Poverty & People with Intellectual Disabilities Eric Emerson
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!
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