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

Socio-Economic Status & Cognitive Development 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 wide range 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 ….

Mothers Report of Child ID: Children Age 2-9 (Unicef MICS3)

High Income Countries Strong link between poverty and the prevalence of intellectual disability

High Income Countries … but mainly for less severe ID

High Income Countries …an association that starts early in life

Poverty & Intellectual Disability Poverty Intellectual Disability 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 Poverty Intellectual Disability 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 Poverty Intellectual Disability 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? 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

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!