AAP Recommendation Recognizes Toll of Financial Insecurity

Over the last few decades, the medical community has increasingly come to view social determinants as a central factor in health and health outcomes. Where and how an individual lives could be as critical a risk factor as genetic predispositions ... and perhaps even more so.

Earlier this year, the American Academy of Pediatrics released a policy statement calling on physicians to ask families if they are able to make ends meet at every well-child visit. "Poverty and Child Health in the United States," which was published in the April 2016 issue of Pediatrics, and an accompanying technical report both described the pervasive ways poverty harms children.

A growing body of research has shown the connection between living in deep, persistent poverty and lifelong health problems, including infant mortality, poor language development, higher rates of obesity and asthma, and an increased risk of injury. The AAP report also noted recent research links childhood poverty with toxic stress that can alter gene expression and brain function and contributes to chronic cardiovascular, immune, and psychiatric disorders.

"Children are the poorest group in our society - one in five children lives in poverty in America," said AAP President Benard P. Dreyer, MD, FAAP. And, he continued, "We know the federal poverty level (FPL) doesn't really capture the full extent of financial insecurity in families. To really get a true picture, you have to go up to about 200 percent (of FPL). If you look at that number, that is almost one in two children in this country."

Dr. Bernard P. Dreyer

Dreyer, who is a professor of Pediatrics and director of the Division of Developmental-Behavioral Pediatrics at New York University School of Medicine, called poverty one of the most serious non-communicable diseases affecting children. "Because so many children are living in poverty, pediatricians are seeing this every day. Poverty is everywhere, and suburbia is the fastest-growing area for childhood poverty."

He continued, "It's not as if federal programs don't work. They are just not robust enough." Dreyer said other countries have effectively addressed the situation. "The U.K., for example, has cut their childhood poverty level almost in half. Now, the U.S. has one of the highest childhood poverty rates among developed nations," he stated.

However, it doesn't have to be that way. Dreyer said federal, state and local initiatives to address financial insecurity and meet basic needs in the elderly have lowered the rate of seniors now living below the FPL in the United States to about 10 percent. He is hopeful that a similar emphasis on children could result in much improved numbers for our youngest and most vulnerable citizens.

The need is critical and with lasting impact. "We know that especially experiencing poverty in early childhood is particularly damaging to a child having success in life," Dreyer said. "Parents who are stressed out can't give the social, emotional, language and cognitive supports that children need, and it's hard to make up those deficits afterwards. We know that by the time poor children get to school, they are already way behind those who are not poor."

Dreyer noted the scientific research over the past 15 years has not only provided more insight into brain development but has also highlighted the effectiveness of evidence-based interventions. A bright note is that living at or close to the poverty level doesn't necessarily bar children and adolescents from the healthcare system. Between State Children's Health Insurance Programs, Federally Qualified Health Centers, faith-based clinics and school clinics, most children do have some access to care, which puts pediatric providers in the unique position of having the opportunity to link families to resources.

"We're asking someone in the office or clinic to screen for families' basic needs and then connect them to resources in the community," Dreyer said. "On average, we know that poor families only receive about half the benefits they qualify for."

Dreyer said he and colleagues at the AAP recognize that many pediatricians and primary care providers already feel overwhelmed with all that has to be accomplished in a day. "Do whatever you can is our message. If you don't feel you can help them with all of their problems, start with what you can. Food insecurities? Connect them with a food bank."

He added that South Carolina has set up a successful model where practices and clinics share findings through the state and local chapters, making it easier for everyone to access information on the myriad resources and social services available. "We are asking our chapters to play a key role in this around the country," Dreyer said.

The national organization also has an array of resources available to help pediatricians and other providers begin the conversation with both patients and policymakers. Screening tools and sample surveys to help assess need, practice tips, talking points and links to supplemental resources are accessible at aap.org/poverty. Additional information is also available through the AAP homepage under the federal section of the 'Advocacy & Policy' tab.

As pediatricians, Dreyer concluded, the goal is to work with families to ultimately produce the next generation of healthy, successful adults. "Fortunately, we have realistic solutions that we know will work. This is a problem that can be solved, and it's well within our reach."