Poverty & People with Intellectual Disabilities Eric Emerson Institute for Health Research Lancaster University

The Plan What is poverty? Why should we be concerned about poverty and people with intellectual disabilities? What are the implications for research, policy & practice?

The Plan What is poverty? Why should we be concerned about poverty and people with intellectual disabilities? What are the implications for research, policy & practice?

Absolute Poverty ‘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

Moderate & Severe Stunting (Under 5s)

Relative Poverty ‘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’

Child Poverty & Per Capita Gross National Income in Rich Countries

Rise & Fall in Child Poverty: UK Poverty Defined: Living in household with less than 60% national median household income (after housing costs)

Poverty … ‘Fundamentally, poverty is a denial of choices and opportunities, a violation of human dignity. It means lack of basic capacity to participate effectively in society.’ - UN Economic & Social Council (1998)

The Plan What is poverty? Why should we be concerned about poverty and people with intellectual disabilities? What are the implications for research, policy & practice?

In General … Poverty is related to Mortality General health Mental health Educational attainment Life experiences and opportunities

150 Years Ago …..

And Now ……. Male Life Expectancy by Occupational Status England & Wales & Social Class

Equivalised Household Income & Child Mental Health in Britain 1999 & 2004

What Processes Mediate & Moderate the Link Between SEP and Health? Health Status SEP Accumulated Risk of Exposure Across the Lifecourse Physical Hazards (cold/damp housing, pollution, toxins, poor nutrition) Psychosocial Hazards (low status & control, uncertainty, ‘life events’)

Poverty and Risk of Exposure to Housing Hazards Odds ratios >

Poverty and Risk of Exposure to Potentially Adverse Life Events Odds ratios >

What Processes Mediate & Moderate the Link Between SEP and Health? Health Status SEP Accumulated Risk of Exposure Across the Lifecourse Physical Hazards (cold/damp housing, air pollution, toxins, accidents, nutrition arduous work) Psychosocial Hazards (low status & control, uncertainty, ‘life events’) Vulnerability & Resilience Biological (embedded organ or system weaknesses) Psychosocial (human capital, social affiliations & social capital) Health Care (including prevention)

The Plan What is poverty? Why should we be concerned about poverty and people with intellectual disabilities? What are the implications for research, policy & practice?

Poverty and Intellectual Disability In high income economies there is a clear association between poverty and the incidence and prevalence of mild/moderate (but not severe) intellectual disability Leonard, H., & Wen, X. (2002). The epidemiology of mental retardation: challenges and opportunities in the new millennium. Mental Retardation and Developmental Disabilities Research Reviews, 8, Leonard, H. et al., (2005). Association of sociodemographic characteristics of children with intellectual disability in Western Australia. Social Science & Medicine, 60,

Area Deprivation & Identification of Developmental Disability

In General … Poverty is related to Mortality General health Mental health Educational attainment Life experiences and opportunities Intellectual disability

Equivalised Household Income & Conduct Disorder Among British Children with Intellectual Disabilities 1999 & 2004

Life Events & Emotional Disorder

Poverty & Neighbourhood Deprivation 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

Area Deprivation & Self-Rated Health Adults with Intellectual Disability, England 2003/4

Attributable Risk Controlling for increased risks of exposure to potential hazards accounts for 20-35% of the increased risk of poor child health and mental health 100% of the increased risk of maternal unhappiness 50%+ of the increased risk of maternal low self-esteem and self-efficacy Emerson, E., & Hatton, C. (in press). American Journal on Mental Retardation. Emerson, E., & Hatton, C. (in press). Journal of Intellectual Disability Research Emerson, E., Hatton, C., Blacher, J., Llewellyn, G. & Graham, H. (2006). Socio-economic position, household composition, health status and indicators of the well- being of mothers of children with and without intellectual disability. Journal of Intellectual Disability Research 50,

Obesity Among Women

Obesity Among Women (in poverty)

The Plan What is poverty? Why should we be concerned about poverty and people with intellectual disabilities? What are the implications for research, policy & practice? Delivery Conceptualisation & design of ‘interventions’

Inequity of ‘Need’ % of British Children with Intellectual Disabilities & Mental Health Problems by Family Circumstances

Delivery Implications Resource allocation ‘Goodness of fit’ Differential efficacy, effectiveness and efficiency of interventions Does this intervention reduce (or exacerbate) inequalities? ‘financial disadvantage was the most salient moderator of outcomes’ of group-based behavioural parent training Lundahl, B, Risser, H J, Lovejoy, M C (2006). A meta-analysis of parent training: Moderators and follow-up effects. Clinical Psychology Review 26 (2006) 86– 104

Conceptualisation & Design Health Status SEP Accumulated Risk of Exposure Across the Lifecourse Physical Hazards (cold/damp housing, air pollution, toxins, accidents, nutrition) Psychosocial Hazards (low status & control, uncertainty, ‘life events’) Vulnerability & Resilience Biological (embedded organ weaknesses, fitness) Psychosocial (human capital, social affiliations & social capital) Health Care (including prevention)

Interventions Generic risk reduction Poverty reduction Specific risk reduction (mediating variables) Housing quality Parenting practices Child protection ‘The reforms outlined in the Child Poverty Review must be implemented to end child deprivation and therefore reduce risk factors for mental health problems.’

Conceptualisation & Design Health Status SEP Accumulated Risk of Exposure Across the Lifecourse Physical Hazards (cold/damp housing, air pollution, toxins, accidents, nutrition) Psychosocial Hazards (low status & control, uncertainty, ‘life events’) Vulnerability & Resilience Biological (embedded organ weaknesses, fitness) Psychosocial (human capital, social affiliations & social capital) Health Care (including prevention)

Interventions: Building Resilience Individual Family Community Nurturing, affectionate and secure relationships with parent Supportive relationship with other adult Positive, rewarding school environments Sense of ‘connectedness’ to the school and/or local community Positive personal achievements Involvement in pro-social peer groups Positive ‘temperament’ Problem solving Sense of meaning

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 social & clinical interventions and directly address the social factors that generate inequality