Children raised in poverty have—on average—higher rates of a multitude of problems, including school failure, antisocial behavior and delinquency, early pregnancy, drug addiction, and depression (Compton, Thomas, Stinson, & Grant, 2007; Kalichman et al., 2006; Valdez, Kaplan, & Curtis Jr., 2007). Recent evidence further shows that a child raised in poverty has a 30 to 60% higher likelihood of heart disease as an adult, as well as asthma and autoimmune disorders—even when they transcend poverty by adulthood (Chen et al., 2006; Dube et al., 2009; Kittleson et al., 2006). The enormity of the economic burden on society for such problems including the cost of the most common problems for all youth, such as violence, drug abuse, high-risk sexual behavior, poor academic achievement, high school dropouts and suicide attempts, totals nearly $500 billion annually (estimated in 2014). And these estimates do not include the compounding costs of later problems in adulthood, from unemployment and incarceration to serious physical health problems and mental illness.
The Potential of Prevention Science
Efforts to combat poverty have primarily focused on increasing family income. However, programs and policies that improve family income will not necessarily ameliorate established patterns of conflict that may have resulted from the stresses of living in poverty. Interventions are needed that support the ability of families and schools to effectively nurture our children and build the social and academic skills of young people.
Prevention science has reached a point at which all U.S. communities can ensure that young people reach adulthood with the skills, values, and health habits needed to lead productive lives in caring relationships with others. The 2009 Institute of Medicine (IOM) report identified numerous tested and effective programs, policies, and practices that can prevent the most common and costly problems of youth. Some interventions can directly affect the economic well- being of those in poverty or who are vulnerable to falling into poverty. Others do not directly or immediately affect economic standing, but ameliorate the negative effects of poverty, such as academic failure, delinquency, depression, and unwanted pregnancy. Of course, alleviating some of these effects can very well improve later economic well-being; e.g., decreasing school drop-out rates and improving academic performance. Many of these interventions can also help to prevent inter-generational poverty. If a national initiative ensues that widely implements these effective interventions, virtually every citizen and entire communities will benefit.
The value of an evidence-based prevention science approach is that it invests only in proven programs; precious resources are not wasted and problems are prevented before they develop rather than after they have become entrenched. Along these lines, Rep. Ryan and Senator Murray have introduced bipartisan legislation for the Commission on Evidence-Based Policy Making. This body recognizes the need to infuse scientific evidence into the decisions of policy-makers as the first step to effectively designing policies that improve our lives while not wasting tax-payer money on unproven strategies. The Commissioners have been charged with three general tasks: (1) to improve the federal data infrastructure while respecting privacy and security concerns; (2) to incorporate outcomes measurement, cost-benefit data, evaluation, randomized controlled trials (RCTs), and rigorous impact analysis into federal program design; and (3) to consider the value and nature of a clearinghouse that would facilitate access to data by various constituencies and enable the research community to judge what works and what does not. The Commission will focus on ways to incentivize the rigorous evaluation of programs and policies that aim to reduce the problems associated with detrimental prevailing conditions and promote more healthful and productive outcomes. Until now, many programs we invest in do not possess stringent indicators of their effectiveness and, thus, there is no justification for their continuation.
Relevant to poverty reduction, such a bipartisan, evidence-based approach avoids more controversial economic measures and, thus, is more likely to bring legislative success. Over time, proven interventions save government money; e.g., there is no longer a need to institute programs to counteract problems that no longer exist. In addition, those no longer in poverty are more productive and able to actively contribute to society leading to more money in government coffers. This scenario is certainly preferable for all involved, from those directly impacted by poverty to those affected by the exorbitant costs of poverty, such as threats to public safety and the need for more specialized educational, mental health and juvenile justice services.
Building a Comprehensive National Prevention System
The U.S. can exert a measurable impact on poverty and improve the chances for success among our youth by implementing tested and effective programs, policies, and practices. It is a significant undertaking that requires several years of concerted effort, but if we unite everyone around a common understanding of what is needed, we can build a system to support child and adolescent development and prevent problems to a degree never before seen.
A comprehensive and effective prevention system would have four facets: (a) implementation of a large-scale and sustainable system of family supports; (b) infrastructure for positive behavioral reinforcements and social competency skills for children in schools; (c) ongoing public education about the importance of building environments conducive to healthy child and adolescent development; and (d) a data-driven system for monitoring the wellbeing of children and adolescents. A realistic plan for this system can be created if all the agencies and organizations designated to address health and wellbeing (e.g., education, juvenile justice, health care, etc.) coordinate their efforts.
There is a solid body of evidence showing that community, family and school-based interventions can prevent the development of most of the problems cited above and thereby minimize the harm of poverty and assist many children in eventually escaping from it. From the prenatal period through adolescence, there are programs that can help families nurture their children’s cognitive, social, and physical development. They teach parents how to reduce conflict in the home and how to help their children develop key skills for social and academic success. Such programs can prevent impoverished children from failing in school and from developing aggressive behavior that leads to delinquency, substance abuse, early pregnancy, and continued poverty.
An analysis by Sawhill and Karpilow (2013) at the Brookings Institution analyzed the potential impact of four evidence-based interventions that are available from infancy through adolescence. Their report concluded that if these interventions were systematically implemented and scaled, they could close the gap by 70% between more and less advantaged children in their ability to enter the middle class by mid-life. And in doing so, this approach would result in substantial savings to the taxpayer, increasingly over time.
The programs analyzed by Sawhill and Karpilow were found by previous research to be effective. They include the Home Instruction for Parents of Preschool Youngsters, Success for All, Social Emotional Learning (particularly PATHS, Incredible Years, and High Scope Pre- School), and the Talent Development (TD) initiative (particularly Career Academies). Programs and policies need to cultivate soft skills as well. Initiatives like the Nurse Family Partnership, Parent Management Training, the Family Check-up, Treatment Foster Care Oregon, Strong African American Families Project, and Multisystemic Therapy (MST) are all valuable in this regard. Each of these programs can reduce family conflict, improve parents’ skill and patience, and prevent the development of myriad problems including academic failure, aggression, delinquency, and depression. A nine year follow-up of the Parent Management Training Oregon found improved mothers’ standard of living as measured by income, occupation, education, and financial stress as well as frequency of police arrests. If these programs can be successfully “scaled up,” there is potential for transformative effects on poverty (Dreyer et al., 2016).
One of the key characteristics of prevention science is the adoption of a public health perspective to benefit large segments of the population including children and families experiencing adverse conditions associated with poverty. Prevention efforts that avoid stigma and engage the whole community have a better chance of acceptance and impact. For example, the use of car seats, the elimination of second-hand smoke in public settings, and the availability of high-quality low-cost childcare serve the needs of all children, including those living in poverty. With respect to evidence-based parenting and family support, community-wide prevention can reduce problems that disproportionately affect children in poverty such as child abuse (Prinz, 2016), low school readiness (Welsh, Bierman, & Mathis, 2013), and school dropout (http://www.doe.mass.edu/dropout/). Furthermore, these kinds of prevention strategies are known be economically beneficial in terms of return on investment, as documented by the Washington State Institute for Public Policy.
In addition to interventions aimed at improving parenting skills, connection to schools and other pro-social behaviors, there are also quite a few policies with the promise of reducing poverty and addressing its effects on children, families and communities. One possible bipartisan means of large-scale implementation is via “social impact”/”pay-for success” bonds, which draw in private money to help implement and sustain programs. This mechanism is growing in popularity across the aisle in various states, and now in bills introduced into Congress.
Additional policy recommendations on poverty have been excerpted and slightly revised from three prominent organizations (see the reports: Brookings Institution/American Enterprise Institute and American Academy of Pediatrics). We focus on those recommendations that are supported by rigorous prevention science and the evidence-based strategies shown to work.
Increase access to effective parenting supports.
Help young, less-educated men and women prosper in work and family.
Improve skills to obtain well-paying jobs.
Increase public investment in two underfunded stages of education: preschool and postsecondary.
Educate the whole child to promote social-emotional and character development as well as academic skills.
Fund quality early childhood programs that can have a significant financial return on investment, but more importantly, making healthy development of young children a national priority while addressing social determinants of health helps families and communities build a foundation for lifelong health.
Protect and expand funding for essential benefits of programs that assist low-income and poor children. Invest in children’s health and development by appropriately funding evidence-based programs, including Early Head Start and Head Start, Medicaid, CHIP, WIC, home visiting, SNAP, school meal programs and other programs that increase access to healthy food, and Child Care Development Block Grant–funded programs. Streamline enrollment and renewal processes for public benefit programs.
Support 2 to 3-generation strategies that focus on helping children, adolescents and parents simultaneously. Promote the coordination and alignment of adult- and child-focused programs, policies, and systems.
Make a national commitment to fully fund home visiting programs for all children living in low-income or poor households. The Bureau of Maternal and Child Health has identified 19 programs, including but not limited to Nurse-Family Partnership, Early Head Start, Healthy Families America, and Parents as Teachers, that target families with pregnant women or children younger than 5 years.
Support integrated models of care in the medical home that promote effective parenting and school readiness, such as Healthy Steps, Reach Out and Read, VIP, Incredible Years, Medical Legal Partnerships, and Positive Parenting Program. Both Medicaid and education funding agencies should provide support in the medical home for parenting and literacy promotion.
Support a comprehensive research agenda to improve the understanding of the effects of poverty on children and to identify and refine interventions that improve child health outcomes. Research is needed to identify better ways to measure how poverty affects children, what works to help families in poverty, and how to translate the information gained into real solutions for the poor.
There is a need for States to identify government efforts relevant to treatment and prevention without restricting the focus to any one domain (e.g., substance abuse) since all aspects of behavioral, mental and physical health are amenable to prevention through programs and policies that make young people’s environment more nurturing (Biglan, 2015). A set of activities (mentioned above) that can move the nation forward is delineated below:
1. Increase the availability of evidence-based supports for family wellbeing. States need to be encouraged to assess how well they are reaching families who will benefit. For example, the Nurse Family Partnership (NFP), which provides supports to poor women during their first pregnancy and the first two years of the child’s life, can prevent child abuse and the development of delinquency at the same time that it improves families’ economic wellbeing. States should be encouraged to gradually increase the proportion of families that are being reached with such programs.
2. Strengthen the system for supporting prosocial behavior in schools. This effort is already underway in many states thanks to the Positive Behavioral Intervention and Support (PBIS) movement and the growing adoption of the Good Behavior Game (GBG). We need to encourage states to develop systems to monitor how well schools are supporting prosocial behavior through evidence-based interventions.
3. An effective system of data gathering/survey system. We cannot assume that these programs will work without careful implementation, evaluation and tracking. Sound public policy requires that we set up systems to monitor their impact, regardless of their pedigree. Communities need to know what proportion of children and adolescents are developing successfully. This is why more resources are needed for the collection, analysis, and feedback of the data to the public. We further propose that the federal government (and expert contractors) develop an automated clearinghouse that will provide comprehensive information regarding evidence-based programs and policies (EBPs) to users; e.g., researchers (who can populate the database), policy-makers (who need to know what to legislate and fund), and community organizations, practitioners and government agencies (that need to identify best practices). The data populating this toolkit will provide parameters needed to readily map available EBPs to existing needs, whether that be to identify best violence prevention practices for any given community or to determine which policies to fund to reduce poverty. Also needed is flexibility to include innovative and/or promising programs that have yet to be subjected to rigorous evaluation but are in the database denoted by their stage of development and need for further study.
4. Public Education. Researchers and practitioners need to educate citizens and state and local policymakers about all of the programs and policies that are available to prevent the most common and costly problems of youth. We need to engage the media to be responsible reporters about the long- term consequences of our actions for children’s development and outcomes. These efforts will not only generate support for the policies sand programs that are needed, they will enhance support for policymakers to implement these policies.
The National Prevention Science Coalition to Improve Lives (NPSC; www.npscoalition.org) stands by a scientifically sound strategy to advance a national mentality and governmental policies that prioritize the prevention of problems before they occur. The goal is to reduce government expenditures, while supporting conditions under which children, adolescents, families and communities can thrive. The NPSC can provide guidance, materials, connections to scientists, practitioners and policy-makers, and other resources needed to enact this strategy.
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Diana Fishbein, Ph.D.
Anthony Biglan, Ph.D.