As the pace of social change quickens, children are faced with new social and environmental risks to their growth and development. Of these changes, childhood poverty poses the greatest threat to children's well-being. One in four American children under the age of 3 years lives in poverty; (Haggerty 1999) a higher percentage of children live in poverty than any other age group. As pediatricians, we know that children in poverty experience a double jeopardy. First, they are more frequently exposed to risks to their health and development (such as lead poisoning, malnutrition, and family dysfunction). Second, children suffer more negative consequences (such as developmental delay and school dysfunction) from such exposure than do children with more advantaged socioeconomic circumstances. (Barry 2000)
Although recognition of and sensitivity to these risks have increased, primary preventive efforts, the cornerstones of pediatric practice, have failed to keep pace with changing circumstances. On the contrary, the pediatric primary-care clinician is asked to shoulder an ever greater burden in reducing the effects of social disadvantage on children--a trend that continues to increase as the social safety net for children has become increasingly porous. The primary-care clinician is enjoined to provide anticipatory guidance, to perform developmental surveillance, to prevent unintentional injuries, to recognize and address parental substance use and depression, to solve issues of child abuse and family violence, to advocate with the school system and other social agencies, to manage behavioral and family issues, etc--all in the context of a 20-minute health supervision visit. Clearly there is a limit to a clinician's ability to address such a daunting agenda, and that limit has long since been exceeded, even for families without social disadvantages.
Perhaps the problem lies neither in the primary-care pediatrician's abilities or motivation nor in the multitude of clinical expectations, but rather in a model of pediatric practice that has been essentially unchanged for the past 50 years: clinicians working one-on-one with a family in an office (with occasional support from a nurse or social worker). We need new models of pediatric primary-care service delivery--ones that link needed services within the pediatric practice (colocate) that traditionally have not been there or link services to other community-based programs. Such services should be those needed by parents to promote their children's health and well-being and should be tailored to address common problems of children and families in that community. Although many families need and benefit from a coordination of services, families living in poverty may need additional help to ensure that they have the basics and access to other needed services in a fragmented system.
We will present some of the common problems facing pediatricians, family physicians, and nurse practitioners who work with children, especially those growing up in poverty, and suggest solutions based on our experience at Boston City Hospital (BCH), where we are developing a model of enriched pediatric primary care. This work is based on earlier work of Haggerty et al, (Haggerty 1999). We hope to stimulate creative thinking about how important services and professionals can be linked in the pediatric setting or in other child programs (eg, Head Start programs, day care, and family support programs) to enhance preventive efforts and combat social risk.
Providing the Basics
Lack of money restricts a family's ability to afford medical care, medication, housing, and healthful food, and to live in a safe neighborhood. At BCH, for example, we have found that children are more likely to be underweight in the winter months (Frank 1991) (presumably because limited funds are being diverted from food to fuel), and that iron deficiency is less common among children whose parents received housing subsidies...
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