The nation’s leading pediatrics group is urging doctors to ask parents during checkups whether families are able to make ends meet – a move that is part of a larger effort to improve public health and mental health outcomes in children.
The new policy, which comes from the American Academy of Pediatrics, indicates the group is recognizing that poverty can create stress, which impacts how well a child learns and how they behave as well as their relationships.
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“We’re starting to see a shift in the conversation about how we view health, and we are starting to be more holistic on what factors we can intervene on and what we can change,” says Monica Wang, assistant professor at Boston University School of Public Health, who was not involved in writing the guidelines.
The emotional and economic burdens of poverty often result in toxic stress, which can alter brain function, contributing to chronic heart, immune and psychiatric disorders. To manage chronic stress, children and adolescents can turn to risky health behaviors like smoking, excessive drinking, overeating, unsafe sex and substance abuse. Poverty can affect health outcomes for asthma, obesity and injuries.
To screen children for poverty, the American Academy of Pediatrics recommends that at checkups doctors ask parents, “Do you have difficulty making ends meet at the end of the month?” They then recommend asking more specific questions about basic needs, such as whether their food, housing and heat are adequate.
“We have to start with small steps with a lot of pediatricians because they are very busy people,” says Dr. James Duffee, one of the authors of the policy statement and a primary care pediatrician in Springfield, Ohio.
Pediatricians are also encouraged to help families identify how they can address problems at home and care for their children, including through the use of support networks that reinforce their relationships through the use of things like humor, common interests, and their spiritual and cultural beliefs.
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“The next step is not just to screen and identify, but for doctors to do a bit of retooling for the practice to include some degree of care coordination,” Duffee says, adding that this could include working with a nurse or social worker that would provide a list of resources in the community, whether state public health departments, legal services, food pantries or social work organizations.
Wang says the guidelines are a good start to the conversation but adds that the policy document could be more clear in defining what the screening items look like and in creating uniform questions. “There needs to be an agreement about how we are going to assess poverty,” she says, adding that without enforcement and accountability on this type of screening, the policy cannot make much of a difference.
According to 2014 U.S. census data, 1 in 5 children, or 15.5 million, under age 18 live in poverty. The guidance comes after another policy position from the group in October, which recommended that doctors screen households for “food insecurity,” or hunger, and that doctors subsequently connect families with community resources like food banks or churches that offer free food.
In the U.S., families are considered to be living in poverty when making less than $16,020 for a two-person family, and $24,300 for a family of four. Most families need at least double these amounts to meet their basic needs, and those that fall short are referred to as “low-income.” Families making only half those amounts are considered to be in “deep poverty” – a category into which 9.3 percent of U.S. children younger than 18 fall. Differences are also apparent when broken down by race. At the end of the Great Recession, in 2009, the median household wealth for white families was 18 times that of Latino families and 20 times that of black families.
The guidelines influence pediatrician practices across the country, as well as state laws and requirements. They could also lead to additional recommendations from the U.S. Preventive Services Task Force, a government-appointed panel that has the authority to decide whether screening for poverty is something that would be paid for by heath insurance.
The direct impact is unclear. According to the research group Child Trends, children who do not have insurance – a factor tied to poverty – are less likely to receive their annual checkups. In 2013, the group found, 68 percent of uninsured children under the age of 6 received their wellness visit, compared with 92 percent of children who were insured.
“There is a risk of missing those who are perhaps some of the most vulnerable,” Wang says. “I think this means that we can’t view physicians as bearers of the sole responsibility for intervening.”