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Rising from a Culture of Violence to a Culture of Health

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Sara McLanahan, Editor-in-Chief of Future of Children, along with several colleagues, recently prepared a policy report published by the Robert Wood Johnson Foundation (RWJF) that describes children's exposure to violence in the Fragile Families Study (see the Future of Children Fall 2010 volume to learn more about Fragile Families). The report examines neighborhood violence, intimate partner violence, and harsh parenting, and finds that these types of violence are endemic and interrelated. An implication of these findings is that we need to tackle all these kinds of violence simultaneously, rather than in isolation. The authors point out, for instance, that reducing harsh parenting practices of mothers who experience domestic violence and are worried about their child's safety won't be as effective as reducing harsh parenting while also taking on the other problems.

What's preventing us from achieving this vision?

Part of the problem, as the policy report points out, is that our efforts to combat violence could be more holistic. In other words, there might be a number of specialized programs working on different types of violence within the same community, and yet there can be a disconnect in communication and coordination between these well-meaning efforts. This disconnect warrants consideration.

To gather ideas from stakeholders on how to "break down the silos" between specialized efforts, RWJF has provided a discussion forum led by Senior Program Officer Martha Davis, along with a dialogue on RWJF's LinkedIn Leadership Network. In the discussion threads, a common theme I noticed from several community leaders was that we should use common needs as a way to build relationships that cross program boundaries. The proposition that all stakeholders--such as prevention, intervention, community services and government--should come together, trust one another, share information and resources, and work together on objectives seems promising.

As a social worker, I often wonder how ideas and research can make a meaningful difference in people's lives. With this in mind, I recently connected with Martha and discussed the bigger picture. What I learned from our conversation was that we can all catch RWJF's vision of a culture of health in our communities--part of which is that all children will be able to grow up in safe and nurturing environments at home, in the neighborhood, and at school. And that all children will have a real chance from the very beginning to develop to their full potential as individuals. Risa Lavizzo-Mourey, the President of RWJF, describes this vision in her 2014 President's Message. I'm excited by the challenge to promote a culture of health.

I would like to invite you to join the conversation. Read the policy report and comment below to share your ideas. Tell us about any programs or policies you believe are making a difference that we can learn from, how you think we can move from a culture of violence to a culture of health, or anything else you think can be part of the solution for improving environments for children and their families.

Health of Caregivers and Childhood Food Insecurity

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We often assume that low household income causes children's food insecurity. But the Future of Children's recent research report highlights a number of additional factors that contribute to food insecurity.  One notable risk factor is a caregiver who faces mental or physical health problems.

The latest research shows that even when we account for income level, caregivers' health is still central to children's food security. For example, a recent paper in the Journal of Children and Poverty found that mothers in food-secure families had better overall health and were less likely to report substance use compared with mothers in food-insecure households. Craig Gunderson and James Ziliak's Future of Children report cites a number of health factors that can contribute to children's food insecurity, including parental depression, parental drug use, or living with an adult with a disability.

What can we do to help children in these situations? The authors point out that the effect of caregiver's mental and physical health on family food security raises concerns about families' ability to navigate the welfare system. A caregiver's health problems may also be exacerbated by lack of access to services. While the authors argue that improved access to services could improve food security, they also state that we need further research on how policy makers can create more accessible systems. The authors offer one suggestion to address the risk factor of substance use: ensuring that mothers who seek substance use treatment are enrolled in SNAP and WIC, if they are eligible. Perhaps a similar idea could be implemented in other contexts where caregivers receive medical or mental health treatment.

As more researchers explore the relationship between food security and health, new policy possibilities may come to light. However, the research highlighted in the Future of Children report makes us aware that health contributes to food security, and low income is not the only indicator of risk. In following blog posts, we will explore additional factors that influence food security. To learn more about health and food insecurity, see the Future of Children's Fall 2014 research report.

Childhood Food Insecurity in America

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This past year, lighthearted quizzes have been popular to share and discuss on social media. They've allowed to me to find out everything from what U.S. state I actually belong in to which Disney princess I would be if I existed in the cartoon realm, simply by answering odd and seemingly unrelated questions about my personality and preferences. The researcher in me feels a little annoyed at how unscientific these assessments are, but at the same time they are sometimes too fun to pass up--and somehow the results can feel so valid. I'm definitely not opposed to the idea of living in New York as Mulan.

As fun as it can be to spend free time taking and sharing these quizzes, one quiz that ought to go viral is the Hunger Quiz from the Feeding America charity. While it won't tell you which vegetable you are, it will inform you of some of the surprising facts about hunger in America, and possibly some of your misconceptions about food insecurity. A take-home message is that hunger is a significant problem in America that can alleviated. But what can we do about it?

In a new Future of Children research report, professors Craig Gunderson of the University of Illinois and James Ziliak of the University of Kentucky use the latest research to describe childhood food insecurity in the U.S. They write that the government defines food insecurity as "a household-level economic and social condition of limited access to food" and surprisingly, in 2012, over 1 in 5 children met this criterion. This is disheartening, especially since the government spent over $100 billion in fiscal year 2012 on federal food-assistance programs.

The authors argue that one reason food insecurity rates remain stubbornly high is that we don't fully understand what causes food insecurity or how programs help alleviate it. The research in the report helps fill this gap and can contribute to policy initiatives that could result in powerful improvements in the health and wellbeing of children.

In upcoming blog posts, we'll be exploring factors that contribute to food insecurity and what policies are worth consideration in light of these factors. To learn more about food insecurity in America, see the Fall 2014 research report in the Future of Children.

Policy Prescriptions to Prevent Teen Pregnancy

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Most teens would probably say they don't want to become pregnant--in fact 87% of teen pregnancies in 2001 were reportedly unintended (see Figure 1). Even though there have been tens of thousands of teen pregnancies in recent years, teen births in the US have actually declined over the last 20 years, from 61.8 live births per 1,000 females aged 15-19 years in 1991 to 29.4 in 2012. This trend, which is due to factors that include teens making more informed decisions regarding their sexual health, is encouraging and suggests we can continue to make progress in preventing teen pregnancies.

First, we need to understand what makes teens more likely to get pregnant. Isabel Sawhill, Adam Thomas, and Emily Monea, in the Future of Children, outline several plausible explanations including cultural norms of increased acceptance of premarital sex and having children outside of marriage, a lack of positive alternatives to single motherhood, an attitude of fatalism, the high cost and limited availability of contraception, lack of knowledge about contraception and reproductive health, and inconsistent or incorrect use of contraception. The authors point out that these explanations generally fall into the categories of motivation, knowledge, and access.

Next, we can examine possible solutions. The Centers for Disease Control and Prevention recently released a Vital Signs brief outlining what the federal government, health care professionals, parents/caregivers, and teens can do to prevent teen pregnancy. What I like about the CDC's suggestions is that they start where the teen is and show how adults can support teens' healthy development. For example, professionals can encourage teens to delay sexual activity but should also encourage sexually active teens to consider the most effective methods of birth control. Parents can know where their teens are and what they are doing (isn't there an app for that?), especially after school, and talk with their teens about sex.

Finally, are programs that promote these types of solutions worth the cost? Sawhill and colleagues, in their Future of Children article, conducted simulations of the costs and effects of policy initiatives that encouraged men to use condoms (motivation), discouraged teen sexual activity and educated participants about proper contraceptive use (knowledge), and expanding access to Medicaid-subsidized contraception (access). All three had good benefit-cost ratios, suggesting they are excellent social investments that can actually save taxpayer dollars. For more information on how to prevent teen pregnancy and unintended pregnancies in general, see the Fragile Families volume of Future of Children.

A Holistic Approach to Healthcare

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The health of parents and children are closely intertwined, yet the health-care system generally does not take an integrated approach to family health treatment. For instance, pediatricians who treat children with asthmatic symptoms often do not ask about parents' smoking and rarely intervene to help change the parents' smoking behavior. It's probably not considered within the scope of their practice and they aren't able to bill the treatment to the child's insurance. This situation is problematic since a primary cause of the symptoms is likely the secondhand smoke in the child's environment. Pediatricians don't necessarily need to abandon their specialization and start treating parents and children in the same practice, but the solution likely lies in reforming the health care system to be more holistic and interconnected.

Sherry Glied and Don Oellerich write in the Two-Generation issue of Future of Children that few programs aim to treat parents and children together due to structural barriers in the U.S. health-care system. They argue that the Affordable Care Act, which expands coverage to millions of lower-income parents, is a necessary step to help establish a policy environment to allow for two-generation approaches to health.

Importantly, it's up to the states to take two further steps. First, they need to ensure that parents and children can be treated in the same programs despite Medicaid eligibility. Second, they should give providers incentives to generate meaningful changes in their practices, such as embracing the patient-centered medical home model which makes additional payments to providers who coordinate their services with other medical and social service providers.

Glied and Oellerich conclude that the rationale for two-generation programs that target both children's and parents' health problems is strong, and there are new opportunities ahead to develop and implement these programs.

Expanding the Two-Generation Approach to Combat Stress

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Stress can make or break a child. Manageable stress is necessary to help a child develop self-regulation and coping skills; yet, toxic stress can contribute to long-term mental and physical health problems. With this in mind, what can be done to help children in potentially stressful environments such as poverty or the foster care system?

Ross A. Thompson explains in the Future of Children that the early plasticity (capacity to change) of the brain and other biological systems offers hope to those who aspire to help at-risk children. "We may be able to intervene early in children's lives with experiences that help reorganize biological systems constructively." He advises, however, that plasticity declines over time so early screening and intervention is ideal. For instance, one study found that children who spent eight or more months in a Romanian orphanage, while being profoundly deprived of normal human relationships, before being adopted fared worse in terms of health consequences than similar children who only spent four months or less in the that environment.

Thompson emphasizes that a key point of intervention to ease the consequences of chronic stress is improving the quality of relationships between children and adults. "Whether two-generation programs target parents, preschool teachers, foster parents, or ... [grandparents], focusing on relationships is likely to enhance their success." This shows promise in helping strengthen families so children can experience a manageable amount of stress in their lives that contribute to healthy development.

To learn more about this approach to combating stress, see the Two-Generation issue of the Future of Children.

Reducing the Risk of Parental Incarceration

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To reduce children's exposure to the negative effects of having a parent incarcerated (for example, family financial strain, health and social problems, housing insecurity, etc.), Future of Children authors Bruce Western and Christopher Wildeman urged policymakers to limit prison time and provide effective drug treatment for nonviolent drug offenders. In line with this call, Attorney General Eric Holder recently announced that the Justice Department would stop perusing mandatory minimum prison sentences for certain nonviolent offenders and promote drug-treatment alternatives to incarceration. The changes, effective immediately, should help to reduce the prison population and the number of children exposed to incarceration.

 

With about half the current prison population meeting the criteria for drug dependence or abuse, effective drug treatment for prisoners and parolees is a serious concern. As the incarceration rate begins to decline, thousands of men and women will be sent back into their communities, and many will need substance abuse treatment. Western and Wildeman report that prisoner reentry programs have been found to reduce recidivism by connecting ex-prisoners to substance abuse treatment services as well as education and employment opportunities.

 

Policymakers and practitioners should also focus on early contact with the criminal justice system. Laurie Chassin notes that substance abuse disorders are common among adolescents in the juvenile justice system and underscores the need for effective screening methods so that youth can be redirected away from the juvenile and criminal justice systems as early as possible. She highlights the role of the youth's social environment and mental health and finds evidence in favor of family-based treatment models.

          

Limiting prison time, providing effective drug-treatment for offenders and ex-prisoners, and identifying and addressing substance-use disorders early on should help to lower the proportion of children exposed to parental incarceration. For more on this topic, see the Future of Children issues on Fragile Families and Juvenile Justice.


Decreases in Childhood Obesity

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Rates of childhood obesity have risen for decades in the U.S., and there are many reasons why its prevention and treatment ought to be a focus of public policy. For one, preschoolers who are overweight or obese are five times more likely than normal-weight preschoolers to have weight problems during adulthood. And one preschooler in eight is obese, with higher rates among some racial minorities.

Recently, the Centers for Disease Control and Prevention (CDC) found encouraging evidence that these trends might be improving. In a study of 11.6 million low-income preschoolers, the CDC found a small decrease in childhood obesity rates in 19 U.S. states and territories from 2008 to 2011. Experts attribute the good news partially to programs that encourage child exercise, an increase in breast-feeding, and improved nutrition in foods provided to low-income families through federal programs. This research suggests that the problem of childhood obesity can be ameliorated.

In the Future of Children, Ana C. Lindsay, Katarina M. Sussner, Juhee Kim, and Steven Gortmaker argue that successful interventions must involve parents from the earliest developmental stages to promote healthful practices in and outside the home. Regarding the racial and economic disparity in childhood obesity rates, Shiriki Kumanyika and Sonya Grier observe that low-income and minority children tend to watch more television than do white, non-poor children and are potentially exposed to more commercials advertising unhealthy foods. One strategy would be for Congress and the Federal Communications Commission to reduce or eliminate advertising time for non-nutritious foods aimed at children. For more recommendations on how to promote childhood health, see the Future of Children issue on Childhood Obesity.

Involving Parents in Childhood Obesity

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Obesity levels have more than doubled among children and tripled among teens in the past three decades. Today, CDC estimates that 12.5 million kids are obese - nearly 17 percent of children and adolescents in the US. Future of Children author Stephen R. Daniels reports that obesity has serious consequences for children and teens, including health conditions that were previously considered adult-only issues: high blood pressure, nonalcoholic fatty liver disease, hardening of the arteries, and type 2 diabetes, to name a few.

 

In the Future of Children, author Christina Paxson and colleagues explain that that while researchers have proposed many environmental and policy solutions to the obesity problem, such as regulating the sale of soda in schools or building more sidewalks, several strategies are more promising for the short term. These include in-school, after-school, and child-care initiatives, as well as improving pediatric care. The most effective strategies will involve parents, who play a significant role in obesity prevention from gestation and infancy through adolescence.

 

Time Magazine recently highlighted a five-month intervention program in which parents and children learned about healthy eating and exercise, and parents learned how to set limits and teach their children to monitor their own eating. In addition, these families met for 20 minutes with their physician every two weeks to be weighed and receive advice and reading material. Results showed significant weight loss in the treatment group, while the control group continued to gain weight.

 

Future of Children author Ana C. Lindsay and colleagues explain, "By better understanding their own role in influencing their child's dietary practices, physical activity, sedentary behaviors, and ultimately weight status, parents can learn how to create a healthful nutrition environment in their home, provide opportunities for physical activity, discourage sedentary behaviors such as TV viewing, and serve as role models themselves." For more information on research-based childhood obesity intervention, see the Future of Children issue on Childhood Obesity.

Over the past fifty years, the number of reported childhood disabilities has steadily increased and the nature and consequences of disability have changed drastically. Prior to 1960, the poster child for childhood disabilities would have been a child with polio, wearing leg braces and using crutches for support. Today's poster child could be a child with autism.  Where the pre-60s child wore his disability for the world to see, in many cases today's child experiences his disability internally. Over the past several decades, predominant childhood disabilities have shifted away from physical disorders toward mental health disorders.  (Future of Children: Childhood Disabilities)

 

Much public attention and many resources are focused on medical research to identify risk factors and mitigate symptoms of disability for individual children.  However, Stephen Rauch and Bruce Lanphear, in their chapter "Prevention of Disability in Children: Elevating the Role of the Environment," argue for a broader focus on environmental influences that put entire populations at risk. "Identifying and eliminating or controlling environmental risk factors that incrementally increase the prevalence of disability is the key to preventing many disorders," they write.

 

When seeking to prevent disability, there are three levels that need to be considered. Primary prevention seeks to keep disabilities from developing.  Secondary prevention utilizes methods of screening and early detection to identify problems before they can do "too much damage." Tertiary prevention focuses on restoring health and function to people who have already developed a disability. Tertiary and secondary prevention are the primary efforts of the clinical community. But in order to reduce the prevalence of disability in the population, primary prevention is essential.

 

The causes of many disabilities in childhood are complex and result from the interplay of environmental risk factors and genetic susceptibility. Purely genetic and purely environmental disabilities exist, but they are rare. Children are particularly vulnerable to environmental stressors; they pass through several delicate developmental stages and, pound for pound, they eat and breathe more environmental contaminants than adults. An exposure that is harmless in adults can have a dramatic effect when it occurs during fetal development or early childhood.

 

One example of an environmental risk for disabilities in children is lead in house paint. Lower IQ and ADHD in children have both been linked back to lead as has criminal behavior in adulthood.  A cost-benefit analysis of requiring lead based paint to be removed concludes that every $1 spent to reduce lead hazards in housing would produce between seventeen and two hundred twenty one dollars in benefits by reducing screening and treatment for lead toxicity, ADHD treatment, and special education.

(Rauch and Lanphear Future of Children: Childhood Disabilities)                

 

In a long awaited move, the CDC recently cut the threshold for lead poisoning.  This new lower threshold "means public health agencies have a bigger job to screen children for lead and to prevent exposure in the first place," said Lanphear in an interview with John Ryan of Seattle station KUOW "The new standard from the Centers for Disease Control and Prevention nearly doubles the number of children considered to have lead poisoning. Now, one out of 40 American kids has what's deemed a dangerous level of lead in their blood, reported Northwest public radio."  (http://www.nwpr.org/post/cdc-cuts-lead-poisoning-threshold)   

 

This change in lead level standards is just one example of how our regulations and knowledge about environmental risk factors changes over time.  In the face of such changes, it makes sense to consider a preventive approach that shifts the entire population's health curve in a positive direction. As Issue Editors Janet Currie and Robert Kahn summarize in the introduction to Children with Disabilities, "the heart of [Rauch/Lanphear's] argument is that societal choices can shift the curve of child health outcomes to increase the probability that some children will be moved from a nondisabled to a disabled state. Exposure to chemicals in the environment, for example, may decrease the attentiveness of all children, but in a subset of more vulnerable children, the exposure may lead to symptoms and impairment that warrant an ADHD diagnosis. The implication is that society should pay attention to shifting the entire distribution of health outcomes in a positive direction and that doing so will reduce the toll of childhood disability. Such a public health focus on prevention is a useful comple­ment to the usual medical focus on improving technology or the quality of medical care for children who already have disabilities."

 

For more information, read our Children with Disabilities volume: www.futureofchildren.org.

 

 

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