Poverty & People with
Intellectual Disabilities
Eric Emerson
Four Questions
 What is poverty?
 Why should we be concerned about
poverty?
 What is the link between poverty and
intellectual disability?
 What are the implications for
research, policy & practice?
Poverty (Relative)
 ‘The inability, due to lack of
resources, to participate in society
and to enjoy a standard of living
consistent with human dignity and
social decency’
Fabian Commission on Life
Chances and Child Poverty
(2006)
Poverty (Absolute)
 ‘A condition characterised
by severe deprivation of
basic human needs,
including food, safe
drinking water, sanitation
facilities, health, shelter,
education and
information’
UN World Summit for Social
Development, Copenhagen
1995
Poverty …
 Is not inevitable
 Is not fixed
 Is the direct result of inequalities in
the way we distribute resources
Our World .... by Land Mass
By Wealth
(GDP adjusted for PPP)
By Poverty
(Population Living on <$2 a Day PPP)
Child Poverty & Per Capita Gross
National Income in Rich Countries
25%
$60,000
Child Poverty
GNI (PC)
$50,000
20%
$40,000
15%
$30,000
10%
$20,000
Denmark
Finland
Norway
Sweden
France
Netherlands
Germany
Spain
Japan
Australia
Canada
UK
$0
Ireland
0%
Italy
$10,000
USA
5%
Four Questions
 What is poverty?
 Why should we be concerned about
poverty?
 What is the link between poverty and
intellectual disability?
 What are the implications for
research, policy & practice?
Poverty Influences …
 Life and death
 Health (including
mental health)
 Educational
attainment
 Life experiences
and opportunities
 Productivity
 And so …..
 Millennium
Development Goals
 ‘Make Poverty
History’
 WHO Commission
on the Social
Determinants of
Health
 ... and so on
Under 5 Mortality: 2006
% Children Born Alive but Dying by Age 5
Sierra Leone
Angola
Afghanistan
Niger
Liberia
Mali
Chad
Equatorial Guinea
Congo
Burkina Faso
Low income countries
Middle income
High income countries
0%
5%
10%
15%
20%
25%
30%
Average Position in
Distribution
Socio-Economic Status
& Cognitive Development
100
90
High
SES,
low
ability
80
70
60
50
40
Low
SES,
low
ability
30
20
Low
SES,
high
ability
10
0
22 months
3.5 years
5 years
10 years
Child Age
Feinstein, L. (2003) Inequality in the early cognitive development of
British children in the 1970 cohort. Economica 70, 73-97
Accumulated
exposure
across the
lifecourse
Poverty
(Duration
& Depth)
to a wide
range of
material
&
psychosocial
hazards
(e.g., toxins,
uncertainty,
adverse life events)
Vulnerability &
Resilience
Biological
+
(genetics,
early development)
Psychosocial
(human capital,
social affiliations)
Community
(social capital,
Health Care)
WellBeing
Four Questions
 What is poverty?
 Why should we be concerned about
poverty?
 What is the link between poverty and
intellectual disability?
 What are the implications for
research, policy & practice?
Low Income Countries
 Little research
 Expected link between poverty and
the incidence of intellectual disability





Low birth weight
Skilled birth attendants
Under-nutrition
Infections
Toxins
 Prevalence ….
Mother’s Report of Child ID:
Children Age 2-9 (Unicef MICS3)
6%
5%
4%
Mongloia
3%
Thailand
2%
Macedonia
1%
0%
Poorest
2
3
4
Richest
High Income Countries
12%
10%
8%
6%
4%
2%
Neighbourhood Deprivation
Rich
9
8
7
6
5
4
3
2
0%
Poor
Prevalence of ID
 Strong link
between
poverty and
the
prevalence
of
intellectual
disability
High Income Countries
12%
Mild ID
Severe DD
10%
8%
6%
4%
2%
Neighbourhood Deprivation
Rich
9
8
7
6
5
4
3
2
0%
Poor
Prevalence of ID
 … but
mainly for
less severe
ID
High Income Countries
12%
Age 5-16
Age 3
10%
8%
6%
4%
2%
Neighbourhood Deprivation
Rich
9
8
7
6
5
4
3
2
0%
Poor
Prevalence of ID
 …an
association
that starts
early in life
Poverty & Intellectual Disability
Intellectual
Disability
Poverty
Process: Uncompensated costs (direct & indirect)
increase the risk of experiencing poverty
Implications: Compensate for or prevent extra
costs to reduce the link between poverty and
intellectual disability (this will not change the
overall prevalence of intellectual disability)
Three Problems
 Largely circumstantial evidence
 Why is the link stronger for children
with less severe intellectual disabilities?
 How does this link emerge so early in
life?
Poverty & Intellectual Disability
Intellectual
Disability
Poverty
Process: Poverty impairs child development, more
poor children will have an intellectual disability
Implications: Reduce exposure to poverty (or the
pathways through which it impairs child
development) to prevent poorer children acquiring
an intellectual disability
Poverty & Intellectual Disability
Intellectual
Disability
Poverty
Parental
Capabilities
Implications:
Provide
additional
support to ‘at
risk’ parents
Summary
 Whatever the mechanisms …
 Children with more severe ID or ASD are
just as likely to be exposed to poverty as
other children
 Children with less severe ID are much
more likely to be exposed to poverty
than other children
Relevance?
The ‘Immunity Hypothesis’
 Does the
association
between
poverty and
well-being seen
in the general
population also
evident for
people with
intellectual
disabilities?
Emotional Disorder
30%
25%
ID
TD
20%
15%
10%
5%
0%
Conduct Disorder
50%
40%
ID
TD
30%
20%
10%
0%
0
1
2
3
4
Cumulative Social Risk
5+
Four Questions
 What is poverty?
 Why should we be concerned about
poverty?
 What is the link between poverty and
intellectual disability?
 What are the implications for
research, policy & practice?
Implication 1: Understanding
Health and Social Inequalities
 Extensive documentation of poor
health and social outcomes for
people with intellectual disabilities
 This may (in part) be due to their
increased risk of exposure to
poverty ….
Child Mental Health
9
8
7
Uncorrected
odds
Corrected
odds
16%
14%
TD
TD (matched)
12%
6
10%
5
8%
4
6%
3
4%
2
2%
1
0%
Emotional Conduct
Disorder Disorder
Cog Delay
ADHD
Sample: 17,000 British children age
5-16
Emotional
Difficulties
Conduct
Difficulties
Sample: 4,000 Australian children
age 6/7
 Exposure to
poverty is likely to
be a key (social)
determinant of the
health of people
with intellectual
disabilities
Prevalence of Conduct Disorder
Implication 2: Understanding
Risk & Protective Factors
45%
ID
TD
40%
35%
30%
25%
20%
15%
10%
5%
0%
0
1
2
3
4
5+
Cumulative Social Risk
Poverty, Neighbourhood Deprivation and
the Life Chances of Adults with Intellectual
Disability in England














Living in unsuitable
accommodation
Having less privacy at home
Unemployment
Not having a voluntary job
Not having enjoyed school
Being bullied at school
Not taking a course
Not attending a day centre
Not having control over
money
Less likely to see members
of their family
Being an unpaid carer
Seeing friends less often
Doing a smaller range of
community activities
Not having voted














Not knowing about local
advocacy groups
Feeling unsafe
Being bullied
Being a victim of crime
Having poor health
Having a long-standing
illness or disability
Smoking
Not being happy
Being sad or worried
Feeling left out
Feeling helpless
Not feeling confident
Having unmet needs
Having wanted to complain
about the support they
receive
Implication 3: Poverty as
Moderating Variable
 ‘Moderators’
influence the
strength or
direction of
associations
between two
other variables
 ‘Interaction
effects’
 Educational programmes
are more effective for
more affluent families
 The association between
child ID and maternal
well-being is stronger
among more affluent
families
 The association between
child ID and the reported
impact of child ID on
siblings is stronger
among more affluent
families
Implications for Measurement
 Measure ….
 .... the duration and depth of poverty
(accumulated risk over time)
 .... material & social hardship due to lack
of resources directly
 .... area and household level indicators
separately
Implications for Analysis
 Use models that specify mediating
pathways
 Investigate downstream (proximal)
and upstream (distal) determinants
Implications for Policy & Practice
 Getting the balance right between ….
 Poverty reduction or resilience building?
 Changing the odds or beating the odds?
 Upstream or downstream determinants?
 Build resilience
 Avoid contributing to inequity
 Make interventions and supports
accessible and effective for all
In Conclusion ….
 The health & social inequalities faced by
people with intellectual disabilities are, in
part, the result of poverty (rather than
intellectual disability)
 To address these inequalities we need to
 think beyond traditional social & clinical
interventions and directly address the social
factors that generate inequality
 ensure that our interventions are accessible and
effective for all
 We need more (and much better) research!