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

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

0% 5% 10% 15% 20% 25% 30%

High income countriesMiddle income

Low income countries

Burkina FasoCongo

Equatorial GuineaChadMali

LiberiaNiger

AfghanistanAngola

Sierra Leone

Socio-Economic Status & Cognitive Development

0

10

20

30

40

50

60

70

80

90

100

22 months 3.5 years 5 years 10 years

Child Age

Avera

ge P

osi

tion in

Dis

trib

uti

on

HighSES,lowability

LowSES,lowability

LowSES,highability

Feinstein, L. (2003) Inequality in the early cognitive development of British children in the 1970 cohort. Economica 70, 73-97

Well-Being

Poverty(Duration & Depth)

Accumulated exposure across the lifecourse

to a widerange 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)

+

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)

0%

1%

2%

3%

4%

5%

6%

Poorest 2 3 4 Richest

Mongloia

Thailand

Macedonia

High Income Countries Strong link

between poverty and the prevalence of intellectual disability

0%

2%

4%

6%

8%

10%

12%

Poor 2 3 4 5 6 7 8 9

Ric

h

Neighbourhood Deprivation

Pre

vale

nce

of

ID

High Income Countries … but

mainly for less severe ID

0%

2%

4%

6%

8%

10%

12%

Poor 2 3 4 5 6 7 8 9

Ric

h

Neighbourhood Deprivation

Pre

vale

nce

of

ID

Mild IDSevere DD

High Income Countries …an

association that starts early in life

0%

2%

4%

6%

8%

10%

12%

Po

or 2 3 4 5 6 7 8 9

Ric

h

Neighbourhood Deprivation

Pre

vale

nce

of I

D

Age 5-16

Age 3

Poverty & Intellectual Disability

PovertyIntellectualDisability

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

PovertyIntellectualDisability

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

PovertyIntellectualDisability

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

0%

5%

10%

15%

20%

25%

30%

ID

TD

Conduct Disorder

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5+

ID

TD

Cumulative Social Risk

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

Sample: 17,000 British children age 5-16

Sample: 4,000 Australian children age 6/7

Implication 2: Understanding Risk & Protective Factors Exposure to

poverty is likely to be a key (social) determinant of the health of people with intellectual disabilities

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

0 1 2 3 4 5+

Cumulative Social Risk

Pre

vale

nce

of

Conduct

Dis

ord

er

IDTD

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!