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To Create a Better World for Children and Families: The Case for Ending Childhood Poverty

  • Benard P. Dreyer
    Correspondence
    Address correspondence to Benard P. Dreyer, MD, Department of Pediatrics, NYU School of Medicine, 8 East 11 NBV, 462 First Avenue, New York, NY 10016.
    Affiliations
    Department of Pediatrics, New York University School of Medicine, New York, NY
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      Introduction

      The Academic Pediatric Association (APA) is a great and unique organization. The best minds and hearts in pediatrics are our members. We are a family of teachers and scholars and advocates and healers presiding over academic pursuits, over the education and nurturing of our young, fertilizing the ground of the future of society. We have our eyes on protecting and supporting and improving the lot of the most vulnerable children and families. We do so many good things. We are open to all levels of diversity. We live in a village of pediatric organizations, and we reach out to our sisters and brothers and embrace them and make them our partners. There has been no greater calling or honor or sacred duty for me than leading the APA for this year and yet I feel incredibly humble and insignificant compared with those whose accomplishments have preceded this presidential address for more than 5 decades. I truly stand on the shoulders of giants.
      This past year, the APA Board, as part of strategic planning, rewrote the APA mission, vision, and core values and rededicated the APA to keeping children first in our minds and actions.

      Academic Pediatric Association. Mission/vision. Available at: http://www.academicpeds.org/aboutUs/about_mission_vision.cfm. Accessed October 7, 2012.

      When we thought about our vision for the future, it was to make a real difference for children, “to create a better world for children and families.” And as our mission now clearly states, our focus is both “the health and well-being” of children. Furthermore, we have been advocating for and continue to advocate for an “equitable child health agenda.” Our efforts are especially for poor and vulnerable children and adolescents.
      My comments are made in the context of the important advocacy that our organization, along with other pediatric organizations, effectively does through the Pediatric Policy Council. We have actively advocated for NIH funding for research, Children's Hospital Graduate Medical Education, Title VII & VIII health professions funding, Title V Maternal and Child Health Block grant funding, and funding for preventive care services and WIC. We have fought to protect Medicaid and CHIP as well as children's health insurance benefits as health care reform unfolds, and strongly supported the Pediatric Subspecialty Loan Repayment and Emergency Medicine Services for Children programs and the reauthorization of the Best Pharmaceuticals for Children and Pediatric Research Equity Acts.

      Academic Pediatric Association. Public Policy and Advocacy. Advocacy in action. Available at: http://www.academicpeds.org/public_policy/public_policy_SignOn.cfm. Accessed October 7, 2012.

      These are important issues, and we should be proud of our ongoing advocacy and should continue these efforts.
      However, there are big issues for children, issues that affect their lives and their life trajectories, about which we as pediatricians have talked, but not shouted, and have not effected much change. Poverty and its consequences is an issue that hovers over, and dwarfs all other issues; and the gross inequities among children based on race/ethnicity are very much related to and interwoven with poverty. I would like to focus this address on childhood poverty and on making a case for ending or at least dramatically decreasing childhood poverty as well as alleviating the effects of poverty on poor children.

      Childhood Poverty in the United States

      Figure 1 shows different levels of poverty for children from 1975 to 2010.

      Childtrends. Children in poverty: indicators on children and youth. 2011. Available at: http://www.childtrendsdatabank.org/?q=node/221. Accessed October 9, 2012.

      A total of 22% are currently below the federal poverty level (FPL)
      • DeNavas-Walt C.
      • Proctor B.D.
      • Smith J.C.
      Income, Poverty, and Health Insurance Coverage in the United States: 2010 (US Census Bureau, Current Population Reports, P60-239).
      and almost half of these, 10% of all children, are in extreme or deep poverty. Poverty has been stubbornly persistent for children, going up and down with the economic cycles, but resistant to real change. In general, 1 in 5 children grows up poor, and we haven't been able to do much about it.
      Figure thumbnail gr1
      Figure 1Percentage of children living below selected poverty thresholds, selected years, 1975−2010.

      Childtrends. Children in poverty: indicators on children and youth. 2011. Available at: http://www.childtrendsdatabank.org/?q=node/221. Accessed October 9, 2012.

      The official US federal poverty level was developed in the mid-1960s based only on food consumption: minimal adequate diet by US Department of Agriculture standards.
      • Short K.
      US Census Bureau, Current Population Reports, P60-241, The Research Supplemental Poverty Measure: 2010.
      At that time it was assumed that food represented approximately one-third of family expenditures, so this number was multiplied by 3 and adjusted for family size and has been adjusted annually for changes in the average cost of living in the United States.
      There are 2 major weaknesses in the way we measure the federal poverty level. First, food now costs between 10% and 20% of budgets in most of the United States, not 33%. Housing and child care expenses now account for much larger percentages of a family's budget. Second, regional variations in cost of living have a tremendous impact. In a 2005 study of basic family budgets, estimates of minimal budgets for a family of 2 parents and 2 children ranged from 163% of the FPL in Casper Wyoming to 338% of the FPL in Boston.

      Allegretto S. Economic Policy Institute Briefing Paper #165, Basic Family Budgets: Working families' incomes often fail to meet living expenses around the US. August 30, 2005. Available at: http://www.epi.org/publication/bp165/. Accessed October 10, 2012.

      Therefore, at least 200% and perhaps as high as 350% of the FPL is the amount necessary for a family to barely meet its minimum needs and has been referred to as a “family self-sufficiency standard.” Families living below that level and above the 100% FPL are living in “near poverty.” Research documents that near poverty negatively affects the same cognitive, mental health, social, emotional, and academic outcomes that poverty affects.
      • Aber J.L.
      • Bennett N.G.
      • Conley D.C.
      • Li J.
      The effects of poverty on child health and development.
      If we look at the numbers of children living under 200% of the FPL, 43%, or nearly 1 in 2 children in the United States is poor or near poor.

      Childtrends. Children in poverty: indicators on children and youth. 2011. Available at: http://www.childtrendsdatabank.org/?q=node/221. Accessed October 9, 2012.

      Children are the poorest group in our society (see Fig. 2), and children younger than 5 years of age are even poorer, with 1 in 4 living in poverty.
      • DeNavas-Walt C.
      • Proctor B.D.
      • Smith J.C.
      Income, Poverty, and Health Insurance Coverage in the United States: 2010 (US Census Bureau, Current Population Reports, P60-239).
      Considering the importance of early brain development, this is a national disgrace. In contrast, only 9% of seniors live in poverty. These age differences are even more dramatic when deep poverty, that is, those who live at below 50% of the FPL, is examined. Children are 4 times more likely to be extremely poor than seniors, or 10% versus 2.5%.
      Figure thumbnail gr2
      Figure 2Percent living below the federal poverty level by age, 2010.
      • DeNavas-Walt C.
      • Proctor B.D.
      • Smith J.C.
      Income, Poverty, and Health Insurance Coverage in the United States: 2010 (US Census Bureau, Current Population Reports, P60-239).
      It wasn't always like this. Figure 3 contrasts trends in poverty among children and seniors from 1959 to 2010. A half century ago, in 1959, seniors were the social group with the greatest rate of poverty at 35%. Then came the expansion of Social Security and the introduction of Medicare, and senior poverty plummeted to 25% in 1969, 15% in 1979, and down to 9% today.
      • Sachs J.
      The Price of Civilization: Reawakening American Virtue and Prosperity.
      The pattern for children is a different story. Child poverty dropped from 27% to 14% in the 60s due to Medicaid and other social supports but began a gradual long-term climb so that now more than 1 in 5 children grow up in poverty. There are lessons in these numbers. Government can work to make life better for people. We have made decisions as a society to support the elderly, but not to support, to the same degree, children. If we took these government benefits away from seniors, their poverty level would increase 5-fold, back up to 1959 levels. And I am not saying this to pit children against seniors. What we have done for seniors is a good thing. The question is: why not for children?
      Figure thumbnail gr3
      Figure 3Percent poverty for seniors and children, 1959−2010, selected years.
      • Sachs J.
      The Price of Civilization: Reawakening American Virtue and Prosperity.
      There are large inequities in poverty rates. More than 1 in 3 African-American and Hispanic children are living below the FPL. And almost 1 in 2 African–American children younger than 5 years of age lives in poverty.

      Childtrends. Children in poverty: indicators on children and youth. 2011. Available at: http://www.childtrendsdatabank.org/?q=node/221. Accessed October 9, 2012.

      Minorities are also likely to experience extreme poverty, as well as persistent poverty and be poor for the duration of their childhood. Long-term rather than short-term poverty is associated with the most severe impact on cognitive and social-emotional development. Families who are persistently poor may also face concentrated neighborhood poverty as well as family level hardship. Finally, they are also more likely to lack “wealth” defined as net worth, the total value of assets minus debts. There are vast differences of wealth or assets by race. Overall, black families have a median net worth of 1/12th that of whites at the same income level and Hispanics have 1/8th the net worth at the same income level.
      • Aber J.L.
      • Bennett N.G.
      • Conley D.C.
      • Li J.
      The effects of poverty on child health and development.
      In summary, racial/ethnic minority children are much more likely to be poor, much more likely to be extremely poor and persistently poor throughout their childhood, and to lack assets that might cushion the experience of poverty. And these inequities are magnified for the youngest children, who are going through rapid brain and skill development.

      Comparison of US Poverty With Poverty in Other Developed Nations

      How do we compare to other developed nations? Figure 4 compares rates of relative childhood poverty (percent living below 50% of the median national income) among 35 developed nations.
      • UNICEF Innocenti Research Centre
      Measuring Child Poverty: New League Tables of Child Poverty in the World's Rich Countries, Innocenti Report Card 10.
      In the United States there are greater poverty rates for children than almost all other developed countries. The average for all 35 developed countries is 12%, compared with 23% for the United States. Only Romania has a greater childhood poverty rate than the United States. As can be seen in Figure 4, many European countries have childhood poverty rates less than 10%. In addition, a number of these countries have greater overall poverty rates than childhood poverty rates, the opposite of what is the case in the United States, where children are the poorest group in our society.

      Child Outcomes 2.2: Child Poverty. OECD Family Database 2011. Available at: http://www.oecd.org/dataoecd/52/43/41929552.pdf. Accessed November 9, 2012.

      This positive outcome in other developed nations is the result of government-led social policy to protect children.
      Figure thumbnail gr4
      Figure 4The United Nations Children's Fund Report Card 10. Relative childhood poverty: percentage of children (0−17 years) in households with equivalent income less than 50% of the national median, in 35 economically advanced countries.
      • UNICEF Innocenti Research Centre
      Measuring Child Poverty: New League Tables of Child Poverty in the World's Rich Countries, Innocenti Report Card 10.

      Consequences of US Childhood Poverty on Child Health and Well-Being

      The consequences to child health of poverty are well known. They include increased infant mortality, low birthweight and subsequent health and developmental problems, increase in frequency and severity of chronic diseases such as asthma, poorer access to quality health care, food insecurity, increased accidental injury and mortality, and increased obesity and its complications.

      Moore KA, Redd Z, Burkhauser M, Mbwana K, Collins A. Child Trends Research Brief, Publication #2009–11, Children in Poverty: Trends, Consequences, and Policy Options. 2009. Available at: http://www.childtrends.org/files/child_trends-2009_04_07_rb_childreninpoverty.pdf. Accessed November 8, 2012.

      • Ogden C.L.
      • Lamb M.M.
      • Carroll M.D.
      • et al.
      Obesity and socioeconomic status in children and adolescents: United States, 2005–2008.
      Perhaps, however, the consequences of poverty for child and adolescent well-being are even more critical than those for health. These are the consequences that change their life trajectories, lead to unproductive adult lives, and trap them in intergenerational poverty.
      • Aber J.L.
      • Bennett N.G.
      • Conley D.C.
      • Li J.
      The effects of poverty on child health and development.

      Moore KA, Redd Z, Burkhauser M, Mbwana K, Collins A. Child Trends Research Brief, Publication #2009–11, Children in Poverty: Trends, Consequences, and Policy Options. 2009. Available at: http://www.childtrends.org/files/child_trends-2009_04_07_rb_childreninpoverty.pdf. Accessed November 8, 2012.

      Children growing up in poverty have poorer educational outcomes with poor academic achievement and greater rates of high school dropout. They also have less positive social and emotional development and in turn have more problem behaviors leading to so-called “trajectory-altering events,” such as early unprotected sex with increased teen pregnancy, drug and alcohol abuse, and increased criminal behavior as adolescents and adults.
      • Handzel J.M.
      • Brodsky N.
      • Betancourt L.
      • et al.
      Longitudinal follow-up of poor inner-city youth between ages 8 and 18: intentions versus reality.
      They are more likely to be poor adults, with lower productivity and low earnings. The lower productivity of poor children growing up to be poor adults is estimated to lower our Gross Domestic Product (GDP) by 1.3% annually. Together with the cost of increased crime and increased health expenditures, the total cost of childhood poverty is almost 4% of the GDP.
      • Holzer H.J.
      • Whitmore Schanzenbach D.
      • Duncan G.J.
      • et al.
      The Economic Costs of Poverty in the United States: Subsequent Effects of Children Growing up Poor.
      And all of these impacts on child well-being are especially likely if children experience deep or extreme poverty (50% FPL), long-term persistent poverty, or poverty in early childhood.

      Moore KA, Redd Z, Burkhauser M, Mbwana K, Collins A. Child Trends Research Brief, Publication #2009–11, Children in Poverty: Trends, Consequences, and Policy Options. 2009. Available at: http://www.childtrends.org/files/child_trends-2009_04_07_rb_childreninpoverty.pdf. Accessed November 8, 2012.

      What can the US Do as a Nation?

      What can the United States do as a nation to reduce childhood poverty? There are really 2 approaches, or 2 prongs of attack. One is to lift children out of poverty, and the other is to alleviate the effects of poverty on poor children, both leading to improved health and well-being of children and giving them a chance at more productive lives. First let's consider how the United States could really try to lift children out of poverty. This involves the country first making a commitment to do so, setting specific goals, and using the power of good government to make it happen.

      Decreasing the Level of Childhood Poverty: Lessons From the United Kingdom

      The United Kingdom is a model of a nation with an agenda to end childhood poverty, and a good role model for what we could be doing here in the United States. In March 1999, Prime Minister Tony Blair declared war on childhood poverty. He said, “Our historic aim will be for ours to be the first generation to end child poverty.” Gordon Brown, then Chancellor and later Prime minister, set a further target of cutting child poverty by half in 10 years. Over the next decade Blair and Brown committed considerable resources to attaining this goal: With the motto “One Percent for the Kids,” an additional 1% of GDP was invested in families and children to decrease childhood poverty.
      • Waldfogel J.
      Britain's War on Poverty.

      Smeeding TM, Waldfogel J. Fast Focus: No 8–2010. Fighting Childhood Poverty in the United States and the United Kingdom: An Update. 2010. Available at: http://www.irp.wisc.edu/publications/fastfocus/pdfs/FF8–2010.pdf. Accessed November 9, 2012.

      • Smeeding T.M.
      • Waldfogel J.
      Fighting poverty: attentive policy can make a huge difference.
      • Waldfogel J.
      First Focus: Tackling Childhood Poverty and Improving Childhood Well-Being: Lessons from Britain.
      What did the British do? They focused on 3 major areas, the first 2 to lift children out of poverty and the third to alleviate the effects of poverty on children. First they had an agenda for promoting work and making work pay, including establishing a minimum wage that moves workers over the poverty line (consisting of 50% of median wages, not 40% as in the United States, which cannot move most families out of poverty), and a kinder, gentler version of the welfare reform in the United States. Second, they took steps towards raising incomes for families with children through expanded universal child tax benefits and credits, an increased Working Tax Credit similar to the US Earned Income Tax Credit for low-wage earning families, and generous child care tax credits that cover up to 70% of the costs of quality child care. These credits are paid throughout the year so that families can use these funds more effectively. They also made sure there were more benefits for younger children. Finally, they invested in children, especially early childhood programs, including universal preschool for 3- and 4-year-olds, preschool for disadvantaged 2-year-olds, extensive paid maternity leave, and home visiting and other services for 0- to 3-year-olds in disadvantaged neighborhoods.
      The results are shown in Figure 5.

      Smeeding TM, Waldfogel J. Fast Focus: No 8–2010. Fighting Childhood Poverty in the United States and the United Kingdom: An Update. 2010. Available at: http://www.irp.wisc.edu/publications/fastfocus/pdfs/FF8–2010.pdf. Accessed November 9, 2012.

      In 1998−1999, when the British began the effort, absolute childhood poverty in the United Kingdom was 26.1%, greater than in the United States (18.9%). As the result of the UK war on childhood poverty, absolute poverty rates dropped dramatically to 12.3% in 2008, and impressively, during the deep recession, have continued to drop, so that in 2010 the rate was 10.6%.
      • Cribb J.
      • Joyce R.
      • Phillips D.
      IFS Commentary c124. Living Standards, Poverty, and Inequality in the UK: 2012.
      The opposite trend is seen in the United States, with rates increasing from 18.9% in 1998 to 22.5% in 2010. Britain's success in reducing childhood poverty over the past decade provides one very clear lesson: where there is a serious public intention and effort to decrease childhood poverty, substantial progress can be made. If we in the United States think that there is nothing that our government can do to reduce childhood poverty, the British example clearly provides strong evidence of what nations can, in fact, accomplish. High childhood poverty rates are not an inevitable feature of our complex and globalized economies. If Britain can cut childhood poverty in half in 10 years, so can the US.
      • Waldfogel J.
      Britain's War on Poverty.
      Figure thumbnail gr5
      Figure 5Absolute childhood poverty in the United States and the United Kingdom, 1989−2009.

      Smeeding TM, Waldfogel J. Fast Focus: No 8–2010. Fighting Childhood Poverty in the United States and the United Kingdom: An Update. 2010. Available at: http://www.irp.wisc.edu/publications/fastfocus/pdfs/FF8–2010.pdf. Accessed November 9, 2012.

      Reprinted from Fast Focus, research brief of the Institute for Research on Poverty, 8 (2010) © 2010 by the Regents of the University of Wisconsin. Used with permission.
      As government in the United Kingdom switched from Labour to the Conservative Party in 2010, there was a multiparty commitment to continue efforts to reduce childhood poverty, and all 3 parties passed the Child Poverty Act of 2010.

      Child Poverty Act of 2010. 2010. Available at: http://www.legislation.gov.uk/ukpga/2010/9/pdfs/ukpga_20100009_en.pdf. Accessed November 9, 2012.

      There is a continued commitment by the nation and the government to reduce child poverty and what we call near poverty by more than half yet again, by the year 2020.

      HM Government, Department for Work and Pensions, Department for Education. A New Approach to Child Poverty: Tackling the Causes of Disadvantage and Transforming Families Lives. 2011. Available at: https://www.education.gov.uk/publications/standard/publicationDetail/Page1/CM%208061. Accessed November 9, 2012.

      Will they succeed in reducing childhood poverty and its effects further? I don't know. I do know that we in the United States cannot succeed because we have not made a commitment, we don't have goals, we don't have plans, and we are afraid of using government, the same government that has done so much for seniors, to help lift children out of poverty.

      Decreasing the Level of Childhood Poverty: Do More of What We Know Works

      One approach we can advocate for in the United States is to do more of what we know already works. The US Census Bureau and the US Department of Commerce developed the supplemental poverty measure to more accurately assess poverty. Government benefits and subsidies to poor families are added as income, and necessary expenses, such as child care for working parents, are subtracted from family finances.
      • Short K.
      US Census Bureau, Current Population Reports, P60-241, The Research Supplemental Poverty Measure: 2010.
      Using these measures, real child poverty in 2010 was actually reduced by these government programs by more than 4%, from 22.5% to 18.2%. The Earned Income Tax credit reduced poverty more than 4% and food stamps by 3%.
      • Short K.
      US Census Bureau, Current Population Reports, P60-241, The Research Supplemental Poverty Measure: 2010.
      • Tiehen L.
      • Jolliffe D.
      • Gundersen C.
      Alleviating Poverty in the United States: The Critical Role of SNAP Benefits.ERR-132.
      In contrast, work and child care expenses increased poverty by 2% and medical out-of-pocket expenses for the family increased poverty by almost 3%.
      Expanding high-quality child care options for families and making it affordable with enhancement of the Child and Dependent Care Tax Credit will simultaneously decrease poverty rates and improve early childhood development.

      Burman LE, Maag E, Rohaly J. Tax Credit to Help Low-Income Families Pay for Child Care. Tax Policy Issures and Options No. 14. 2005. Available at: http://www.taxpolicycenter.org/UploadedPDF/311199_IssuesOptions_14.pdf. Accessed November 11, 2012.

      Furthermore, the Affordable Care Act is likely to insure many parents who are not now insured and protect poor and near-poor families from the significant out-of-pocket medical expenses they presently experience. Together, these measures could decrease childhood poverty by as much as 5%. And why not expand the Earned Income Tax credit and permanently get rid of the marriage penalty built into it?

      The Earned Income Tax Credit. Center on Budget and Policy Priorities: Policy Basics. 2012. Available at: http://www.cbpp.org/files/policybasics-eitc.pdf. Accessed November 11, 2012.

      We should also learn from the British and make these payments periodic so families can effectively use the additional income for their children.

      Holt SD. Periodic Payment of the Earned Income Tax Credit. Brookings Institution. 2008. Available at: http://www.brookings.edu/research/papers/2008/06/0505-metroraise-supplement-holt.aspx. Accessed November 11, 2012.

      These are real steps the United States could take as a nation to use benefits and tax credits to decrease childhood poverty.

      Public Spending on Families With Children: Comparison With Other Developed Countries

      A comparison of public spending in the United States on families with children to public spending in other developed countries is sobering (Fig. 6).
      • Whiteford P.
      • Adema W.
      OECD Social, Employment and Migration Working Papers No. 51. What Works Best in Reducing Child Poverty: A Benefit or Work Strategy.
      We spend a small amount of our GDP on benefits and tax breaks to families. The average for other developed nations in this 2003 analysis is 2.4%. The United States only spends 1% of our GDP. In contrast, the Scandinavian countries, such as Denmark, spend 4% of GDP to help parents, including child payments and allowances, parental leave benefits, and high-quality childcare supports. We have a way to go to even reach the average investment in families with children of other developed countries. And it is not just Scandinavia. The United Kingdom was spending 3% of its GDP on supporting families with children, well before their latest Child Poverty Act.
      Figure thumbnail gr6
      Figure 6Public spending among selected developed nations on family benefits in cash, services, and tax breaks as percentage of each nation's GDP, 2003.
      • Whiteford P.
      • Adema W.
      OECD Social, Employment and Migration Working Papers No. 51. What Works Best in Reducing Child Poverty: A Benefit or Work Strategy.

      The Other Prong of Attack: Alleviate the Effects of Poverty on Children

      The other prong of attack on this problem, of course, is to alleviate the effects of poverty on children; and here we have ample evidence of effective programs, especially in early childhood, as well as programs addressing school and second chance job training. The problem is that we haven't implemented what we know works.
      The clearest case for interventions is for investments in early childhood. We know that brain architecture and skills are caused by an interaction of genetics and individual experience. We know that the skills needed to be a “competent adult” and the underlying neural pathways are hierarchical, that is, each level builds on earlier foundations. We know that cognitive, language, and social-emotional skills are interdependent and are all important both individually and through interaction with each other. We also know that early childhood is the most plastic and receptive time to environmental influences and interventions. And finally, we know that focusing on the family and on parenting is as important as focusing on schooling, in fact more important.
      • Knudsen E.I.
      • Heckman J.J.
      • Cameron J.L.
      • et al.
      Economic, neurobiological, and behavioral perspectives on building America's future workforce.
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      • Phillips D.
      From Neurons to Neighborhoods: The Science of Early Childhood Development.
      Early childhood is where the action is. Figure 7 shows math achievement scores from age 6 to 12 by income level. The majority of the gap caused by income at age 12 is already there at school entry, with little change after that. By third grade, gaps are stable by age, suggesting that it is hard to make up for an inadequate early childhood environment in the home.
      • Heckman J.J.
      Skill formation and the economics of investing in disadvantaged children.
      • Carneiro P.
      • Heckman J.J.
      Human capital policy.
      The same outcomes are true for reading skills. By the 4th grade, half of poor children have difficulties reading and most will never catch up. To quote James Heckman, 2000 Nobel Laureate in Economics, “Investing in disadvantaged young children is a public policy initiative that promotes fairness and social justice and at the same time promotes productivity in the economy and society at large.”
      • Heckman J.J.
      Skill formation and the economics of investing in disadvantaged children.
      Figure thumbnail gr7
      Figure 7Average percentile rank on Peabody Individual Achievement Test-Math score by age and income quartiles. Income quartiles are computed from average family income between the ages of 6 and 10.
      • Heckman J.J.
      Skill formation and the economics of investing in disadvantaged children.
      Heckman JJ. Skill formation and the economics of investing in disadvantaged children. Science. Jun 30 2006;312(5782):1900–1902. Reprinted with permission from the AAAS.
      We have good models of early childhood programs that work. Figure 8 shows the High/Scope Perry Preschool Program findings when graduates reached age 40 years.
      • Schweinhart L.J.
      • Montie J.
      • Xiang Z.
      • et al.
      The High Scope/Perry Preschool Project Through Age 40: Summary, Conslusions, and Frequently Asked Questions.
      As can be seen in Figure 8, the program had impacts on IQ at age 5, basic achievement at 14, high school graduation rates, earned income and employment, and led to fewer arrests (and fewer arrests for violent and drug-related crime). In addition, more graduates of the program owned their own home, owned a car, and had savings accounts. There was significantly less use of social service programs. And more men raised their own children. Cost benefit analyses have shown cost-benefit ratios of 10 to 1 or more!
      • Schweinhart L.J.
      • Montie J.
      • Xiang Z.
      • et al.
      The High Scope/Perry Preschool Project Through Age 40: Summary, Conslusions, and Frequently Asked Questions.
      Figure thumbnail gr8
      Figure 8Major findings: High/Scope Perry Preschool study at age 40.
      • Schweinhart L.J.
      • Montie J.
      • Xiang Z.
      • et al.
      The High Scope/Perry Preschool Project Through Age 40: Summary, Conslusions, and Frequently Asked Questions.
      From The High Scope/Perry Preschool Project Through Age 40: Summary, Conclusions, and Frequently Asked Questions.
      Ypsilanti, MI: High/Scope Press; 2005. (p. 2) by Schweinhart LJ, Montie J, Xiang Z, et al., Ypsilanti, MI: HighScope Press. © 2005 Year HighScope Educational Research Foundation. Used with permission.
      Home-visiting programs targeting parenting and improved child development outcomes have also been shown to be successful. They are less intensive and less expensive than programs like High/Scope Perry. One example is the Parent-Child Home Program, which provided twice-weekly visits for 2 school years to poor, low-education mothers with 2- to 3-year-old children. Intervention children had significantly increased pass rates of cognitive skills assessments in the first grade compared with all children, poor children, or other African-American children.
      • Levenstein P.
      • Levenstein S.
      • Oliver D.
      First grade school readiness of former child participants in a South Carolina replication of the Parent–Child Home Program.
      All these results were statistically significant. Other replications of this intervention have been shown to increase high school graduation rates significantly, so long term effects are also seen.
      Finally, least intensive, and least expensive are interventions in primary care pediatric programs serving poor children. These programs have also shown results, although there are as of yet no long-term studies of these programs. Reach Out and Read now reaches more than 4 million children per year, about one quarter to one third of all low-income children in the United States. It has been shown to increase parent reading aloud to their children and to increase child receptive and expressive language.
      • Mendelsohn A.L.
      • Mogilner L.N.
      • Dreyer B.P.
      • et al.
      The impact of a clinic-based literacy intervention on language development in inner-city preschool children.
      Other somewhat more intensive interventions have also been studied. The Video Interaction Project for children from birth to 3 years, developed at Bellevue Hospital, has been shown to increase parent-child interactions and vocalizations; improve child cognitive, language and social emotional development; and reduce the need for early intervention services.
      • Mendelsohn A.L.
      • Dreyer B.P.
      • Flynn V.
      • et al.
      Use of videotaped interactions during pediatric well-child care to promote child development: a randomized, controlled trial.
      • Mendelsohn A.L.
      • Valdez P.
      • Flynn V.
      • et al.
      Use of videotaped interactions during pediatric well-child care: impact at 33 months on parenting and on child development.

      Summary and Conclusions

        In summary, as a nation:

      • We need to commit to reducing childhood poverty and alleviating its effects.
      • We need to emulate the United Kingdom and set national goals, make long term plans, and delegate responsibilities.
      • We know how to help through benefits, cash transfers, and tax breaks: Let's do more! Let's go from 4% help to 10%! Let's make a commitment to spend “One Percent More for the Kids.”
      • Science supports a focus on early childhood programs: We should fully fund preschool, home-visiting, and primary care pediatric interventions for all poor and near poor children.

        What can the APA do as an organization?

      • We can raise our voices: make this our greatest priority advocacy activity.
      • We can make it our business: act!
        • Our Committees, SIGs, Regions can discuss this issue, write policy papers, hold workshops, and sponsor symposia and plenary sessions at Pediatric Academic Societies' Annual Meetings.
        • We should publish a special journal issue/supplement on childhood poverty, not only to review the evidence of its impact, but to suggest solutions.
        • We should and will create a Task Force on Childhood Poverty to lead these efforts.
      • We should educate our residents, fellows, and young faculty about this, the most important problem facing children in the United States today.
      • And we should lead from the front: We should reach out to engage our pediatric colleagues in other organizations so that we can speak with one voice.
      There are many voices of hate and selfishness and know-nothingness in our country now. We can hunker down and try to do what we know how to do. And we should continue to do what we do well, including promoting research, education, and professional development. There are those who say, let's wait it out; perhaps it will get better. Some espouse a realpolitik approach: let's not alienate the powers that be and interfere with our ability to accomplish the good that we can accomplish. I say that we go to sleep every night knowing many children are hungry, that many will never graduate from school, that many will never become productive adults, and that many will never be able to, as our Declaration of Independence says, pursue happiness. I say, we must at least try, as individuals, but more importantly as the APA.
      So, as an agenda for children and adolescents for the APA, let us pledge together to speak out about childhood poverty, and all the important issues that affect the life trajectories of children and adolescents. Let us feel powerful. We are the most important advocates for the most vulnerable children and families. What we say in unison matters to our elected officials and policy makers. Let us focus on starting the long process to end childhood poverty. All great changes start with a vocal few.
      All religions have the concept of social justice, compassion, and mercy: responsibility for our fellow humans. Almost two thousand years ago, the rabbis writing the Talmud, reeling from the trauma of the destruction of Israel by the Romans, wrote of “Tikkun Olam,” the duty to repair or perfect the world. I believe that pediatricians in general and APA members in particular believe deeply in that principle. The rabbis said, “It is not your obligation to complete the task of perfecting the world, but neither are you free to stop from doing all that you can.”
      And I say, “We in the APA don't have to complete the task of ending poverty for children, but it is our obligation to start trying to do so and to do all that we possibly can.” If not us, who? If not now when? Remember, the children are depending on us!

      Acknowledgments

      I would to thank my wife Constance, who is my true partner in life, and who inspires me with her courage and moral strength. She has been with me every step of the way through this year as APA President, as well as through the fight to do something about childhood poverty. Her love sustains me. Of course, I want to acknowledge how much I cherish my children (in age order, Craig, Dimitra, Derek, as well as Derek's wife Rose) and my granddaughter Adeline; you have taught me so much about life, and I am amazingly proud of all of you. I also want to thank my professional family in the Department of Pediatrics at New York University School of Medicine and Bellevue Hospital, as well as in the APA. Finally, I want to thank all the children and families whom I have known during the last 46 years, since I started at medical school, and who have struggled to succeed in the midst of poverty; you have been my true heroes and my teachers.

      Supplementary Data

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