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The nation's largest pediatricians' group is urging its 64,000 members to ask patients a question: "Do you have difficulty making ends meet at the end of the month?" The question, designed to screen for poverty, will help identify kids and families that are likely suffering ill effects from the chronic stress that often accompanies life for people living below the poverty line. Chronic or toxic stress, caused by long term exposure to stress hormones and inflammation, can lead to lifelong health consequences.

(Lisa DeJong, The Plain Dealer)

CLEVELAND, Ohio -- In the fall, the nation's largest pediatricians' group urged its members to ask their patients if they regularly had enough to eat or ever went hungry.

Now, the same group, the American Academy of Pediatrics, is asking its 64,000 members to pose another question during doctor visits: "Do you have difficulty making ends meet at the end of the month?"

It's a simple way doctors can screen for poverty, the group says, and there are many reasons why pediatricians should care if their patients are poor.

"Poverty shortens life and it makes people ill," as children and later as adults, said Dr. James Duffee, a pediatrician with 30 years of experience who practices in Springfield, Ohio. "It influences how a child grows, even how the actual architecture of the brain develops."

Poverty's effects can be measured at birth. Kids born into poverty are more likely to be underweight and are less likely to survive the first year of life. Children living in poverty are also more likely to suffer from a number of chronic health and developmental conditions, including ear infections, obesity, diabetes, asthma, anemia, and pneumonia, inability to concentrate, attention-deficit/hyperactivity disorder (ADHD) and conduct disorder.

Where a child is born and grows up is a "tremendously powerful determinant of a child's health over the life course," Duffee said. It's a truth that can be measured in life expectancy: In the Cleveland area, residents in the East Side neighborhood of Hough die, on average, 24 years younger than those who live only 8 miles away in Lyndhurst, for example.

Duffee, one of the lead authors of the policy statement released today by the AAP, said it's the organization's duty to speak up for kids.

"Pediatricians are advocates for children," at both the policy and personal level, he said. "Our job is not only to build a treatment team... but to also link people to community resources. Pediatrics in the 21st century is not just one doctor in the office with one family or one child."

At the core of AAP's recommendations are some stark statistics about how American children are faring post-Recession, a wealth of research that links poverty to child health, and the growing body of evidence that reveals exactly how being poor may influence health.

Poverty is 'everywhere'



Nationally, about one in five children live below the federal poverty level ($24,230 for a family of four), according to U.S. Census data. That's 15.5 million children. Taking into consideration the high relative costs of housing and transportation, economists estimate that closer to twice that number -- about 43 percent of U.S. kids -- are really threatened by a lack of economic stability in their homes.

Black, Hispanic and American Indian children are three times more likely than white or Asian children to live in poverty.

In Cleveland, the picture is even more alarming. The city was among 35 of the 50 largest U.S. cities that saw an increase in child poverty from 2000 to 2013, despite an overall national decrease in the rate. The city's child poverty rate, at 54 percent, is second only to Detroit's 59 percent.

And the problem is not confined to the city, said Dr. Andrew Garner, a University Hospitals Rainbow Babies & Children's Hospital pediatrician with a practice in Westlake and president of the Ohio chapter of the AAP.

"It's everywhere, and any doctors who say it doesn't affect their practices are wrong," said Garner, who practices in the West Side suburb of Westlake, where the median household income is $76,000.

"It's a place that you wouldn't think you'd see much poverty, but there isn't a day that goes by when I don't have a conversation with a family about costs of medicine, or reluctance to see a specialist because of high copays, or problems with transportation."

Since the beginning of the Great Recession in late 2008, suburbs have been the sites of the fastest increases in poverty nationwide. And while being born into poverty and spending longer in poor conditions does more damage to children, even short spells of poverty are dangerous for kids, the AAP report points out.

"The biology connecting poverty and health is universal; it's not confined to certain kids in certain places," Garner said.

Starting the conversation

The connections between poverty and child health aren't new. There's plenty of research linking the two, and AAP's report lays that evidence out for doctors.

So how does being poor make people ill? It's pretty clear that it's due to the cumulative effects of chronic stress, what researchers now deem "toxic stress" because of its serious health consequences.

Under stress, the body produces hormones such as adrenaline and cortisol, which in small, short-term doses are helpful for coping with immediate problems. But if a child is subjected to the stresses of poverty on a daily basis, such as not knowing where or when he'll eat next (which is called food insecurity); moving frequently or being evicted or becoming homeless; breathing or ingesting environmental toxins such as lead paint or secondhand smoke; or generally having an unstable or unreliable home life, the consequences are severe.

"Normal stress helps us live and grow," Duffee said, because it's short-lived and then turned off. "For many kids in poverty, that stress response is never turned off and exposes them to long-term inflammation and internal wear and tear."

Some of the cumulative effects of these daily stresses show up in the decades of research on the health effects of exposure to trauma in childhood, or "adverse childhood experiences" such as witnessing violence or living with a parent who is an alcoholic or drug addict, among others. The more of these experiences children have, the more likely they are to suffer poor health outcomes in adulthood, including substance abuse, obesity, mental illness and other problems.

Garner says asking parents if they're having trouble making ends meet, along with the previously recommended questions about food availability, will hopefully start conversations beyond talk about ear infections and vaccinations.

The goal is to build trust with families so that they're comfortable talking about potentially embarrassing topics like evictions, job loss, or lack of food. Doctors would then be able to help connect families to social services and keep a closer eye on children who may be affected by the increased stress.

The pediatricians recognize, however, that they're limited in how much they can do in the doctor's office, with short appointments and pressure to see many patients.

Duffee sees the pediatrician's role as that of convener, one who can ease access to services and explain the connections between poverty and health to families.

The doctor saw three patients in a single day this week who had serious health and behavioral issues he traced to poverty-related causes. One of them, a teen boy, was behaving defiantly towards his father and showing signs of hyperactivity, but had only started acting that way when his family lost their home and all moved into a single room in a hotel.

"We could have prescribed a stimulant or treatments for [attention deficit disorder] but what they really needed was a better place to live," Duffee said. "We can't do everything, but we can help."

Garner recognizes that the recommendations, which include support for programs such as the earned income tax credit, Temporary Assistance for Needy Families (TANF, or welfare), and food stamps or SNAP, may lead to some difficult conversations between doctors and patients and among doctors themselves.

"Some doctors will say that we're here to talk about sore throats, and this is not something we can control. Part of what we're trying to do is get the message out that poverty is a legitimate health issue, and there's not a single magic bullet, but there are things we can do to help."