ full/ Development of a tool to identify 31, 2015 120/ 3/ e658 poverty in a family practice setting: a pilot study. Int J Family Med. 63. Lumeng JC, Kaciroti N, Sturza 72. Perrin EC, Sheldrick RC, McMenamy 2011;2011:812182 J, et al. Changes in body mass JM, Henson BS, Carter AS. Improving index associated with head start parenting skills for families of young 82. Cutts DB, Meyers AF, Black MM, et al. participation. Pediatrics. 2015;135(2). children in pediatric settings: a US housing insecurity and the health Available at: www.pediatrics. org/ cgi/ randomized clinical trial. JAMA Pediatr. of very young children. Am J Public content/ full/ 135/ 2/ e449 2014;168(1):16–24 Health. 2011;101(8):1508–1514 64. US Department of Health and Human 73. Bauer NS, Webster-Stratton C. 83. Shonkoff JP, Richter L, van der Gaag Services. Maternal, Infant, and Early Prevention of behavioral disorders J, Bhutta ZA. An integrated scientifi c Childhood Home Visiting Program. in primary care. Curr Opin Pediatr. framework for child survival and early Available at: http:// mchb. hrsa.gov/ 2006;18(6):654–660 childhood development. Pediatrics. programs/ homevisiting/ index. html. 2012;129(2). Available at: www. 74. Diener ML, Hobson Rohrer W, Byington Accessed July 31, 2015 pediatrics. org/ cgi/ content/ full/ 129/ 2/ CL. Kindergarten readiness and e460 65. Health Resources and Services performance of Latino children Administration. Home visiting models. participating in Reach Out and Read. 84. Heckman JJ. Skill formation and Available at: http:// mchb. hrsa.gov/ J Community Med Health Educ. the economics of investing in programs/ homevisiting/ models. html. 2012;2:133 disadvantaged children. Science. Accessed July 31, 2015 2006;312(5782):1900–1902 75. Mendelsohn AL, Mogilner LN, 66. Avellar S, Paulsell D, Sama-Miller Dreyer BP, et al. The impact of a 85. Barnett WS. Benefi t-cost analysis of E, Del Grosso P, Akers L, Kleinman clinic-based literacy intervention preschool education. 2004. Available R. Home visiting evidence of on language development in inner- at: http://nieer. org/ resources/ fi les/ effectiveness review: executive city preschool children. Pediatrics. BarnettBenefi ts. ppt. Accessed July 31, summary. Washington, DC: Offi ce of 2001;107(1):130–134 2015 Planning, Research and Evaluation, 76. Weintraub D, Rodgers MA, Botcheva 86. Yoshikawa H, Aber JL, Beardslee WR. Administration for Children and L, et al. Pilot study of medical-legal The effects of poverty on the mental, Families, US Department of Health and partnership to address social and emotional, and behavioral health Human Services; 2015. Available at: legal needs of patients. J Health of children and youth: implications http:// homvee. acf. hhs. gov/ HomVEE_ Care Poor Underserved. 2010;21(2 for prevention. Am Psychol. Executive_ Summary_ 2015. pdf. suppl):157–168 2012;67(4):272–284 Accessed January 3, 2016 77. Vasan A, Solomon BS. Use of colocated 87. McEwen BS, Gianaros PJ. Central role 67. Olds D. The nurse–family partnership: multidisciplinary services to of the brain in stress and adaptation: an evidence-based preventive address family psychosocial needs links to socioeconomic status, health, intervention. Infant Ment Health J. at an urban pediatric primary and disease. Ann N Y Acad Sci. 2006;27(1):5–25 care clinic. Clin Pediatr (Phila). 2010;1186:190–222 68. National Center for Community-Based 2015;54(1):25–32 88. Johnson SB, Riley AW, Granger DA, Riis Child Abuse Prevention. Protective 78. Garg A, Butz AM, Dworkin PH, Lewis J. The science of early life toxic stress Factors Survey. Available at: http:// RA, Thompson RE, Serwint JR. for pediatric practice and advocacy. friendsnrc. org/ protective- factors- Improving the management of family Pediatrics. 2013;131(2):319–327 survey. Accessed July 31, 2015 psychosocial problems at low-income 89. Woodrow Wilson School of Public 69. Zuckerman B. Promoting early literacy children’s well-child care visits: and International Affairs at Princeton in pediatric practice: twenty years the WE CARE Project. Pediatrics. University; Brookings Institution. of reach out and read. Pediatrics. 2007;120(3):547–558 Helping parents, helping children: 2009;124(6):1660–1665 79. Council on Community Pediatrics; two-generation mechanisms. Future 70. Mendelsohn AL, Dreyer BP, Brockmeyer Committee on Nutrition. Promoting Child. 2014;24(1):1–170. Available at: CA, Berkule-Silberman SB, Morrow food security for all children. www.princeton. edu/ futureofchildren/ LM. Fostering early development and Pediatrics. 2015;136(5). Available at: publications/ journals/ journal_ details/ school readiness in pediatric settings. www.pediatrics. org/ cgi/ content/ full/ index. xml? journalid= 81. Accessed In: Dickinson D, Neuman SB, eds. 136/ 5/ e1431 January 11, 2016 Handbook of Early Literacy Research. 80. Hager ER, Quigg AM, Black MM, et al. 90. Heckman JJ, Kautz T. Fostering and Vol. 3. New York, NY: Guilford; Development and validity of a 2-item measuring skills: interventions that 2011:279–294 screen to identify families at risk for improve character and cognition. In: 71. Minkovitz CS, Strobino D, Mistry KB, et food insecurity. Pediatrics. 2010;126(1). Heckman JJ, Humphries JE, Kautz T, al. Healthy Steps for Young Children: Available at: www.pediatrics. org/ cgi/ eds. The Myth of Achievement Tests: sustained results at 5.5 years. content/ full/ 126/ 1/ e26 The GED and the Role of Character in

Downloaded from www.aappublications.org/news by guest on October 3, 2021 PEDIATRICS Volume 137 , number 4 , April 2016 13 American Life. Chicago, IL: University of 93. Rosenthal EL, Brownstein JN, Rush CH, and Families; Offi ce of Head Start; Chicago Press; 2014:293–317 et al. Community health workers: part USA.gov. Training guides for the Head of the solution. Health Aff (Millwood). Start Learning Community: abstracts. 91. Waldfogel J. Tackling child poverty 2010;29(7):1338–1342 2000. Available at: http:// eclkc. ohs. and improving child well-being: acf. hhs. gov/ hslc/ tta- system/ pd/ pds/ lessons from Britain. Report for 94. Nationwide Children’s. Healthy Cultivating%20 a%20 Learning%20 First Focus and Foundation for Child neighborhoods, healthy families. Organization/TrainingGuidesf. htm. Development. 2010. Available at: http:// Available at: www. nationwidechildre Accessed July 31, 2015 fcd-us. org/ resources/ tackling- child- ns.org/ healthy- neighborhoods- healthy- poverty- and- improving- child- well- families. Accessed July 31, 2015 97. Center for the Study of Social Policy; being- lessons- britain. Accessed July 95. The Annie E. Casey Foundation. American Academy of Pediatrics. 31, 2015 Improving access to public benefi ts Primary health partners. Promoting children’s health and resiliency: a 92. Antonelli RC, McAllister JW, Popp J. helping eligible individuals and strengthening families approach. Making care coordination a families get the income supports Available at: www.cssp. org/ reform/ critical component of the pediatric they need. April 2010. Available strengthening- families/ messaging- health system: a multidisciplinary at: www.aecf. org/ ~/ media/ Pubs/ at- the- intersection/ Messaging- at- the- framework. The Commonwealth Topics/ Economic%20 Security/ Intersections_ Primary- Health. pdf. Fund; 2009. Available at: www. Family%20 Economic%20 Supports/ Accessed July 31, 2015 commonwealthfund. org/ publications/ ImprovingAccessto PublicBenefi tsHel fund- reports/ 2009/ may/ making- care- pingEligibl/ Benefi tsAccess414 10. pdf. 98. The Neighborhood Developers. coordination- a- critical- component- of- Accessed July 31, 2015 Available at: www. theneighborhoodde the- pediatric- health- system. Accessed 96. US Department of Health and Human velopers.org/ money- wise/ . Accessed July July 31, 2015 Services; Administration for Children 31, 2015

Downloaded from www.aappublications.org/news by guest on October 3, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS Poverty and Child Health in the United States COUNCIL ON COMMUNITY PEDIATRICS Pediatrics originally published online March 9, 2016;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2016/03/07/peds.2 016-0339 References This article cites 38 articles, 17 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2016/03/07/peds.2 016-0339#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Advocacy http://www.aappublications.org/cgi/collection/advocacy_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on October 3, 2021 Poverty and Child Health in the United States COUNCIL ON COMMUNITY PEDIATRICS Pediatrics originally published online March 9, 2016;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2016/03/07/peds.2016-0339

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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