Jonathan Wallace

December 1, 2008

Welcome to The Future of Children blog. In these blog posts, we highlight findings from our various volumes – making an effort to tie the research and policy recommendations to current affairs.

Please contribute your thoughts. We look forward to an interesting dialogue about the future of children and the various ways we can make that future promising and worthwhile.

Jonathan Wallace, Managing Editor

Marriage Revisited and Long Acting Birth Control

Millennials are marrying later and less often. Comedian Aziz Ansari recently released Modern Romance, a smart and hilarious book of sociological research that discusses how technology provides us endless access to potential partners. So many options leave many millennials like myself wondering, “Why choose?” However, the luxury of choice does not extend to everyone. While marriage is declining overall across many high income countries, minorities and those with less education are even less likely to marry, for very different reasons. Researchers suggest that this pattern could be due to men’s increased difficulty in finding stable jobs, or changes in social norms surrounding marriage and family formation.

The latest issue of the Future of Children provides a timely reflection on the state of marriage and its effect on child wellbeing a decade following our original 2005 volume on Marriage. Some key results show that despite their best efforts, policies to improve the family by encouraging marriage, such marriage education and programs to improve education and workforce opportunities that would make men more “marriageable,” have fallen short. However, many couples that do not marry are not avoiding childbearing: 41% of births occur to unmarried parents. While cohabiting was once considered a precursor to marriage, it is increasingly replacing marriage, while the birth rate has remained similar, around 45 per 1,000 people, since 1990.

The Fragile Families study, which follows the health and social welfare of almost 5,000 unmarried and married parents and their children, shows that unmarried parents are less likely to stay together until their child is 5, and disruptions to family relationships can be harmful to the child’s wellbeing.

So, how do we help children? The Future of Children policy brief offers several concrete suggestions, such as offering long-acting reversible contraceptives (which include the implant and IUD, or intrauterine device) to help women delay unintended pregnancies until they are in stable relationships and ready for children. This recommendation comes at a time when IUDs are used more than ever in the US: 12% of contraceptive users chose an IUD, up from 2.6% of users in 2002. Both implants and IUDs have by far the lowest failure rates of any modern method (except permanent sterilization) and are extremely safe. Programs to provide these services can be funded through a number of mechanisms, which are discussed in detail in the brief.

For more information on the current state of marriage and childbearing and evidence for reducing unplanned pregnancy and childbirth, check out the latest issue of the Future of Children.

Children’s Neighborhoods, Homes, and Health

One of my favorite things to do is explore cities on foot. Of course, I like some cities more than others—New York City being among my favorites. Until recently, I hadn’t quite articulated what makes a city attractive and appealing to me. Then I came across a video by the School of Life, an organization based out of London. According to the video, some of the things people tend to enjoy about cities include order and variety in physical structures, visible life such as street-level businesses with large windows, and a sense of mystery about places to discover.

These are things that adults might think about when exploring or moving to a new neighborhood, but what about children? What do they need and how does their housing and neighborhood affect their health and wellbeing? In the Future of Children, Ingrid Gould Ellen and Sherry Glied summarize what we know from research. One thing is clear—poor children tend to live in more disadvantaged environments.

For instance, poor children are more likely to live in inadequate housing. The U.S. Census Bureau considers a unit inadequate for reasons such as not having hot and cold running water, no bathtub or shower, no flushing toilet, and having exposed wiring. Recent estimates indicate that 11% of poor households with children and 5.9% of all households with children were physically inadequate, respectively. Thankfully, these figures have been cut in half since the 1970s. Nevertheless, children living in these circumstances probably experience greater emotional and behavioral problems and may perform worse in school.

The physical condition of children’s neighborhoods and what happens in them is also important. For example, when violent crime occurs close to where a child lives, that child is likely to perform poorer on cognitive tests within the next week. Car pollution is associated with asthma and even premature birth. As for the physical condition of things, poorly maintained playgrounds, crumbling sidewalks, and littered glass may result in physical injury or less outdoor activity. We should keep in mind that injuries and homicide are among the leading causes of death among children.

What can we do to make children’s homes and neighborhoods healthier and safer?

Speed bumps and safe walking/biking paths can reduce rates of child pedestrian injuries.

Installing window bars on apartment buildings can reduce fall-related deaths among children.

Introducing the E-ZPass at toll booths can reduce pollution in nearby residential areas. This strategy has been shown to reduce the incidence of preterm births in these neighborhoods.

There are many things we can do to make the homes and neighborhoods of children safe and healthy. However, Ellen and Glied caution that improvements to housing and neighborhoods can increase costs, thereby driving out low-income families. While subsidies can offset these costs for some families, the authors suggest that policymakers experiment with offering subsides to more families while reducing the size of the subsidy available per family. To learn more, see the Future of Children issue, “Policies to Promote Child Health.”

Child Health and Health Care Access

Many celebrated outside the Supreme Court two weeks ago following SCOTUS’s decision to allow health care subsidies through the Affordable Care Act (ACA). I was among those who breathed a sigh of relief at home after reading that our coverage through the Marketplace would be continued. Now as life returns to normal and we no longer have to worry for the time being, let’s not forget the importance of health care access, especially for children, and the fact that there are still children who don’t have it. Exactly how important is health care access? Lindsey Leininger and Helen Levy joined forces in the latest Future of Children issue to tell us about the influence access has on child health.

Research on this question has had varying results, but Leininger and Levy argue that, overall, access to care does improve child health and that the influence is often more significant for those who are marginalized. The classic RAND Health Insurance Experiment, for instance, suggested that in the population as a whole, the generosity of insurance coverage did not significantly determine overall health. However for high-risk (meaning low-income) children, generosity of coverage did affect health.

Studies on Medicaid eligibility show further evidence: in the year after implementation, mortality fell among nonwhite infants, and this effect persisted for at least 10 years. Also, among children in low-income families, those who experienced more years of Medicaid eligibility were in better health. A variety of other studies have associated expansions of Medicaid eligibility with reductions in child mortality. With regard to Medicaid enrollment, positive effects have also been seen, such as increased enrollment leading to decreases in hospital admissions for conditions that could be well-managed by primary care.

Leininger’s own research has shown that lack of coverage can be a strong detriment to child health. Her study showed that each additional month without coverage was associated with a small, statistically significant decline in the probably of a child seeing a doctor for a well-visit or any other visit. A four-month spell of being uninsured, for example, resulted in a 4 percent decrease in the likelihood of any visit and a 9 percent decrease in the likelihood of a well-visit.

So insurance coverage is good for child health, especially for marginalized children. But according to our authors, although “the ACA builds on the earlier successes of Medicaid expansion and CHIP to promote children’s access to care… challenges remain.” Access to care improves child health, but it is not the only factor. For example one study cited by Leininger and Levy estimates that lack of access to medical care explains only about 10% of early mortality in the population as a whole; less than genetics (30%), social circumstances (15%), and behavioral factors (40%). To improve children’s health overall and consider policies that may do so, we must also consider the larger picture. To learn more about other factors that influence children’s health, read the full Future of Children issue on Child Health.

Child and Public Health in a Libertarian Legal Framework

Earlier this year the West Coast saw a measles outbreak, another recurrence in a string of previously eradicated childhood illnesses. Stories of parents’ various objections to vaccination quickly flooded the news, underscoring the main question: who is responsible for these public health crises, families or the state? While some people may have been surprised or confused to see such illnesses return, Clare Huntington and Elizabeth Scott’s explanation of children’s health in a legal framework for The Future of Children provides valuable context.

The U.S. legal system, say Huntington and Scott, “gives parents the authority and responsibility to make decisions about their children’s health care, and favors parental rights over society’s collective responsibility to provide for children’s welfare” or, in the case of vaccination, overall public health. They call this a libertarian legal framework as a way to describe the legal context in which parents are permitted to make their own decisions about child health. There are exceptions, such as when a child’s life is in danger or when a child is in juvenile justice custody; however, since parental rights are constitutionally protected, a high standard of harm must be met before intervention can occur.

In public health cases such as vaccination, where can the line of “harm” be drawn? Currently, all healthy children are required to receive vaccinations in order to attend school. However, almost all states offer exemptions for religious beliefs and many also offer them for other philosophical convictions. The balance between the libertarian argument and public health theoretically rests on the understanding that those with strong beliefs both deserve their right to decide and are a small enough segment of the population that the overall public interest of immunity is still met. However the return of some childhood illnesses shows that this balance is no longer being maintained.

Now many states are tightening their exemption policies. For example, California (origin of the measles outbreak) is on the verge of eliminating philosophical exemptions. For some states, making these adjustments may be more difficult. As Huntingdon and Scott put it, “without an affirmative legal obligation to promote children’s [or public] health, governmental investment is optional.” In this context, public health policy is often reactive rather than proactive or preventative.

Recent shifts in both cultural and legal views of vaccination deliver an immediate and crucial example of the libertarian legal context for child health policy and its limits. To read further on current issues in children’s health, see our latest issue of The Future of Children, Policies to Promote Child Health.”

Defragmenting Child Mental Health

If you’re ready for a crash course in mental health, read Alison Cuellar’s article in the new volume of Future of Children Policies to Promote Child Health.” She introduces us to internalizing and externalizing conditions that children experience, as well as the trajectories and outcomes that can accompany them. She also describes prevention programs, and interventions from academic, juvenile justice, and medical and social service angles.

Unfortunately, well intended programs and interventions often come with an unintended consequence. Cuellar argues that due, in part, to differing funding structures of schools, health care providers, and juvenile justice programs, there is an inherent lack of integration among treatment providers; thus, children sometimes fall through the cracks. For example, health insurance might not pay for anything beyond direct professional services provided to a child; whereas parent education or family treatment might be necessary but not be covered. Another example would be programs funded by the Substance Abuse and Mental Health Services Administration—while there might be more flexible funding available for intervention and prevention initiatives through this funder than health insurance, funding is limited to particular communities and settings; thus excluding children not found in these areas.

I’ll be frank in saying that there isn’t an easy method to defragment a complicated system of service delivery. Cuellar concludes that we need to identify ways to overcome fragmentation between services. Volume editors Currie and Reichman call on governments to follow the lead of businesses and make use of the vast amount of data available to them to “create an integrated portrait of child health or to target policies to those who have the most to gain from them.”

In a blog post last year, I wrote about how the Affordable Care Act was a step in the right direction to allow for a more integrated health care system and that there were existing initiatives, such as the patient-centered medical home model, that encourage coordination among providers. Perhaps future policies and practices will encourage coordination among mental health services, thereby improving child mental health.

Evidence for Supporting Military Families

Following our discussion of the evidence-based movement, I would like to highlight the recent work of Future of Children contributor Col. Stephen Cozza (U.S. Army, retired) and the National Military Family Bereavement Study. In a recent interview, Cozza, who is a professor of psychiatry and associate director of the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences, explained that the study aims to guide policy by creating a greater base of empirical data on how immediate family members are affected when a service member passes away.

In the interview, Cozza argued that basing policy on research is important for these families, whose needs vary based on relationship to the deceased, the type of death, geographic location, and other factors. By gathering data on these scenarios, Cozza hopes to better advise policy makers on how to help these families.

Even before the study began, Cozza established the importance of this research in his Future of Children article with Allison Holmes and Paula Rauch. A parent’s death in combat not only brings immediate grief, it can also mean that survivors lose their identity within the military community, especially if they have been living on base and need to leave. Additionally, sudden, violent deaths—such as suicides, accidents, and combat-related deaths—are more common among service members than in the general population, and such deaths have been shown to bring a greater risk of PTSD and other emotional issues for surviving loved ones.

Another Future of Children article suggested building communities of care for military families and pointed to a need for further research on how to best do so. In the article, communities of care are defined as complex systems that work across individual, parent/child, family, community, military, and national levels of organization to promote the health and development of military children and families. The authors highlighted the tensions that exist in creating these interdisciplinary care communities. When we attempt to create collaborative communities of care and run into conflicts between the training of clinicians and public health professionals, research evidence could create an objective common ground on which to base programs and policy. Cozza’s National Military Family Bereavement Study is an example of the evidence-based movement in action.

For more Future of Children articles on military families, see our Fall 2013 issue, Military Children and Families. For more on the evidence-based movement, check out this interview with Future of Children senior editor Ron Haskins.

The Evidence-Based Movement

“Despite decades of efforts and trillions of dollars in spending, rigorous evaluations typically find that around 75 percent of programs or practices that are intended to help people do better at school or at work have little or no effect,” says Future of Children senior editor Ron Haskins in a recent New York Times op-ed related to his new book.

Haskins isn’t arguing for massive budget cuts for federally funded social programs—instead, he’s hoping the new Congress won’t cut funding for evaluation research, which is a relatively new federal initiative. Evaluation research helps us know which programs work and don’t work; then we can expand what works and modify or eliminate what doesn’t work. Haskins concludes his op-ed by affirming that “social policy is too important to be left to guesswork.”

Research is one of the best tools to inform policy decisions because it’s more objective than political ideology. A lot is at stake when deciding which programs will be used to tackle social problems. This is especially true when considering child-related issues because what happens to people as children is likely to have lifelong effects. Regardless of what Congress decides to do, the Future of Children can be used as a nonpartisan resource to promote effective policies and programs for children and families based on the best available research.

For instance, when addressing childhood disability, begin with our volume “Children with Disabilities.” You’ll learn about the importance of policy measures that increase coordination between different types of services. Additionally, you’ll see how technology can improve outcomes but can also expand disparities unless access is provided equitably.

If you’re interested a multigenerational approach, read our volume “Helping Parents, Helping Children: Two Generation Mechanisms.” You’ll learn about what the most promising programs are doing for families. For example, you can read about how preschool and home-visiting programs can alleviate children’s stress, how increasing parent’s education levels can strengthen children’s healthy development, how improving parent’s health can improve children’s health, how carefully timed income support can promote children’s healthy development, and how helping poor families build assets can help children succeed.

For those interested in improving the literacy of young Americans, see “Literacy Challenges for the Twenty-First Century.” You’ll read of the breadth and complexity of literacy challenges, but also find policy implications such as the need to focus more attention on informational text and analytical writing in K-12 education, as well as arguments to increase access to strong preschool programs for children from low-income and non-English-speaking families.

Whatever your political persuasion, the best research can bring people together to solve social problems. Whenever possible, let’s leave guesswork behind and follow the evidence. To read our research publications, visit

Childhood Food Insecurity: Especially Vulnerable Populations

If you’ve read our recent posts, you now know that a number of factors besides household income influence childhood food insecurity, including caretakers’ mental and physical health, parents’ marital status, and childcare arrangements. However, even when these factors are taken into account, children of immigrant parents and children of incarcerated parents remain especially at risk for childhood food insecurity, according to the Future of Children‘s Fall 2014 research report.

For example, writes John Cook, after controlling for other risk factors, “children of foreign-born mothers were three times as likely to experience very low food security as were children of U.S.-born mothers.” And a study by Kelly Balistreri found that 40 percent of children experiencing very low food security are children of immigrants, even though they constitute less than 25 percent of all children in the US.

When children have one or more parents incarcerated, this factor also decreases food security, however the reasons for the effect of incarceration are unclear. The research report highlights several theoretical explanations, but none have been thoroughly investigated. For example, incarcerating a parent might theoretically improve a household’s food security because of decreased demands on resources or by removing a negative influence in the household. On the other hand, incarceration might reduce food security because that parent’s financial, child care, and other contributions are removed. Given these conflicting theories, you might think that other factors correlated with incarceration, such as drug use or mental illness (which I discussed in a previous blog), are causing the effects we see. However, Wallace and Cox found that children with an incarcerated parent are more likely to be food insecure even after controlling for correlated factors.

We need to better understand exactly how these populations are affected, but it’s clear from the research report that children of immigrant or incarcerated parents may need additional support to obtain stable nutrition. Given that these are often two difficult-to-reach populations, policy makers should consider how to best serve these children within existing programs or with new possibilities. For more information about these vulnerable populations, see the Future of Children‘s Fall 2014 research report. For more about children of immigrants in the U.S., see Volume 21 on Immigrant Children.

Food Insecurity and Marital Status

So far, in our blog series on the Gunderson and Ziliak Future of Children research report, we’ve outlined how 1 in 5 children in America are food insecure and how there are more reasons for this besides low household income. For example, caregivers’ mental and physical health, as well as child care arrangements, are contributing factors. Another piece of the puzzle is family structure.

I’ll start with some basic statistics. This table from shows the differences in the percentage of food-insecure households with children by family structure in 2011. Without taking any other contributing factors into account, female-headed households with no spouse present are more than twice as likely to be food-insecure than households headed by married couples (40 vs. 15 percent). Households headed by a father with no spouse present have a 28% prevalence of food insecurity, in between married couples and single mothers.

These differences aren’t surprising. But there’s more to the story.

Gunderson and Ziliak summarize several studies that give us clues about how marital status is related to food insecurity. For example, Balistreri found that children living with a single parent or with an unmarried parent in a more complex family (such as when the mother is cohabiting with a partner and there’s also a grandparent in the household) are at greater risk of food insecurity than children living with two biological parents or in a stepfamily. Also, Neeraj Kaushal and colleagues found that children living with their biological parents, whether married or cohabiting, have a lower risk of food insecurity. In contrast, Miller and colleagues found no substantive differences across family types after controlling for socioeconomic status and demographic characteristics. Regarding unmarried families, Nepomnyaschy and colleagues have shown that nonresident fathers’ consistent support, whether in cash or in kind, is associated with lower food insecurity; interestingly, inconsistent support was worse than no support at all.

Based on these findings, it’s important not to jump to conclusions about marital status and food insecurity. While married-couple households seem to be at least risk, this doesn’t mean a marriage certificate solves food insecurity, and that we should rush people into marriage. Family complexity, socioeconomic status, and nonresident fathers’ support also play a contributing role.

The Fragile Families Study and the work of Sara McLanahan, editor-in-chief of the Future of Children offer potential policy implications. In a recent article about unmarried parents, McLanahan and Jencks concluded that to prevent the negative outcomes associated with having children outside of marriage, women with lower socioeconomic status can be encouraged to postpone having children, giving them time to mature and increase their education and earnings. By extension, since women aren’t likely to marry men with poor earning capacity, men need to increase their capacity to provide for a family. Initiatives such as the promotion of effective birth control and education access seem promising. For currently unmarried families, Nepomnyaschy’s article underscores the importance of consistent child support in reducing the risk of childhood food insecurity.

Food insecurity and child care for low-income families

So far, we’ve written several blogs about how characteristics of children’s parents can influence food security. As the authors of our Fall 2014 research report remind us, however, three-quarters of children spend some portion of their preschool years in the care of people other than their parents, so we need to look at how child-care arrangements may also influence food insecurity among children. This is especially important given that children in center-based care may receive a majority of their nutritional needs at their center rather than in the home.

The research report highlights a study by Heflin, Arteaga, and Gable that compared child care by parents to child care by someone else, among low-income families. Specifically, they examined five types of child-care arrangements: child-care by parents, by a relative, by someone unrelated to the child in a home care setting, in a child-care center, and in Head Start. They found that compared with children cared for exclusively by their parents, low-income preschoolers attending a child-care center had lower levels of both food insecurity in general and of very low food security. Children cared for by a relative were less likely to experience food insecurity in general but equally likely to experience very low food security and children cared for by an unrelated adult were more likely to experience very low food security.

The finding that low-income preschoolers attending child-care centers had lower levels of food insecurity and very low food security compared to those cared for by their parents has several theoretical explanations. First, parents of these children may be better able to work while their children attend the center, which increases household income. Second, these children may receive some of their nutritional needs directly through the child-care center.

While school-based nutrition programs have proven to help alleviate food insecurity for some children, this research reminds us that preschool children must also be considered in policy discussions. Improving access to child-care services for low-income parents of preschool children may improve food security within this age group.