Recently in Public Policy Category

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.

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.

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.

Higher Autism Rates: What Can Be done?

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The newest data on Autism Spectrum Disorder (ASD) from the Centers for Disease Control and Prevention (CDC) offer an alarming picture of childhood disability in America. Approximately 1 in 68 children who were 8 years old in the 11 participating states in 2010 were identified with ASD. This new estimate is more than twice as high as the earliest estimates from 2000 and 2002. The CDC states that "we don't know what is causing this increase. Some of it may be due to the way children are identified, diagnosed, and served in their local communities, but exactly how much is unknown."

People with ASD can have numerous strengths, but the challenges associated with ASD and other disabilities can be persistent and costly for individuals, families, and society. In the Future of Children issue on Children with Disabilities, Stabile and Allin calculated that the average annual cost (in 2011 dollars) to families of children with disabilities was approximately $10,800, and approximately $19,700 to social programs such as Medicaid and special education.

Even though there might be extra costs early on, Aron and Loprest note that early detection and intervention is crucial, and both sets of authors point out that early detection can provide long-term cost savings. However, some families are not screening their children due to barriers such as limited access and the belief that it's unnecessary. Stabile and Allin emphasize that mental health problems, as opposed to physical disabilities, appear to be particularly associated with negative effects on future wellbeing in adulthood.

Having previously practiced social work in a treatment program for adults with ASD, ADHD, and learning disabilities, I've seen first-hand the difficulties that such adults can experience. These include difficulty developing and maintaining relationships (especially romantic relationships), finding and keeping gainful employment, and having healthy self-esteem after years of being bullied by peers.

With the increased prevalence of ASD among children, policy makers should remember that this is not simply a childhood disability, but a lifelong disorder with potentially significant long-term costs and challenges. Clearly, we need more research to understand the causes of ASD, but the funding and evaluation of expensive interventions to prevent and reduce the negative aspects associated with ASD, and other disabilities, during childhood and early adulthood might be justified given the research found in this Future of Children issue.

Examining For-Profit Colleges

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My graduate school curriculum, in clinical social work, consistently emphasized "self-awareness," or being conscious of one's feelings, beliefs, biases, and overall state of being. I suppose a benefit of this training is that I've developed a habit of trying to recognize and challenge my own biases.

One bias I've had since childhood concerns the role of for-profit colleges. It likely originates from peers who made fun of certain teachers at our elementary school because they had attended for-profit universities. Back then, I thought they were institutions where students bought an easy low-quality degree. More recently, I've considered them overpriced, insufficiently regulated, and limited in educational effectiveness. Now an article by David J. Deming, Claudia Goldin and Lawrence F. Katz in the Postsecondary Education issue of the Future of Children that has given me a more nuanced view.

They explain that for-profit colleges have seen a large increase in enrollment during the past fifteen years. Possible explanations for this include overcrowding at community colleges, aggressive marketing strategies, a more career-oriented curriculum, and the ability to quickly expand program capacity for high-demand occupations. Importantly, they enroll a disproportionately high share of disadvantaged and minority students, and those who are less prepared for college.

To me, this doesn't sound too bad. It seems that they help meet the demand for higher education, especially among the disadvantaged, and might even be considered innovative. But there's more to the story.

Graduates of for-profit schools tend to have higher loan balances and default rates than comparable students at nonprofit schools, have lower earnings on average, are less likely to be employed six years after initial enrollment, and are less likely to believe their education was worth the cost. Additionally, a very high portion of for-profit revenue (sometimes close to 90%) is drawn from students' federal financial aid. Partially due to the high cost to taxpayers and students, the federal government recently proposed stricter "gainful employment" regulations that could put schools with poor outcomes at risk of losing federal aid eligibility. If the regulations are implemented, some schools will likely need to restructure their programing to stay in business.

Deming and colleagues come to several conclusions. First, for-profits schools seem necessary to help meet the growing demand for higher education. Second, for-profit colleges generally work best with short, well-defined programs that are occupation-oriented. Finally, since longer programs have the potential to amount to great costs to students, they  need to be well regulated. The authors recommend requiring counseling by an independent third party to ensure that prospective students understand financial aid packages and accompanying obligations, and to restrain aggressive and misleading recruitment practices.

Bias confirmed? Partially, since for-profit colleges tend to be more expensive and seem to need more regulation to help prevent negative outcomes. However, it was unfair of me to believe these were all low-quality degrees, especially given the strengths of for-profit education.

Preventing Childhood Sexual Abuse

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Chances are that you or someone you know has been sexually abused. David Finkelhor, director of the Crimes Against Children Research Center, writes in the Future of Children that approximately 3% of children are likely victimized in a single year, and 25-40% of women and 8-13% of men report a history of sexual abuse. Many potentially negative consequences can result from this type of abuse; thus, prevention and treatment should be a matter of public policy.

What type of person sexually abuses a child? The answer might not be what you think. Finkelhor explains that only 14% of sexual abuse victims who come to law enforcement attention are victimized by a stranger, while 26% are victimized by a family member and 60% are abused by someone in the family's social network. And it's not just adults who perpetrate--about a third of abusers are juveniles. Also, only a small percentage of new offenders have a prior record. Luckily, many abusers are relatively low-risk for re-offending once caught.

Some of these figures might seem frightening to parents who feel a lack of control over their children's safety. However, parents can use proactive strategies to protect their children, and if abuse happens, it should be reported promptly (regardless of who the perpetrator is) and followed immediately by professional treatment for victims. Having practiced social work with youth offenders and victims and their families, I understand it can sometimes be difficult to take the matter outside the family, but it really is in everyone's best interest.

Policy makers have tried to alleviate the problem by focusing primarily on offender management (for example, registering sex offenders, conducting background employment checks, controlling where offenders can live, and imposing longer prison sentences) and school-based educational programs (for example, teaching children how to identify dangerous situations, refuse an abuser's approach, and summon help). Surprisingly, there is little evidence to suggest that offender management prevents sexual abuse, despite its popularity. In addition to more research into these practices, Finkelhor recommends using law enforcement resources to catch more undetected offenders and concentrating intensive management efforts on those at highest risk to re-offend. School-based programs, on the other hand, have been shown to achieve some of their goals, but studies are inconclusive about whether these programs actually reduce victimization. For more information on how to prevent child abuse, see the Future of Children issue on Preventing Child Maltreatment.

Making Sense of International Comparisons of Students

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We are regularly exposed to news reports about the results of international tests, in which children's scores in the United States lag behind those of their peers in many other nations in math, reading, and science. The results spur public debate as to why the nation's educational system is "mediocre" or why test results could be meaningless altogether--for instance, China, with very high rankings, reports scores only from the wealthy cities of Shanghai and Hong Kong.

Is it even worth participating in these tests? What can they tell us, if anything, about America's educational system and how to make it better?

In the Future of Children, Daniel Koretz weighs in with some answers. He stresses that these tests do not provide unambiguous information about the effectiveness of American high schools compared to those of other nations. For example, participant countries vary by year, making it difficult to compare U.S. students with an international average, and the varying curriculums and complex sampling designs also pose problems.

Despite their many limitations, Koretz argues there is value in these tests. In using the results, we should consider multiple tests rather than a single source. We should ignore small differences between countries and consider comparing the U.S. to nations that are similar, such as Australia or Canada, or that are particularly high-achieving. Perhaps the most important benefit of testing is the numerous hypotheses that result about what impedes or improves student performance, which can then be tested and evaluated.

While there are certainly more important indicators of student success (e.g., graduation rates, college degrees), test scores offer useful information, which should be considered but not relied on solely. To learn more about how to make sense of test scores and how to improve the educational system, see the Future of Children issue on America's High Schools.

An Invisible Division

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One of the largest subcultures in America is also one of the least visible. Military children and families are everywhere--not just on or near installations. To illustrate, only a handful of counties across the continental United States had not sent Guard and Reserve members to Iraq or Afghanistan by 2011. Even though these families are everywhere, they often do not stand out. Military children do not wear uniforms. We need to develop a community-based model, to increase resilience and minimize health risks among military children.

In the Future of Children, Harold Kudler and Colonel Rebecca I. Porter (U.S. Army) explain that communities of care "extend the responsibility for developing [an] environment of respect and positive expectations from the clinic to the community." With a shortage of mental health professionals, especially in rural areas, it is imperative to intervene at the community level. In order to make communities of care happen, the first step is identification--every clinical program should routinely ask everyone who enters its system, "Have you or has someone close to you served in the military?", and all clinical staff should be taught about military culture and deployment mental health. A next step is to flag military family status in education, employment, and medical records so that it is not overlooked and tailored support can be offered across time. Also, health-care programs and insurance companies could offer incentives to providers to take military history as a way to improve health outcomes and perhaps reduce costs through better treatment. Additionally, clinical programs competent in working with military families should register their names and basic information in the National Resource Directory to help increase accessibility to community resources.

As Kudler and Porter note, perhaps "the secret of creating communities of care for military children is creating communities that care about military children." To learn more see the Future of Children issue on Military Children and Families.

Evidence-Based Programs for Military Children

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Given the sacrifices that military personnel make, children of military families deserve to have policies and support programs designed to fit their needs. Notable examples include subsidized childcare, deployment assistance, moving assistance, child development programs, and community awareness initiatives that train and support communities in their efforts to improve the lives of military infants and toddlers. Unfortunately, many current programs for military children were implemented quickly, at a time of pressing need; thus, few are based on scientific evidence of what works, and even fewer have been evaluated for their effectiveness.

In the newly released Military Children and Families issue of the Future of Children, an overarching theme is the need for better research about military families and the programs intended to help them. Despite the overall lack of evidence-based programs, there are important directions we can take to implement the principles of best practice to improve programming.

For example, Molly Clever and David R. Segal show that military families are diverse by factors such as age, race, ethnicity, and cultural background. Rather than compelling these families to fit into a fixed and rigidly structured set of programs, we should make support programs accessible to families of all backgrounds and at all stages of life. This is challenging, but programs designed for diverse non-military families have been well researched and evaluated, and this research should help in developing flexible and adaptive programs and policies.

We can also learn from the strengths of programs that appear to be working. Major Latosha Floyd and Deborah A. Phillips recount how the military's child-care program went from a system in distress to a model for the nation, directly serving or subsidizing care for 200,000 children every day. They tell how the success of this program rests on four pillars--military certification, national accreditation, minimum standards in hiring, and a pay scale that reduces staff turnover.

As we learn from the strengths of good programs, and as we rigorously evaluate as many programs as we can, we will be able to better support military children and families by implementing the best services possible. For more information, see the Future of Children issue on Military Children and Families.

Caregivers and Baby Boomers

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According to a new report by the AARP Public Policy Institute, in 2010, each person aged 80 or older had more than 7 potential family caregivers aged 45-64. However, as the oldest baby boomers begin to retire, America is entering a period of transition in which this ratio will decrease sharply, hitting 4.1 by 2030 and continuing downward to 2.9 by 2050. This projection is worrisome because family caregivers provide the majority of long-term care for older adults. Caregivers  are usually women, and most are employed. They spend an average of 20 hours per week providing care, and over one-third have children or grandchildren under 18 living at home.

Indeed, the emotional, relational, financial, and time burdens can be difficult for caregivers to manage--especially employed caregivers. In the Future of Children, authors Ann Bookman and Delia Kimbrel say that adults may actually spend more time caring for their parents than they did caring for their children. Smaller families, and the fact that potential caregivers live further away than in the past, make it more challenging to care for older family members. To care for the growing elderly population and ease the burden on caregivers, Bookman and Kimbrel argue for better coordination among health-care providers, nongovernmental community-based service providers, employers, government, families, and the elderly themselves. They especially recommend that employers offer more flexible work arrangements for caregivers, such as part-time work, paid leave, paid sick days, and other "elder-friendly" benefits. They also remind us that "today's children will be the workers, citizens, and family caregivers who will care for the growing U.S. elderly population tomorrow. Focusing on children's healthy development and education will build their capacity to provide supportive care for the elders of future generations." For more information see the Future of Children issue on Work and Family.

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