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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 27
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 28
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 29
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 30
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 31
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 32
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 33
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 35
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 37
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 39
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 40
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 41
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 42
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 43
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 44
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 45
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 46
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 47
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 48
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 49
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 50
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 51
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 52
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 53
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 54
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 55
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 56
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 57
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 58
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 59
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 60
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
×
Page 61
Suggested Citation:"Contents of Report." Institute of Medicine and National Research Council. 1998. New Findings on Poverty and Child Health and Nutrition: Summary of a Research Briefing. Washington, DC: The National Academies Press. doi: 10.17226/6102.
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Page 62

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Concerns about the well being of children and adolescents who live in poverty have grown as the nation has embarked on cz major restructuring of welfare, income support, health, and social service policies over recent years. As such decisions are macle, it is critical that they consider the most current research regarding the effects of poverty anc3 welfare clepenclency on chil- ciren, anc3 the outcomes of efforts to inter- vene in the lives of children anc3 their fami- lies. Although the attention of those who craft welfare reform proposals has been focused largely on the objectives of job training anc3 placement of welfare clients, the new fec3- eral welfare law highlights the health anc3 well-being of children as outcomes that warrant assessment in efforts to evaluate the effects of welfare reform. And while a grow- ing number of interdisciplinary teams are engaged in empirical anc3 evaluation work focused on children living in poverty anc3 in families receiving welfare, little of this re- search actresses issues related to physical health anc3 nutrition. Furthermore, although there is a broacler research literature on the links between income anc3 health (Newacheck et al., 1994; Wise anc3 Meyers, 1988; Wilkinson, 1996), as well as on low-income chilciren's access to health care (Fossett et al., 1992), more information is needled about this complex relationship, including the reasons for anc3 extent of the links. Moreover, although scientists are studying issues related to chilciren's nutrition, their work is largely being carried out in Third World countries. Complicating efforts to assure health care for impoverished children anc3 adolescents are difficulties obtaining accurate estimates of the number lacking health insurance. In an effort to bring together researchers engaged in current studies of poverty anc3 child health anc3 nutrition, to encourage discussion of these issues, anc3 to identify the gaps in U.S.-basec3 research in this field, the Board on Children, Youth, anc3 Families (of the National Research Council anc3 the Institute of Medicine) chose this issue as the subject of its third annual research briefing on welfare anc3 chilciren's development. The briefing, held in May 1997, was co- sponsorec3 by the Family anc3 Child Well- Being Research Network (of the National Institute of Child Health anc3 Human De- velopment, U.S. Department of Health anc3 Human Services). The briefing hac3 three objectives: · to highlight research that bears on contemporary clebates about welfare policy anc3 health care policy for the poor, · to bring this research some of it preliminary to the attention of federal anc3 state policy makers, anc3 · to consider next steps for research that confirms some of these findings, anc3 to explore areas of new research on the well- being of children anc3 youth in the context of devolving responsibility for welfare anc3 health care. 1

This report is organized around the follow- ing three questions that emerged from the presentations and discussions at the briefing: . How do income and poverty affect the health of children and adolescents? How does nutritional status affect children's development? How are children and youth affected by changing patterns of health insurance coverage? Each of these Questions has been the tonic ~ . ~ ot research tor a number ot years. But as with any research, the accumulation of knowledge is incremental and new policy contexts pose new questions that can chal- lenge prior evidence. The briefing as- sembled both well-known and new re searchers investigating these questions to present new findings that, collectively, can expand the knowledge base. In some cases their findings were generated from reanaly- ses of existing datasets (e.g., the Infant Health and Development Project, the Na- tional Health Interview Survey). In other cases, new datasets were analyzed specifi '' r ~. a. ~ 1 ~ catty tor the briefing te.g., the Add Health Study, the Iowa Youth and Family Project, the Community Tracking Study). Most of these data were collected before the enact- ment of major changes in federal welfare and health care policy. In every case, the researchers tried to respond to new informa- tion requirements emerging because of con- temporary policy changes. In the area of child and adolescent health, 2 for example, there is new interest in exam- ining neighborhood-level influences on health care and health status. The ~resent ~ ~ . a. ~ ~ ers at the briefing shared an interest in ex- amining the context in which health care is sought and provided, and in understanding the family processes that may mediate the effects of both neighborhood and economic factors on child and adolescent health. In the area of child nutrition, emerging issues addressed at the briefing include the re- versability of different types and degrees of early malnutrition, the differing conse- quences of the developmental timing of malnutrition, and how environmental fac- tors interact with malnutrition to affect development. r The briefing included pre- sentat1ons trom new longitudinal and evalu- ation research designed to address these questions. Research on children's insurance coverage, as a major determinant of their access to care, is relatively new and has received focused attention in today's policy context. The research on this issue pre- sented at the briefing comes from the new Community Tracking Study, new analyses of the National Health Interview Survey, and a new survey of state Medicaid officials. The briefing also featured a discussion by state health administrators of data and re- search needs from the perspective of state and local officials. Comments from this discussion are presented in quotations that appear throughout the report. Participants' . · . . · . r. 1 Ideas about topics that warrant turtner re- search are included in a section at the end of the report.

The research briefing also incluclec3 presen- tations anc3 discussions of several new child health interventions, some of which are expected to yield data in the near future. These projects are clescribec3 in Appenclix A. Appenclix B contains a list of projects monitoring the effects of welfare reform. The presenters were selected through a lengthy process of peer nominations, start- ing with calls to major experts on child poverty, health, anc3 nutrition. The goal was to identify investigators who hac3 new findings on the issues of concern so that the information could move quickly from re- searchers to policy makers. Although efforts were macle to identify the most significant new research at the intersection of child poverty, health, anc3 nutrition, some rel- evant areas of inquiry were not incluclec3 (for example, although incidence in children of asthma anc3 injuries can be related to pov- erty status see Halfon anc3 Newacheck, 1993, anc3 Rivara, 1995 this report floes not include literature on these areas because they were not part of the research briefing) anc3 there is uncloubtecily much more re- search uncler way than we iclentifiec3 in our planning process. This summary of findings is best viewed as a supplement to the literature on child pov- erty, health, anc3 nutrition, rather than a comprehensive or representative review of current research on these issues. The report offers important new incremental eviclence on these topics from one of a series of re- search briefings of the Board on Children, Youth, anc3 Families that present work in progress anc3 recent findings on various as- pects of welfare anc3 chilciren's development. 3

HOW DO INCOME AND POVERTY AFFECT THE HEALTH OF CHILDREN AND ADOLESCENTS? At a time of tightening health care budgets and enormous health system change, re- searchers are attempting to determine the specific ways in which poverty affects the health of children and youth, and policy makers are searching for the most effective solutions to poor children's lack of health care. Twenty-one percent of children were poor in 1995 (U.S. Bureau of the Census, 1996~.1 The association between poverty and poor child health outcomes has been well documented. For example, research has shown that low-income children were 73 percent more likely to have a severe health condition than nonpoor children (Newacheck, 1994~. Further studies have found that poverty is associated with in- creased neonatal and post-neonatal mortal- ity rates, higher risk of injuries from acci- dents or physical abuse and neglect, higher risk of asthma, and lower developmental scores in a range of tests at multiple ages (Aber et al., 1997~. Less is known about the mechanisms through which poverty oper ates, which aspects of poverty are most dam aging, and the multivariate nature of pov erty and its effects on children and youth. Longitudinal studies show that family income is more strongly associated with children's ability and achievement than emotional outcomes, and early childhood poverty may have an even larger impact (Brooks-Gunn and Duncan, 1997~. Re- searchers studying the relation between income and poverty and the health of chil- dren and youth have found that child health varies by family income, with the percentage of children and adolescents in very good or excellent health rising as fam- ily income increases2 (Federal Interagency Forum on Child and Family Statistics, 1997~. Researchers have also shown that health problems affecting children in the United States, including iron deficiency anemia, underweight and obesity, and asthma, are more prevalent among the poor (Newacheck et al., 1994; Wise and Meyers, 1988~. Research on child health outcomes pre- sented at the briefing addresses these issues by focusing on the context (e.g., families, neighborhoods, etc.) in which health care is provided and seeking to understand how poverty affects children's health. (The sec- ond and third sections of this report also 1This statistic uses the official poverty line, which has been criticized for being too low (Betsen and Michael, 1997~. 2About 88 percent of children and youth in families with annual incomes of $35,000 or more were in very good or excellent health in 1994, compared to 63 percent of children and youth in families with annual incomes under $10,000 (Federal Interagency Forum on Child and Family Statistics, 1997~. 4

explore how poverty influences child health anc3 nutrition anc3 health insurance cov- erage. ~ A study presented by Jeanne Brooks-Gunn of Columbia Univer- sity examined the ef- fect of family anc3 neighborhood income 1 1 1 1 "There has been a transition away from being able to name and count the problems to wanting to know what are our strengths, what is protective of our problems." Susan Nalcler, New Mexico Department of Health on the health care use of young children who were born premature anc3 at low birth- weight (Brooks-Gunn et al., 1997~. The study used data from the Infant Health anc3 Development Program (1HDP), which in- clucles 985 low-birthweight preterm infants anc3 their families in eight sites across the country; the children were seen ~ ~ times from birth to age 8 (Gross et al., 1997~. A quarter of the mothers were white, half were black, anc3 the rest were I-atina. Maternal reports about health care use, family in- come, health insurance, anc3 family charac- teristics were obtained when the children were 12, 24, anc3 36 months of age. Neigh- borhooc3 income was based on census tract residence at time of birth. In the study, the mothers proviclec3 information on hospital- izations. clays spent in the hospital, doctor visits (for well-baby care as well as illness), anc3 emergency room visits in the past year. Data were averaged over the chills first three years of life. Low-birthweight chil- ciren from poorer3 families were more likely to be hospital- izec3, to spend more clays in the hospital, anc3 to have more visits to the emergency room than low- birthweight children from more affluent families, taking into account all other vari- ables, including public and private health insurance. Number of doctor visits was not associated with poverty status. Residence in poor and middle-income neighborhoods was associated with more visits to the emergency room than residence in affluent neighbor- hoods, independent of family-specific in- come and all other characteristics measured (a finding that has heretofore been largely linked to low-income families and low- income neighborhoods). Interestingly, the finding about middle-income families runs counter to the conventional wisdom that low-income families primarily account for 3Families in the study were classified as poor or nonpoor using the 1986 U.S. poverty thresholds, based on family income and size at the 12-month assessment (conducted in 1996~. Regarding neighborhood income, families living in neighborhoods in which fewer than 10 percent of neighbors earned more than $30,000 were designated as poor; families in neighborhoods in which 10 to 29 percent or more of neighbors earned $30,000 or more were designated as middle income; and families in neighborhoods in which 30 percent or more of the neighbors earned more than $30,000 were designated as affluent. 5

emergency room visits. Families in middle- income neighborhoods also reported more well-baby visits than families in poor or affluent neighborhoods, controlling for health insurance coverage. The study also found that health insurance was associated with more doctor visits for the low-birth- weight babies, but not with hospitalizations or emergency room use. Based on the findings of this study. Brooks ~1 1 11 i, Dunn and ner colleagues concluded that among families with low-birthweight babies not only does family income shape the pat- tern of health care use, but the neighbor- hood in which the family resides also plays a role. They called for further exploration 1 . ~ . 1 into identi~vina how novertv affects chil a variety of neighborhoods may alter the relationship between neighborhood and . . emergency V1S1tS. A study presented at the briefing by Kathleen Mullan Harris of the University of North Carolina looked at the effects of nov . i' erty anct welfare receipt on physical health and health risk behavior among adolescents (Harris, 1997~. The study used data from the National Longitudinal Study of Adoles- cent Health (Add Health), a nationally representative sample of 12,105 adolescents in grades 7 to 12 in the United States in 1995. The Add Health survey, which fea- tures a school-based design, was geared to help explain the causes of adolescent health and health behavior. with special emphasis ,, ~ - - -- - - ~ 0 - - - r - - - ~ - - - -- - - -- - - - -- - - - ~ - - - -A - - - - r 1 ~ 1 1 1 A ~ 1 ~1 '' ~1 1 . 1 . ~ dren s health care use. As ~rooks-~unn noted, the study suggests that reducing fam- ily poverty might reduce emergency room use and the number of hospitalizations among low-birthweight babies. In contrast, increasing the number of children with insurance would be more likely to affect . ... . . routine and well-baby doctor V1S1tS. 1 bus, this study suggests that a combination of economic and health care policies would be most effective in improving health care use among poor families with low-birthweiaLt 1 1 . A 1 .1 1 babies. As children are increasingly covered by health maintenance organizations (HMOs) and similar plans, efforts to pre- vent emergency room visits may increase. The ability of HMOs to offer urgent care in on the ettects ot the multiple influences on adolescent life.4 Among the sample, 7,644 adolescents (63 ~ ~ A. percent' were non-~1snanic white. 2.294 is ~ ~ , , id percept J were non-Hispanic black, 1,442 (12 percent) were Hispanic, and 667 (5 percent) were non-Hispanic other. Eigh- teen percent of the adolescents surveyed lived below the poverty line ($16,000 in 1995) and 29 percent lived within 150 per- cent of poverty ($24,000~; 19 percent lived in families that had received some form of social welfare within the previous month. The study found that the effects of poverty and welfare receipt on health and risk be 4Subsequent to the research briefing, the first data from the Add Health study were released (in September 1997~. 6

havior were negative and consistent across a range of outcomes (see Table ~ ). that is. for , , , each neattn outcome, adolescents who live below poverty experience poorer health than nonpoor adolescents; in most cases, the welfare poor those receiving either Aid to Families with Dependent Children (AFDC) or food stamps have the poorest 1 1 1 1 . 1 neattn ancr engage In the riskiest health behavior. Specifically, adolescents living below the poverty line had poorer general health (as reported by the adolescents and their parents); were more likely to miss school due to health or emotional problems; were more likely to have neurological im' pairment, obesity, and asthma; and were more likely to engage in risky behaviors than nonpoor adolescents. The only nega' live behavior that low income adolescents engaged in at a lower rate than or at the same rate as nonpoor adolescents was sub' stance abuse (defined as use of drugs, alco' hoi, and tobacco). This finding may indi' care that this behavior occurs across income lines, although different factors may account for the same rates of use within the two income groups. Furthermore, no differences on any of these outcome measures were found between adolescents who lived below the poverty line and those living in families who were also poor and received welfare. Harris explained the study's findings by noting that access to health care and insure ance coverage differs between nonpoor and poor adolescents, with poor adolescents more likely to lack insurance or have trouble obtaining medical care. Even if they are covered by Medicaid, poor adolescents can encounter difficulties obtaining high' quality care (see section on health insure ance). In addition, when low income ado' lescents have health insurance, they are less likely than adolescents without health in' surance to report that they are in poor health, but they still report poorer health than nonpoor adolescents, according to Harris. Characteristics associated with increased risks of poverty (e.g., family structure- living with a single mother, urban residence, minority and immigrant status) are also 1 . 1 . 1 assoc~atecr with ~ncreasecr risks of health problems among adolescents, according to Harris. In addition, contextual influences, such as family interaction and parenting behaviors, affect adolescents' health and risk behavior. Parents in low~income families tend to monitor their teenage children's behavior to the same extent or more than nonpoor parents, the study found, while low-income parents seem to be less involved in other dimensions of their adolescents' lives (e.g., talking to other parents; becom' 1 1 . ing involved in their children's school; and 5Risky behaviors include ever having sex, lack of birth control at first intercourse, lack of birth control at last intercourse, ever having a sexually transmitted disease, excessive symptoms of depression, delinquent behavior, violence toward another, violence as a victim, and substance abuse. 7

Table Adolescent Health Status and Health Behavior by Poverty Status Percent Percent Nonpoora poorb Percent Welfare PoorC Physical Health General health fair to poor Missed school due to health or emotional problem Neurological impairment Obesity Asthma 4.6 33.7 15.9 24.5 31.2 1.5 9.1 10.1 40.8 13.2 44.5 26.4 32.0 13.9 Health Risk Behavior Ever had sex 35.3 47.0 48.3 Birth control at first intercourse 66.5 58.9 55.0 Birth control at last intercourse 69.8 62.5 62.5 Ever had a sexually transmitted disease 5.7 8.4 10.0 Depression 19.8 29.5 32.5 Delinquency 21.8 25.5 25.5 Violence toward others 32.0 44.2 47.5 Violence as a victim 18.4 26.0 28.1 Substance abuse 20.0 17.3 17.9 a Nonpoor adolescents live in families with incomes above the poverty line for a family of four {$ 16,000 in 1995~. b Poor adolescents live in families with incomes below the poverty line. c Welfare poor adolescents live in families with income below the poverty line and receipt of either AFDC or food stamps. SOURCE: Data from Harris ~ 1 997] . communicating with their children about friends, personal problems, anc3 school ac- tivities). The study also found that in fami- lies that ate dinner together anc3 parented clemocratically,6 aclolescents were less likely to have sex, be clepressec3, or act violently toward others. School anc3 neighborhood effects, which the presentation clic3 not ex- plore, could also play a role in explaining the findings, Harris said; among the school anc3 neighborhood effects that research has shown as most promising are neighborhood anc3 community resources such as youth groups anc3 community centers, the quality of schools anc3 teachers, levels of crime anc3 6Shared meals, one of the measures of "family connectedness," represent parents' involvement with their children by virtue of their presence during the meal and the likely communication exchanged, according to Harris; demo' cratic parenting represents a type of parenting behavior (which has beneficial eEects on most outcomes) in which parents and adolescents jointly make decisions about the adolescent's life. 8

violence in neighborhoods, and the socio- economic status of neighborhoods. This study suggests that adolescent health, broadly defined, is associated with poverty, and that family behavior such as sharing meals may contribute to improved out comes among low-income adolescents. Ad- ditiona1 longitudinal research is needed to uncover the causal direction of these rela- tionships and isolate parenting behaviors that improve outcomes. Another study, presented by K.A.S. Wickrama of Iowa State University, ex- plored adolescent health in a rural economy, specifically the effect of family economic pressure on adolescent physical health status. The study (Conger and Wickrama, 1997) used as its sample the Iowa Youth and Family Project, which in- cludes 350 white adolescents and their par- ents in a rural, predominantly agricultural, eight-county area in northern Iowa. Data were collected from ~ 989 to ~ 994. The study considered three variables- economic pressure, parental rejection (signi- fying parents' feelings about their children), and adolescent physical complaints7 as well as changes in these variables over a period of a few years. According to the researchers, economic pressure contributes to the psychological well-beina of parents. . .. . - - O - r- - --, and distressed parents tend to be more irri- table, more power-assertive, less tolerant, more rejecting, and more hostile toward their children. Among the questions the study asked: Does family economic pressure during early adolescence influence parental rejection? Does parental rejection influence adolescent physical health? Does growth or decline in parental rejection parallel growth or decline in family economic pressure? Does growth or decline in adolescent physi- cal health parallel growth or decline in pa- rental rejection? Does parental rejection ~ J during early adolescence directly influence later growth in adolescent physical health complaints? At the outset of the study, parental rejec- tion was higher in families experiencing high economic pressure and both of these factors were associated with more physical complaints by the adolescents. Further- more, these dimensions of family economics and functioning interacted over time so that changes in adolescents' physical complaints co-occurred with changes in economic pres- sure and in parental rejection. 7Family economic pressure was measured by parents' responses to questions about ability to meet their basic mate' . 1 1 r 1 . 1 1 1 . 1 1 1 1 . ~1 rial needs tor such items as a home, clothing, household items, a car, food, medical care, and recreational activities. Parental rejection was measured by parents' and adolescents' responses to allestions aholit parents' feelings of trilst. 1 1 . r . . 1 1 . 1 .1 1 love, and satisfaction with their children. Adolescent nhvsical health status was determined bv responses to Guess tions about common physical -~---r2~- diarrhea, stomach aches, and skin rashes. ~/ / ~1 complaints over the past three months, including headaches, coughs, sore throats, 9

The findings presented at the workshop confirm previous findings that illustrate an association between poverty anc3 health. They further suggest that community anc3 family may alter the relationship between the two. As policy makers seek to improve health outcomes for children anc3 families living in poverty, findings such as these are relevant because they suggest options for intervention. For example, the association between community income anc3 emergency room visits for low- anc3 moclerate-income low-birthweight babies suggests that inter- ventions targeting the incliviclual overlook the potential value in community-level responses. The research presented raises a diverse set of questions for study, many of which are not commonly brought up in discussions of health care among the poor. What is the role of neighborhood context in families' access to health care? How can research explore aspects of health care delivery (i.e., proximity anc3 hours of operation of physi- cian versus hospital services), family anc3 community norms, anc3 prevailing health behaviors? What are the likely conse ~ . quences ot 1mprovmg access to insurance among children with special health risks (such as low birthweight or special health care needs), as compared to children with- out these special circumstances? Should differential effects on amounts anc3 types of health care used be anticipated? 10 The unique health risk behaviors anc3 needs of adolescents, which appear to be worse among the poor, raise questions about the need to adapt tociay's institutions anc3 mech- anisms for delivering health care for cliffer- ent age groups. Does the location of health care facilities anc3 the type of professionals who provide health care affect access to anc3 effectiveness of health care for adolescents, particularly those living in poverty? What is the role of the family alone anc3 jointly with health providers in promoting health among adolescents living in high-risk com- munities? How will recent changes in health care delivery affect this age group, anc3 will the effects cliffer by family income anc3 economic composition of the neighbor- hooc3? Will managed care contracts for the care of adolescents take into consideration the longstanding recognition by medical professionals that special skills anc3 knowl- ecige are required to treat adolescents? Furthermore, what can be learned from families that have successfully navigated their way out of poverty in crafting effective health-care programs for low-income chil- ciren anc3 youth? Does urban poverty affect the health of children anc3 adolescents clif- ferently than rural poverty? What clifferent challenges JO the geographic location of poor populations pose to the health care delivery system? How can racial anc3 income-basec3 disparities in health outcomes be reclucec3?

As states contend with the redesign of health-care delivery systems now uncler ways amid major health system change, how should low-income children anc3 youth, anc3 those with special needs, be tracked to en- sure that they c30 not fall through the cracks? How will cutbacks in state anc3 local funding, the diversion of Meclicaic3 revenues to managed care organizations, anc3 pro- posec3 reductions in disproportionate share funding uncler Medicare anc3 Meclicaic3 affect the ability of public hospitals, teaching hos- pitals, academic health centers, community health centers, anc3 others who have tracli- tionally served the poor anc3 uninsured to continue to serve these populations? Under the proposed Performance Partnership Grants Program, each state must negotiate a maternal and child health action plan with the U.S. Department of Health and Human Services in 1998; the plan will include perfor' mance objectives that are specific in terms of outcomes, processes, and capacity, and that can be achieved over 3 to 5 years. 11

HOW DOES NUTRITIONAL STATUS AFFECT CHILDREN'S DEVELOPMENT? Research on the effects of poverty on chil' ciren's nutrition and subsequent develops ment much of it concluctec3 outside the United States has begun to reveal how these factors may interact over time to exac' erbate early problems. Studies have shown, for example, that poverty affects pregnant women's nutritional status by reducing in' come available for food and failing to ensure that fetuses receive the nutrition essential to normal brain development. Malnutrition in young children can leac3 to iron deficiency and growth failure. Deficits in brain growth and central nervous system development resulting from early malnutrition can com' promise early learning, which can then become a risk for decreased economic op' portunities and poverty Warp, 1993, 1996, and 1997; Pollitt, 1995~. Furthermore, obe' sity has been found to be a serious problem among low income populations in the United States and, combined with poor dietary patterns, can predispose children and youth to diabetes, heart disease, and other health problems later in life (Troiano et al., 1995; Schonfeld'Warden and War' den, 1997; Must, 1996~. Despite these acknowledged links, few data exist to help us understand how poverty affects American children's health and nu- trition.9 Most recent research on malnutri' lion has been done outside the United States in studies of how malnutrition devel' ops and affects the growth and well-being of all children, how poverty affects specific types of nutritional deficiency in children worldwide, and what interventions are ef' fective.10 Research conducted outside the United States has limited applicability to poor populations in this country because of differing environmental conditions and levels of malnutrition and a dearth of infor- mation on the kinds of deficiencies that exist in at~risk U.S. populations. Moreover, 9Two national surveys measure children's nutrition the National Health and Nutrition Examination Survey, or NHANES, and the Pediatric Nutrition Surveillance System, or PED NSS and both have some flaws, according to researchers familiar with them. The NHANES is done infrequently and does not take measurements in the north' em United States during the winter months, which is when significant nutritional problems can arise among chill dren. The PED NSS depends primarily on children already in WIG, a program that features considerable state variability in participation; moreover, the status of those unenrolled (who may be at higher risk of malnutrition) is unknown. In addition, the PED NSS does not link its findings to housing, welfare participation, or other forces that might influence children's nutritional status. Other surveys, such as the Behavioral Risk Factor Surveillance System, have been criticized by researchers for not adequately addressing pediatric undernutrition. Several studies in the United States are exceptions: For more information, see research by Rush and colleagues (Rush et al., 1988) on the eEect of nutritional supplements on the health status of children in the United States, and Brown and Sherman (1995) on the eEect of inadequate nutrition on cognitive development. 12

even when the U.S. data exist, they seldom capture the multiple factors now known to influence chil- dren's nutritional status and development. Despite these limitations, data from low-income countries can be helpful in understanding the effects of poverty on child development in the United States and some malnutrition research in Third World countries offers lessons relevant to American children. Studies that examine the diet of children and adolescents in countries from which children and families immigrate to the United States have impli- cations for the growing share of the U.S. child and youth population that is com- posed of immigrants. Research into the effect of food shortages among children in foreign countries may have implications for . American children living in families that no longer receive food benefits and whose in- comes under welfare reform do not compen- sate for overall benefit losses. And studies overseas of iron deficiency anemia, which affects an estimated 25 percent of infants worldwide (Florentino and ~ ~u~rr~ec, 1984), have implications for the 9 percent of "Malnutrition affects the immune system; if policy makers want to save health care costs, they must nourish kids." Deborah Frank, Boston Medical Center American 1- and 2- year-olds who have iron deficiency anemia (Looker et al., 1997; Federa- tion of American ~ . . r' . Societies tor Exper~- mental Biology, 1984~. Studies presented at the research briefing . ~ ~ ~ ~ . ~ A. . examined the effect of iron deficiency ane . 1 1 1 m1a on the development of infants in Gua- temala, Costa Rica, and Chile. According to Betsy Lozoff of the University of Michi- gan (Lozoff et al., 1997a; Lozoff et al., 1997b), a follow-up study in Costa Rica found that children who had iron deficiency in infancy (and also had treatment) had lower mental and motor test scores at 5 years and at 10 to 13 years, did more poorly in reading and writing at 10 to 13 years, and had more behavioral problems at 10 to 13 years than peers who had good iron status in infancy, taking into account family and environmental factors (see Figure 1). Even more than 10 years after treatment, children with severe, chronic iron deficiency in in- fancy were found to be at a behavioral and developmental disadvantage relative to non-iron-deficient peers. Continued fol i~Pollitt (1994) argues that despite recognition that the magnitude and degree of poverty in low~income countries are larger and more severe than those in the United States. data from these countries can be helpful in understand' . 1 ~ ~ #_ 1 1 . 1 1 1 1 1 ~ ~ 1 . 1 . 1 1 1 1 1 . . A. sing three up.. public health problems: ~ J the ep~aem~otogy and developmental s~gn~cance of iron~deficiency anemia, 2) the impact of early supplementary feeding on cognitive development, and 3 ~ the correlation between common illnesses and concurrent malnutrition, on the one hand, and educational outcomes among low income school children, on the other. 13

Figure 1 Infant iron Deficiency: Effect on Standard Tests in Early Adolescence {Costa Rica} ~- 120 a: ~ 1 10 L~ a: o 100 90 85 - , Chronic iron deficiency Iron sufficient Reading Arithmetic Writing Motor NOTE: All p values < 0.05 after control for background factors. Reading and arithmetic tests are the Wide Range Achievement Test; writing test is the Wechsler Individual Achievement Test; and motor test is the Bruininks-Oseretsky Test of Motor Proficiency. SOURCE: Data from Logoff et al. t 1 997a]. low-up studies will determine the ultimate eclucational level and career paths of chil- ciren and youth in these regions with iron deficiency in infancy. A separate study in Chile found slower nerve conduction in the auclitory pathway among 6-month-oic3 infants with iron clefi ciency anemia, according to Lozoff. Differ- ences were not corrected after a year of iron therapy (Roncagliolo et al., 1996~.~2 This is the first direct eviclence that iron deficiency alters brain development in human infants. Earlier studies also suggested that when iron deficiency progresses to anemia, subjects perform poorly on developmental tests cle i2Iron plays an important role in the creation of myelin which, in turn, affects nerve conduction. Animal studies have shown that iron deficiency during early development produces a deficit in brain iron that is not corrected by iron treatment. 14

spite iron therapy (Walter, 1989), and that iron-deficiency anemia during infancy may be associated with irreversible adverse ef- fects on cognitive performance (Walter, 1994~. In the United States, where infant formula and cereal are supplemented with iron (and sometimes ascorbic acid, which augments iron absorption), there has been a consider . . . . . . able Increase In Iron consumption among infants, according to Lozoff. However, she noted, toddlers and preschoolers still suffer from anemia (Yip et al., 1992~; adolescents are also at risk due to rapid growth and poor diet (Looker et al., 1997~. Because of the changes resulting from welfare reform, re- searchers may need to monitor populations such as the children of immigrants and the near-poor who may no longer be enrolled in entitlement programs that provide food benefits. It is also crucial at this stage to explore how iron deficiency anemia can be prevented, I-ozoff said. A separate study on nutrition in Kenya, Mexico, and Egypt underscores the impor- tance not only of food quantity, but of food quality. The goal of the Human Nutrition Collaborative Research Support Program was to gauge the importance of the quality of children's diets for cognitive develop ment (Sigman, 1995), according to Marian Sigman of the University of California at Los Angeles, who presented the findings. The three-country study, which was orga- nized in the early 1980s, enrolled about 750 families. Over the course of a year, nutri- tional levels were assessed in monthly two- day home observations of food consumed, interviews of all family members, and physi- cal exams of the children. In addition, blood levels of various nutrients were as- sessed, social and economic conditions of the family were measured, and a weekly home visit recorded illness. Diet quantity, as defined by adequacy of protein-energy intake, was only weakly and variably related to cognitive outcomes. In contrast, diet quality, as defined mostly by the availability of animal products, proved important for the development of cognitive abilities in the toddlers and school-age chil- dren studied in the three countries.13 In the Kenya sample, temporary food short- ages in 1984 provided an opportunity for researchers to study the effects of a decline in food availability on the behavior of young children and their mothers (McDonald et al., 1994~. Toddlers were affected the least because their food intake i3Preliminary studies have been done to determine the particular micronutrients associated with scores on the developmental and cognitive scales. In general, animal products were important not so much as a source of energy or protein, but as a source of vitamins and minerals otherwise restricted in local diets. It is also important to con' sider factors in addition to animal product intake such as socioeconomic status, family rearing style, parental abilities and education, and length of child's schooling that could affect children's cognitive scores. 15

Figure 2 Effect of Food Shortage on SchooIchildren's CIassroom Behavior and Activity {Kenya, ~ 984} > 20- a: Lo Q O 16 a: . _ U a: o a: a: O 8 4 . off-Task Classroom Behavior High Activitv on the Playground Before During After Food Shortage * Age of schoolchildren ranged from 7 years, 1 month, to 8 years, 5 months. SOURCE: Data from Sigman [ 1 995~. and weight-for-age did not decline, while their mothers suffered the most they had less to eat and less to feed the rest of the family. The temporary food shortage seemed to have a profound effect on school- children, who had less to eat during the food shortage than the toddlers. As a result, schoolchildren showed a small decline in their attentiveness to classroom tasks and a reduction in activity on the playground (see Figure 2~. In times of food shortage, Sigman noted, Kenyan children are affected not only by the food they eat, but also by their living environment and by how their par ents distribute the food. Studies led by Ernesto Pollitt of the Univer 16 sity of California at Davis looked at the effects during two periods of early supple- mentary feeding on cognition in four Guate- malan villages. The Institute of Nutrition of Central America and Panama longitudi- nal study was conducted from 1969 to 1977; a cross-sectional follow-up of former partici- pants was carried out from 1988 to 1989 (Pollitt et al., 1995~. The aim of the studies was to assess the differential effect of two dietary supple- ments, Atole (a highly nutritious supple- ment containing 163 kcal/682 kI and ~ ~ .5 g protein per cup) and Fresco (a less nutri- tious supplement containing 59 kcal/247 kI and O g protein per cup), which were given

Figure 3 Effect of Supplementation on Vocabulary Scores, by Degree of Poverty {Guatemala, ~ 988-89} 30 Lo .a: ~ 25 Q ~ 20 o a: o ~ 10 supplement ~ Fresco supplement 26 5 27 28 o 26 2S 19 Severe Moderate Degree of Poverty SOURCE: Adapted from Brown and Pollitt t1996~. to Guatemalan mothers, infants, anc3 young children up to age 3. When the subjects reached adolescence, they were given a battery of psychoeclucational anc3 informa- tion-processing tests. Adolescents who as children hac3 received Atole, the supplement higher in nutrients, scored significantly higher on tests of knowledge, numeracy, reacling, anc3 vocabu- lary than those given Fresco. Atole was also associated with faster reaction time in infor- mation-processing tasks. In aciclition, there . rat. . were s~gn~cant Interactions between type of dietary supplement anc3 degree of poverty: At the lower ends of the poverty scale, Slight those who received Atole supplements per- formec3 significantly better than those who received Fresco supplements; at the higher ends of the scale, there were almost no clif- ferences between children who received the supplements (see Figure 3~. From the fol- low-up survey, the researchers concluclec3 that the increase in nutrients proclucec3 by the dietary supplements explain the cliffer ences in test performance of the Guatema- lan children given Atole supplementation anc3 those given Fresco. In another study in West Java, Indonesia, Pollitt anc3 colleagues tested how supple- ments affect nutritionally at-risk children of 17

different ages (Iahari et al., 1996; Walka et al., 1997~. Over a 12-month period, two groups of children ~ I 2 and 1 8 months of age) were given three different nutritional supplements: high energy plus micronutri- ents, skim milk plus micronutrients, and skim milk alone. The children were tested every two months to determine how they were progressing in level of activity, mental development, and interaction with their social and physical environment. As expected, the supplements had different effects with different timetables, according to Pollitt. In most of the developmental areas that were assessed, the group that re- ceived the high energy plus micronutrient supplement benefitted more than the group that received only skim milk. With some exceptions, there were no major differences between results for the group given the en- ergy and micronutrient supplement and the group given the supplement consisting of skim milk and micronutrients. Although research on child malnutrition has been done primarily outside the United States, a study examining the U.S. Food Stamp Program shows how food spending and nutritional intake can vary over the month for families with children. Parke Wilde of Cornell University pre- sented the results of a study of the monthly cycle of food use by food stamp recipients (Wilde, 1 997, and Wilde and Ranney, 1997~. More than 25 million Americans used food stamps in 1996. The study, the 18 first to measure monthly cycles nationally, used two nationally representative surveys- the Bureau of Labor Statistics' Diary Con- sumer Expenditure Survey (CEX), which reports spending by consumer units on food and other frequently purchased items, and the U.S. Department of Agriculture's Con- tinuing Survey of Food Intake by Individu- als (CSFII), which reports actual food in- take by household members; the study used 1 988-92 data from the CEX and 1 989-9 1 data from the CSFII. About half of the food stamp households in the study received AFDC and most of the remaining house- holds had some other source of income, such as wages or social security. Food expenditure and food intake exhibited distinct monthly patterns among the food stamp households, according to Wilde. Mean daily per-person expenditure on food at home peaked sharply in the first three days of the food stamp month and flattened out for the remainder of the month. There was little difference in the spending cycle for families with and without children under age 18. Per-person food expenditure was lower for families with children because children consume less food than adults (teenagers excepted), so this difference does not indicate less adequate food supplies for households with children. The monthly cycle of food intake varied less than the cycle of food spending, because food stamp families store much of the food purchased during their grocery shopping trips at the beginning of the month. Mean

Figure 4 Monthly Patterns of Food Energy Intake of Food Stamp Recipients, by Age Too 90 80 70 60 o a: a: ~ 40 50 30 20 10 o Week 1 Week 2 Week 3 Week 4 Child (46 6%) Adult (53 4%) * Caloric intake in week 4 is significantly less than in week 1. NOTE: Children are defined as ages birth to 18. SOURCE: Data from Wilde ~ 1 997]. food energy intake remained steacly for the first three weeks and clipped moderately in the fourth week (see Figure 4~.~4 Because food energy is so essential, even this mocler' ate clip in food energy intake may inclicate substantial stress in the household budget at the end of the month. Aclults absorbec3 almost the full cirop in food intake, eating significantly less in the fourth week than in the first. Food intake for children and aclo' lescents remained fairly constant over the food stamp month, inclicating that parents may be protecting their children from the cirop in food at month's end (or may be reluctant to report that their children are going hungry). The study found that AFDC nonrecipients i4This dip was not statistically significant for the full sample, but it was significant for some foods, such as dairy products and fruit. 19

experienced a significant drop in food in- take in week four of the food stamp month, while AFDC recipients experienced no drop. This difference could indicate that some aspect of the AFDC progra~per- haps the receipt of cash benefits twice monthly ameliorates food shortages at the end of the food stamp month. Or other household differences between AFDC re- cipients and nonrecipients could be respon- sible, according to the study. Wilde and his colleagues called for further research to assess the nutritional implica- tions of the cycle of food intake, as well as for the addition to current national surveys of questions related to the time of month when households receive cash income; sur- veys currently ask only when households receive food stamps. Wilde's findings, coupled with the possibility that welfare reform may reduce food accessibility for low- income families (Willis et al., 1997 I, raise concerns that reductions in nutrition pro- grams and decreases in welfare rolls may harm childhood nutrition. Poverty and nutritional programs are not the only factors that influence children's nutrition. Anything that affects a family's resources including shelter, transportation, and medical care can affect children's nutritional status (though no U.S. nutrition monitoring system currently considers the entire picture). Deborah A. Frank of Bos- ton Medical Center and her colleagues con- ducted the Nutritional Surveillance Pro- gram in the Pediatric Emergency Room to 20 determine seasonal variations fence of low-weight-for-age among young children (Frank et al., 1996~; weight-for-age is a good predictor of mortality, along with health indicators such as low birthweight, inadequate nutrition, and acute or chronic illness. i n the preva Frank and her colleagues analyzed data on 11,118 children ages 6 to 24 months who visited the Boston City Hospital Pediatric emergency room between July 1989 and June 1992. Medical diagnoses were docu- mented on a randomly selected subsample of ~ rem ~ .' ~ i,30v c~lictren. A questionnaire about food insecurity was administered to a subsample of 269 families with children under 3. The percentage of children visiting the emergency room with weight-for-age below the fifth percentile was significantly higher in the three months following the coldest . ~. . . . . . months of the year than in the remaining months of the year, taking into account year of measurement. The questionnaire sug- gested a relationship between economic stress and food insecurity that might help explain the seasonal effect. Families who were without heat or who were threatened with utility turnoff the previous winter were twice as likely as other families to report that their children were hungry or at risk for hunger. Frank and her colleagues concluded that winter and early spring constituted periods of increased nutritional risk in this sample ot predominantly low-income children,

probably clue to the increased caloric need associated with cold stress anc3 infections.l5 And they called for further research to cle- termine whether clecreasec3 caloric availabil . . . . . . . try aue to nlgn nearing costs a "heat or eat" effect in which families must choose between paying for heating or paying for food also contributes to this phenomenon. Given the potential selection effects associ- atec3 with emergency room use, it would be useful for this study to be replicated using a population-basec3 sample (the researchers found no change in the demographics of emergency room use cluring the course of the stucly). In abolition, it will be important in future studies to supplement parent re- ports of food insecurity (hunger or risk of hunger) with medical reports on nutritional status of the children. in a separate study, Frank anc3 her colleagues tested the hypothesis that poor families' receipt of housing subsidies is associated with improved nutritional status in their children (Meyers et al., 1992/93~. The study was carried out in 1992 in Boston, where 70 percent of low-income renters spend at least half of their income on hous- ing; food support programs alone JO not provide an adequate diet for this population. The study sample was 203 children uncler age 3 anc3 their families who were seen clur- ing one of 27 24-hour periods in the pediat r1c emergency room of Boston City Hosp1- tal. According to Frank, the study found that receiving a housing subsidy is associ- atec3 with improved growth in low-income children, an effect that is consistent with housing subsidies having a protective effect against chilc3hooc3 undernutrition. It is critical to continue research that can inform efforts to intervene in the lives of children who have experienced malnutri- tion, particularly American children anc3 youth. Among the questions that warrant attention: How floes malnutrition affect cognitive development anc3 school achieve- ment? Are some of the consequences of malnutrition easier to reverse than others? Are some irreversible? How the timing of interventions affect development anc3 the onset anc3 duration of the nutritional deficit? What are the implications for targeting scarce funds for intervention? What role floes a chilc3's overall health, the conditions in which he or she was raised, exposure to other risks, anc3 community context play in exacerbating or mitigating the effects of malnutrition? Do these factors vary with child age, age of onset/exposure to poor nutrition, anc3 length of deprivation? How can longitudinal studies of American children who have experienced differing degrees of malnutrition provide policy-rel- evant information? How will changes in federal anc3 state wel- fare policy affect chilciren's nutritional sta i5Malnourished children are more likely to get sick because malnutrition affects the immune system. i6This eEect has been replicated prenatally in a study of low birthweight in Chicago (Roberts, 1997~. 21

tus, anc3 thus their development, anc3 how will these outcomes be monitored ? Will cl ifferent groups of children be affected cl if- ferentially (i.e., infants anc3 tocicilers versus adolescents, immigrants versus native-born children, poor versus near-poor families) ? Among families living in poverty or near poverty, to what extent is the nutritional status of children anc3 adolescents affected by fooc3 programs at school anc3 in other settings? Do these programs have specific effects on fooc3 intake or fooc3 quality? What are the differential effects on child nutrition of policies that use such strategies as the direct provision of fooc3 (e.g., school lunch), fooc3 vouchers (e.g., the Special Supplemen- tal Nutrition Program for Women, Infants, anc3 Children, or WIC, anc3 fooc3 stamps), anc3 nontargetec3 income supplements?l7 Given the research on the importance of fooc3 quality, what role can varying strate- gies such as fooc3 benefits that restrict what can be purchased, as is the case with WIC, consumer education, anc3 dietary supplements play in improving child nu · ~ trltlon! What can aciclitional research tell us about how families package anc3 use their resources over time anc3 across family members (in- clucling among extenclec3 family members anc3 "fictive" kin), anc3 how these choices affect fooc3 expenditures, fooc3 intake, anc3 child nutrition? How c30 these choices af- fect infants, tocicilers, school-age children, adolescents, anc3 pregnant women? 1 7For existing research on the ejects of school nutrition programs, WIC, and food stamps on children and youth, see Fraker, 1990a and l990b; Fraker et al. 1995; Gordon et al., 1995; and Devaney et al., 1989 and 1990. 22

HOW ARE CHILDREN AND YOUTH AFFECTED BY CHANGING PATTERNS OF HEALTH INSURANCE COVERAGE? Several major policy changes affecting health insurance for children anc3 youth have taken place in recent years. Most notably, expansions of the Meclicaic3 pro' gram have increased the number anc3 pro' portion of Meclicaic3'insurec3 children (Newacheck et al., 1995~. Managed care' type plans are serving a growing share of private anc3 Meclicaic3'enrollec3 children (Rowland anc3 Hanson, 1996~. Despite these increases in Meclicaic3 coverage, the percentage of children insured remained stable between 1988 anc3 1992 because of a decrease in private insurance anc3 an in' crease in Meclicaic3 (Newacheck et al., 1995~. There is some evidence of Meclicaic3 coverage "crowding out" private coverage (sub ay anc3 Kenney, 1997; Cutler anc3 Gruber, 1997~. (For more information on Meclicaic3, see box on p. 24.) A number of studies have clocumentec3 the negative consequences of lack of insurance among children anc3 youth. Using data from the 1980 National Medical Care Utilization anc3 Expenditure Survey, Spillman (1992) found that uninsured children anc3 acloles' cents were 14 percent less likely to use medical services (nonemergency ambulatory care) than insured children anc3 youth; among those who used medical services, uninsured children hac3 15 percent fewer visits than insured children. Marquis anc3 Long (1994-95, 1995), using data from the 1987 National Medical Expenditure Survey, found that uninsured children anc3 youth received 70 percent of the outpatient visits received by similar children anc3 youth with insurance, anc3 about 75 to 85 percent of the inpatient clays. Furthermore, children anc3 adolescents who lack health insurance are less likely to have a usual source of care, are less likely to be immunized anc3 receive well~baby care or well~chilc3 care, anc3 are more likely to be hospitalized for conditions that could be avoiclec3 (Kasper, 1987; Rosenbach, 1985; Short anc3 Leftkowitz, 1992; Leftkowitz anc3 Short, 1989~. A Kaiser/Commonwealth Fund health insurance survey found that 34 percent of the uninsured clic3 not receive needled care, anc3 72 percent postponed needled care (Davis et al., 1995~. A recent survey from the National Center for Health Statistics (NCHS) found that, compared with privately insured children from birth to age 18, children and adoles- cents without health insurance are six times more likely to go without needed medical care, five times more likely to use hospital emergency rooms as a regular source of care, and four times as likely to have necessary care delayed (Simpson et al., 1997~; the NCHS study analyzed the Access to Care and Health Insurance questionnaires of the 1993 National Health Interview Survey, the 23

first national survey to ask about unmet needs for health care. Although Meclicaic3 coverage reduces cliffer- ences in access to care, children and youth covered by Meclicaic3 still experience barri- ers in obtaining care. Children and acloles- cents covered by Meclicaic3 have less access to appointments (Meclicaic3 Access Stucly Group, 1994) and physicians (Yuc3kowsky et al., 1990), compared to children and youth covered by private insurance. Low-income children with Meclicaic3 have improved access to care compared to uninsured poor children; however, compared to children living above the poverty level, they are less likely to receive routine care in physicians' offices and more likely to lack continuity of i8For further discussion of problems in access to health care and related services by adolescents, see Office of Tech- nology Assessment, 1991. 24

care between routine and sick care (Peter et al., 1992~. Compared to uninsured chil' dren, Medicaid~insured children (those with a full year of coverage) are more likely to have a well~child visit; but even if all chil' dren under 200 percent of the poverty line had Medicaid, low income children would lag behind other children in their use of preventive services (Short and I-eftkowitz, 1 992~.l9 Despite the expansion of Medicaid and increases in coverage over time, many chil' dren and youth lack health insurance. Kogan and colleagues (Kogan et al., 1995) found that about a quarter of children and youth lacked health insurance for at least one month during their first three years of life and more than half of these children had a gap in insurance for six or more months. Not all children who are eligible for Medicaid are enrolled in the program. Efforts to improve health care for children and youth living in poverty have focused on improving their access to care. An Institute of Medicine report on access to health care defines access as "the timely use of personal health services to achieve the best possible health outcomes" (Millman, 1993 ). Access to pediatric and adolescent care is affected by factors such as income, race and ethni' city, health insurance status, geographic ~ .. . region, tamely makeup, and family values. Research has shown that children and youth in low income families experience racial and income~based disparities in their health outcomes (Newacheck et al., 1994; Wise and Meyers, 1988~. Adding to the problems of obtaining health care for impoverished children and adolescents is the difficulty of getting accurate estimates at the community and state levels of those who lack health Insurance. Several current initiatives to reform health care are focused on increasing insurance coverage among children and youth. Re- cent Congressional actions are likely to further increase the number of children covered.20 Expanding coverage for this population requires programs designed to Challenges remain for assuring that increased investments in Medicaid translate into improved care and out- comes. Piper and colleagues (Piper et al.. 1990) examined whether expansion in Medicaid elipibilitv in Tennessee . 1 1 1 improved prenatal care and pregnancy outcomes by comparing populations before and after the policy change. Despite increased enrollment, they found no improvements in the use of prenatal care in the first trimester and very low or moderate birthweight. Hass and colleagues (Hess et al., 1993) examined a similar expansion of coverage of pregnant women (up to 185 of the poverty level) in Massachusetts. They found that although adequate prenatal care was consistently associated with reduced severity of pregnancy-induced hypertension, the rate of adverse ma- ternal health outcomes in uninsured women, while slightly higher than that for women with private insurance, was . . . not s~gn~6cant. 20The Children's Health Insurance Program (CHIP), an initiative created under the new Title XXI of the Social Security Act and included in the Balanced Budget Act of 1997, for example, sets aside $24 billion over five years for states to expand health coverage to uninsured children whose families earn too much for Medicaid but too little to afford private coverage. 25

consider the number of uninsurec3 children, their characteristics anc3 those of their fami- lies, anc3 the reasons they are uninsurec3. In order to finc3 answers to these questions, the Center for Studying Health System Change is tracking changes in the health care system anc3 their effects on people anc3 providers. The Center's Community Track- ing Study (CTS) features national surveys of households, physicians, employers, anc3 health plans, plus case studies in selected markets. The surveys are being carried out nationwide in 60 randomly chosen health care markets anc3 will be repeated on a two- year cycle. The preliminary findings pre- sentec3 at the research briefing were drawn from the CTS Household Survey, a tele- phone survey with an in-person supplement for households without telephones. Inter- views were concluctec3 between July 1996 anc3 February 1997 anc3 involved 24,000 families (44,000 inclivicluals), a third of which have children (Reschovsky et al., 1997~. Although the results constitute only 70 percent of the ultimate sample for this survey, they fully represent the U.S. popula- tion. The study defines children as incli- vicluals uncler age 18. Some 8.5 million (about 12 percent) American children were uninsurec3 at any point in time cluring late 1996 anc3 early 1997,21 according to preliminary findings presented at the briefing by the Center's James Reschovsky. Furthermore, most un- insurec3 children (6.7 million. or 9.4 percent ~ ~ ~ ~ . ~ ~ ~ ot all ch~ictrenJ were uninsurec3 for all of that one-year time period, anc3 5.4 million chil- ciren (7.6 percent) were uninsurec3 for part of that year. Uninsurance rates among chil- ciren vary considerably from city to city; in some localities, nearly one child in five lacks insurance, while in others, the number is much lower. Thirty-three percent of uninsurec3 children are uncler age 6, the CTS found. More than three-quarters (78 percent) live with work- ing parents anc3 68 percent live in two-par- ent families. More than a third (37 per- cent) live in poverty. A majority of uninsurec3 children are white, although mi- norities are disproportionately represented; this is particularly true for Hispanic chil- ciren, who make up 29 percent of all unin- surec3 children. Fourteen percent of unin- surec3 children are African-American. 2iThis figure is lower than the 9.8 million uninsured children that is most commonly used in the policy debate on uninsured children, and which comes from the March 1996 Current Population Survey, which asked about insur- ance coverage during 1995. The Center believes that although a small portion of the difference between the two numbers could be explained by the CTS data being more recent, the difference most likely reflects methodological differences in how the two surveys ask about health insurance coverage. For an updated estimate of the number of children uninsured for one month or longer during 1995 and 1996, using data from the CPS as well as the Survey of Income and Program Participation, see Families USA, 1997a. 26

Reschovsky anc3 his col- leagues found that the three primary reasons children lack insurance are related to their par- ents' employment: job instability, employers that C3O not offer health benefits, anc3 the cost to workers of employer- sponsorec3 insurance. About 22 percent of uninsurec3 children C3O not have a working parent anc3 consequently lack access to employer-sponsorec3 health insurance benefits. Another 15 percent of children have parents who work for compa- nies that offer health benefits, but the par- ents are ineligible for benefits, usually because they have not worked for the em- ployer long enough or C3O not work enough hours (see Figures 5 anc3 6~. About 39 percent of uninsurec3 children have parents who are working, but their employers C3O not offer health insurance benefits, Reschovsky anc3 his colleagues found. The remaining uninsurec3 children, about one in four, have parents who refused offers of health insurance from their em- ployers, or who work for companies that C3O not offer family coverage. The overwhelm- ing reason parents gave for refusing health . . insurance coverage IS cost. "Our data needs reflect the agency's change from having a primary focus on regulating the health care market to simply understanding it." James Welsh, New York State Department of Health If parents lack access to employer-spon- sorec3 insurance cov- erage for their chil- ciren anc3 are unable or unwilling to pur- chase policies incli- viclually, they can either go uninsurec3 or seek public assis- tance. The CTS study estimated that about 20.3 million children are eligible for benefits through Meclicaic3, the primary public insurance program for chilciren.22 Slightly over half of these are enrolled in Meclicaic3, anc3 another 6 percent have other types of public insur- ance. A quarter of Meclicaic3-eligible chil- ciren (about 5 million) are covered by pri- vate insurance. Finally, CTS estimates that about 16 percent of Meclicaic3-eligible chil- ciren (or 3.2 million) remain uninsurec3; this group constitutes about 38 percent of all uninsurec3 children. Half of these children are uncler age 6, 82 percent live in poverty, anc3 39 percent are Hispanic; little is known about why they remain uninsurec3. In order to learn more about chilciren's ac- cess to Meclicaic3, a separate study called Meclicaic3 anc3 Children: A Decade of Change (Newacheck et al., 1 997) explored the effect of increased enrollments in Med 22The study estimated Medicaid eligibility by applying children's ages and family incomes to the eligibility stan- dards of the states in which they lived; these estimates should be regarded as approximate. Children who qualify for Medicaid due to medical need or other unidentifiable provisions were not included in the count.

Figure 5 Work/Heafth Insurance Status of Parents of Publicly Insured Children Employer offers and parents refuse \ 8% Employer offers and parents \ 'igible \ 8% Employer offers and only parents covered 1 1% Employer doesn t offer health insurance 24% SOURCE: Data from Reschovsky et al. [ 1 997~. Parents ~unemployed 1 49% Figure 6 Reasons Why Working Parents of Uninsured Children Are Ineligible for Employer-Offered Health Benefits Other reasons 10% Do not work enough hours/on-call 32% SOURCE: Data from Reschovsky et al. [ 1 997~. 28 Have not worked long enough/waiting period 58%

. icaid on the access of low-income children and youth to health care. The study's goal was to determine whether the disparity in health care use between poor and nonpoor children has narrowed as a result of Medic . . . alcl expansion. The number of children and youth enrolled in Medicaid has increased dramatically- from 10 million in 1985 to 18 million in 1994 as a result of a series of Congres- sional mandates to expand eligibility by making coverage mandatory for certain segments of the population, according to Paul Newacheck of the University of Cali- fornia at San Francisco, who presented study findings. The study examined the effects of Medicaid coverage on access, using the 1993-94 Na- tional Health Interview Survey on Access. The THIS, which is an annual survey car- ried out by the Census Bureau, includes 45,000 households with 30,000 children. (Unlike Medicare, the Medicaid program has no national population-based dataset.) The study found that Medicaid is associated with improved access for poor children, as indicated by increased use of physician ser- vices, increased likelihood of having a usual source of health care, and reduced likeli- hood of going without needed care (see Tables 2 and 3~. bin 1991, 9 percent of Medicaid beneficiaries were enrolled in some type of managed care arrangement; by 1996, enrollment had jumped to 39 percent. That year, 12.8 million Medicaid beneficiaries of whom at least half can be presumed to be children were receiving their services through a managed care provider (Fox et al., 1997~. Despite these advances, however, problems remain. Even with Medicaid coverage. low- income children and adolescents can have reduced access to after-hours care, reduced access to a regular provider, and higher rates of dissatisfaction with the quality of their care, compared with nonpoor children and ~, 1 1 1 1 . . . youth. Moreover, since children and ado- lescents living in poverty may need more health care, it would be expected that they would actually have more physician visits than their nonpoor counterparts, according to Newacheck. The study concluded that Medicaid is effec- tive in increasing the access of low-income children and youth to health care and in raising their levels of use up to (but not beyond) the care of nonpoor children and adolescents. Medicaid is less effective, how- ever, in making sure that children and youth have high-quality care once they are in the health care system. Newacheck cautioned that the study as- sessed only processes of care, not outcomes, and used primarily subjective health and access measures. The analysis did not dis- tinguish between full-year and part-year Medicaid coverage, and the data were col- lected prior to the widespread adoption of , .. . . Medicaid managed care arrangements23 (used increasingly by states to contain the growth in Medicaid outlays) and prior to 29

Table 2 Children's Usual Source of Health Care, ~ 993-94 Percent with a Percent without usual source a usual source Nonpoor children 95.0 5.0 Poor children with Medicaid 95.2 4.8 without Medicaid 83.g* 16.3 * P<. 0 1 compared to nonpoor children NOTE: Values adjusted by regression analysis. Poor and nonpoor children are defined based on the official U.S. definition of poverty, which classifies as poor those families and unrelated individuals with pretax money income below the applicable poverty threshold for the family size; the poverty threshold for a two-adult, two-child family in 1993 was $ 14,654 {U.S. Bureau of the Census, 1995~. SOURCE: Data from Newacheck et al. { 1 997~. the decoupling of Medicaid enrollment from welfare receipt (with the passage of the Personal Responsibility and Work Opportu- nity Act of 1996~. To find out more about current trends in Medicaid enrollments, specifically how Medicaid managed care policies affect chil- dren and adolescents, Fox Health Policy Consultants conducted telephone surveys of state Medicaid officials in the fall of 1996, and reviewed 1996 managed care contracts, referenced documents, and contract lan- guage revisions (Fox et al., 1997~. According to preliminary results of the sur- vey, presented at the research briefing by Harriette Fox of Fox Health Policy Consult- ants, all states but one have enrolled or will enroll Medicaid-eligible children and youth in some form of Medicaid managed care. The survey found that more states will be relying on fully capitated enrollment ar- rangements in the future, but most will use primary care case management systems (PCCMsy.24 The study found that not only will the num- ber of states using managed care continue to 24Under a PCCM system, primary care providers are paid a small monthly fee to gatekeep specialty and inpatient services for each of the beneficiaries enrolled with them. All primary care and other health services continue to be paid on a fee-for-service basis. Under a fully capitated arrangement, HMOs and certain other types of plans are paid a monthly per capita amount to provide or arrange for a risk-comprehensive package of Medicaid services (at least three mandatory Medicaid services or inpatient hospital services and one other mandatory service) to each enrolled beneficiary (Fox et al., 1997~. 30

Table 3 Inability to Obtain Needed Health Care for Children, ~ 993-94 Percent unable to Percent unable Percent unable obtain medications' to obtain to obtain eyeglasses, medical care dental care mental health care Nonpoor children 1.5 5.3 2.3 Poor children with Medicaid 0.6 * 3.4 * 1 .7 without Medicaid 5.1 ** 14.0** 6.2** * P<. 05 compared to nonpoor children P<. 0 1 compared to nonpoor children NOTE: Values adjusted by regression analysis. Poor and nonpoor children are defined based on the official U.S. defini- tion of poverty, which classifies as poor those families and unrelated individuals with pretax money income below the applicable poverty threshold for the family size; the poverty threshold for a two-adult, two-child family in 1993 was $14, 654 {U.S. Bureau of the Census, 1995] . SOURCE: Data from Newacheck et al. t 1 997~. grow, but also the proportion enrolling chil- ciren anc3 youth statewide will continue to rise. In the future, 43 states 86 percent of those that expect to use managed care for children anc3 adolescents will have man- agec3 care options in place statewide; in 1996, only 58 percent of those with man- agec3 care reported enrolling children anc3 youth statewide. For the most part, those with statewide managec3 care will be more likely to use both PCCMs anc3 fully capitatec3 plans in the future. It is likely that Meclicaic3 managec3 care en- rollment for children anc3 youth may in the future be mandatory, the study found. Of the 50 states that will be using some form of managec3 care, 94 percent expect enrollment to be mandatory for at least some eligibility groups. A mandatory managec3 care enroll- ment policy will be applied to children anc3 youth in all 47 states who were eligible for AFDC, to children receiving Supplemental Security Income (SSI) in 35 states, anc3 to foster care children in 26 states. Fox reported that the transition of Meclicaic3 children anc3 adolescents into fully capitatec3 arrangements is occurring without ample data on how their access to care is affected. Her study called on states to monitor the effect of managec3 care on children anc3 youth to use in structuring their managec3 care contracts, anc3 suggested that states would benefit from more information about effective strategies for meeting the needs of 31

children anc3 adolescents, especially those who have or are at risk for various chronic . . . conclltlons. The Fox study concluclec3 that states need to be able to assess plan capacity adequately anc3, in order to determine how much to pay plans for chilciren's services, should gather more information about the effect of clemo- graphic anc3 diagnostic risk ac3 justors anc3 how they affect access anc3 quality. Finally, the report called for greater investment in the design anc3 evaluation of specialized managed care arrangements for children anc3 adolescents with complex physical, clevelop- mental, emotional, or behavioral concli tions.25 In a related presentation, Peggy McManus of McManus Health Policy, Inc., spoke about the factors that contribute to innova- tive managed care plans. Managed care plans, with their strong focus on preventive anc3 primary care, are well positioned to ., . · ,~ . . 1c~ent1ty Intents once young children who are at risk for health or mental health programs, anc3 to refer them anc3 their parents for en- hancec3 care, McManus said. Among the strategies managed care plans might consider to improve the delivery of preventive anc3 primary care for families with at-risk infants anc3 young children are improved screening anc3 risk assessment, multidisciplinary teams for evaluation anc3 diagnosis, anc3 outreach anc3 home visiting. Among the strategies managed care plans might consider to address adolescents' needs . . . . are improved screening and risk assessment, specialty consultation for primary care pro- viclers, anc3 co-location of mental health anc3 . . primary care services. Based on a national review of innovations in managed care, two plans were iclentifiec3 as exemplary for their initiatives targeted to parents with infants anc3 young children anc3 four plans were iclentifiec3 for targeting the unique problems of adolescents. The plans include a program that identifies high-risk mothers anc3 offers enriched preventive anc3 primary care, health education activities, anc3 family support services, anc3 a program that operates an adolescent center, which serves as a multidisciplinary clinic, provic3- ing comprehensive health care services to teenagers.26 25For more information on managed care for families living in poverty, see Mathematica Policy Research, Inc., 1996a and 1996b, and National Health Law Program, 1997. lenge of holding managed care plans accountable, see GAO, ~r ~ ~ . r . ~ For a General Accounting Office report on the chal 1997. Nor a full list of strategies to enhance preventive and primary care services for high-risk children in HMOs based on a review of the literature, a survey of HMOs, a review of Medicaid-HMO contracts, and site visits see McManus Health Policy, Inc., and Fox Health Policy Consultants, 1995. For more information on how the identi fied strategies are carried out in specific programs, see Fox Health Policy Consultants, 1996, and McManus Health Policy, Inc., 1996. 32

It is unclear whether the increase in the use of managed care by state Meclicaic3 plans will alleviate some of the problems faced by low-income children anc3 youth because little is known about how Meclicaic3-insurec3 children enrolled in managed care plans fare. One study with random assignment of children found that prepaid plan members received the same number of checkups, but fewer acute care visits, than fee-for-service members (Maulclon et al., 1994~. Another study found that managed care plans se- lectec3 anc3 served healthier children (Scholle et al., 1997~; if this phenomenon is wiclespreac3, fee-for-service Meclicaic3 may experience increased problems as it serves a population with poorer baseline health. The research presented on changing pat- terns of health insurance coverage raises a number of questions, including: How can accurate counts of the number of uninsured children anc3 youth be obtained ? Why c30 families whose children are eligible for Mec3- icaic3 fail to enroll? What kinds of outreach efforts would most effectively encourage enrollment? Since some children anc3 aclo- lescents have full-year Meclicaic3 coverage, while others have part-year, are there cliffer- ences in health outcomes for populations that are enrolled continuously over a period of time? Why c30 rates of Meclicaic3 coverage vary so much from region to region, with some geographic areas much lower than others ? What are the most effective strategies for meeting the needs of children anc3 youth through managed care, especially clisablec3 children anc3 youth, those with chronic conditions, anc3 other special-neecis groups? How can problems among Meclicaic3-insurec3 populations, such as reclucec3 access to after- hours care anc3 regular providers, be ac3- ciressec3 ? How can the medical care of chil- ciren anc3 adolescents enrolled in Meclicaic3 be improved ? 33

RESEARCH CHALLENGES AND NEEDS: A STATE POLICY PERSPECTIVE In aciclition to serving as a forum for the presentation anc3 discussion of new findings on poverty anc3 child health anc3 nutrition, the research briefing proviclec3 an opportu- nity for state health officials to identify anc3 ~ . ~ ~ ~ dlSCUSS research needs trom a state and local perspective. As states nav increasing atten . . ~ , ~ Lion to tiara as a guide in making decisions about policy, a number of challenges appear, including the following: · Although states generate a consicler- able amount of data from a range of sources, many lack skilled researchers who can ana- lyze anc3 interpret the data. · As some states build integrated data systems linking information from separate agencies on health, education, anc3 other areas, questions remain about how to obtain data from private physicians anc3 HMOs, how to make such systems available to re- searchers, anc3 how to ensure confidentiality. · Current indicator anc3 outcome mea- sures for children are inadequate for all chil- ciren, but especially for special-neecis popu- lations such as clisablec3 children; there are also questions about which measurement strategies best evaluate chilciren's access to anc3 quality of health care. For example, current tools that measure quality of care in managed care plans, such as the Health Plan Employer Data anc3 Information Set 34 (HEDIS), c30 not even distinguish children with special needs from other children. ~ . . ~ ~ . ~ ~ Marty, with the possible exception of immunization rates, measures that are used in evaluating access anc3 quality are often clesignec3 around the needs of adults anc3 are not sensitive to chilciren's particular needs. · Although there is a high level of in- terest in comparing indicators of health delivery anc3 health outcomes across states, many questions exist regarding the compa- rability of data across states. · There is no stanciarc3 way to measure nutritional status, a factor that complicates assessing how nutrition affects chilciren's development. · State officials lack a reliable estimate of the number of uninsured children anc3 youth, making it difficult to identify anc3 provide coverage to those children anc3 aclo- lescents. · States often have difficulty collecting data across states anc3 tracking children anc3 adolescents as they move. · Because each state has its own clefini- tion of minority populations anc3 these cliffer from survey anc3 census definitions, it is difficult to gather vital statistics on minori- ties as well as on immigrant children anc3 youth anc3 children of immigrants. · Due to staffing, confidentiality, anc3 access issues, states sometimes have trouble releasing data in a timely manner to re- searchers, policy makers, and the public. · Educating the public and other stake . .. . . holders about the importance of data needs and ensuring that funding for research does

not lose out to more visible and compelling needs for . . . . services are crucial issues at the state level. · Monitoring efforts do not always focus on what is happening to the most . . . vulnerable children and youth who are sick and .. . . . . ~ 1lvmg In 1ow~mcome raml' lies. · Communities and states do not always work together on issues of access to health care and use of data, identifying the effec- tive elements of community coalitions so that community members' concerns and suggestions are incorporated into policy. In the context of these challenges, state officials highlighted the need for research that: · is longitudinal, with a focus on how a wide array of factors affect child health, starting in the prenatal period or even prior to conception; · assesses the differential effect of health care for families with different levels of in- come (by studying families in poverty as well as those newly out of poverty) amid changes in the welfare law, and assesses the differential effect for families with special "We're often faulted for not having data, but there are a [ot of data, just no one to analyze them, and no one knows that the data are there." Kathy Wibberly, Virginia Department of Health health care needs amid changes in SST eligibility; · considers the many influ- ences affecting the health of children and adolescents; · considers the health and nutritional defi- ciencies of at-risk children in the United States, in order to better understand the relevance to American children of studies carried out in developing countries; · focuses not only on access to care, but also continuum of care, prevention, and collaboration among different medical spe- cialties, and examines outcomes of care, not lust processes; · identifies not only health problems, but strengths of communities' populations as well as behaviors that protect health in- formation that is increasingly being re- quested by local communities seeking a proactive agenda with which to move for- ward; · promotes access to health care that meets the needs of minority populations; and · can be presented clearly with research representing other perspectives and dissemi- nated to policy makers. 35

APPENDIX A NEW CHILD HEALTH PROJECTS/INTERVENTIONS The research briefing featured presentations and discussions of a number of new child health interventions, several of which seek to promote family-centered, community- based care for children and youth. Some of the projects are expected to yield data that could play a role in informing public and private health care on such issues as cost effectiveness and performance indicators. Healthy Start Healthy Start is a five-year, 15-site, commu- nity-based demonstration program to reduce infant mortality rates by 50 percent (Mathematica Policy Research, Inc., and Harvard School of Public Health, 1997~. The project was launched in 1992; the evaluation started in 1 993 and a final report is expected in 1998. Federally funded, the project's investigators are Mathematica rat 1 ~ rat 1 ~ l-0l1Cy ~esearcn, inc.; Harvard School of Public Health; Health Systems Research, Inc., and RIVA Market Research, Inc. Communities chosen to participate in the project had infant mortality rates greater than 50 percent of national rates and had to show they could organize a community- based response to the problem. Community involvement included creating consortia, instituting contracts with grassroots organi zations, employing residents, reaching out to mothers, and coordinating mothers' care. Sites were also required to develop public information and education programs, ser- vice interventions, fetal-infant mortality review panels, and management informa- tion systems. Based on preliminary analysis of linked birth and infant death records from a subset of sites through 1994 only, controlling for time trend and other variables, the investigators found Healthy Start had little effect on infant mortality rates in 1992, 1993, and 1994 when compared to similar sites with- out funding. Infant mortality rates declined in all the sites, but went down in compari son sites as well. Investigators also found that Healthy Start appeared to reduce the likelihood of preterm . .. . . - r - - delivery rates in some sites. And in one of the sites, there appeared to be an effect on mortality for births in which the baby weighed more than 500 grams at birth. The investigators found a variety of results . . . between sites and over time. Program implementation was gradual, with full implementation until, at best, late in the observation period. Therefore, they note, preliminary estimates are likely to under . '' , state the effects of full implementation. These findings could change once data from . lYYD and lYYO when the project was fully implemented are analyzed. 37

Healthy Steps for Young Children The Healthy Steps for Young Children pro- gram is a multi-site, national initiative to help parents foster the healthy growth and development of their young children (Com- monwealth Fund, 1997~. Sponsored by the Commonwealth Fund in partnership with national and local foundations and with health care providers, the program was launched in 1994 and operates at about 21 sites nationwide. A national evaluation has just begun. Healthy Steps calls itself a new and ex- panded approach to pediatric care that goes beyond monitoring physical health to in- clude child development and family nurtur- ing. Through Healthy Steps specialists who work in traditional pediatric primary care practices, families are offered expert advice, time, and personal support to facilitate the healthy growth and development of their children from birth to age 3. The Healthy Steps approach is based on the belief that the first three years are critical for both child and family, and that relation- ships are the key to development. Healthy Steps expands traditional medical bound- aries beyond monitoring physical health, to include the promotion of child development and family nurturing. The program has eight components: Enhanced strategies in well-child care, periodic home visits, a child health ant! development record, parent 38 handouts, a telephone information line, parent groups, child development assess- ment every six months, and efforts to con- nect families to community resources. One of the goals of Healthy Steps is to test the effectiveness of the approach. A three- year, national evaluation, which has just begun, will try to determine how the pro- gram was successfully implemented; how and to what degree services are used; and how parental knowledge, attitudes, and behavior affect use of the program. The evaluation will also assess the effects of Healthy Steps on child health and develop- ment indicators, the program's cost effec- tiveness, and the potential for replication and institutionalization of HealtEv Steps in ~ . . . TO pecllatrlc practices. Because the program is being carried out at a range of sites (includ- ing clinical hospital settings, private-prac- tice group settings, and managed care), the findings are expected to yield answers to some key questions. Among the lessons learned since the pro- gram was implemented are that team- building takes time, clinicians are not ad- ministrators, and system change is difficult. Furthermore, the project has learned that ongoing contact and technical assistance are crucial. Biweekly technical assistance teleconference sessions are held to answer questions, reinforce training, and trouble- shoot issues within sites; annual monitoring site visits are also scheduled.

Pathways Intervention The Pathways Intervention is a multi-site, 8-year study of obesity prevention in Ameri- can Indian schoolchildren (Davis et al., 1997~. By promoting physical activity and healthy eating in a culturally appropriate elementary school and family-baseu inter- vention, the project seeks to positively in- fluence risk factors thought to be related to obesity. Pathways is being carried out through a cooperative agreement with five . . ~ 1 . un1vers1t1es, seven lnulan nations, and the Heart-Lung Institute. Launched in 1994, the project was piloted in four schools and is now in place in 20. Pathways grew out of a concern about the increased prevalence of obesity, heart ais- ease, and diabetes among American Indian children and adolescents, as well as ae- creaseu physical activity and increased con- sumption of calories and high-fat foods, as these populations become acculturated into the mainstream. The intervention targets a number of risk factors for obesity, including excessive television watching, little encour- agement to engage in physical activity at home, low consumption of fruits and veg- etables at home, high consumption of sugar drinks at home and in the community, and few family-baseu physical activities. At school, food service personnel encouraged children to finish their food and there were too few physical activities in which students could take part. The Pathways curriculum incorporates Na- tive American tradition and values into 24 lessons over a 12-week period to promote health-relateu behavioral changes and a healthful lifestyle. The curriculum incorpo- rates cultural concepts that include Ameri- can Indian customs and practices such as learning through observation and practice, learning from story-telling, learning meta . . .. . .. . . . O phoricatty, holistic learning, learning by trial and error, learning through play, learn- ing cooperatively, and learning through reflection. The training for the curriculum .... estaol1snes a new school environment in which classroom teachers join with food service personnel, physical educators, and the students' families to implement the new behavioral skills. Start Healthy, Stay Healthy Millions of young children and adolescents ~ . trom tow-1ncome working families lack health insurance and are missing out on benefits available to them through Meuic- aiu. The Start Healthy, Stay Healthy pro- gram is a national outreach campaign initi- ateu by the Center on Budget and Policy Priorities to improve chiluren's access to health insurance (Center on Budget and Policy Priorities, 1997~. The initiative is not a research project and does not include an evaluation. Launched in 1994, the campaign uses early 39

childhood programs and other community- based organizations to identify children eligible for Medicaid but not enrolled in the program. The campaign also trains staff of community-based organizations in helping families overcome barriers to Medicaid ap- plication and enrollment. By facilitating the enrollment of these children in Medic- aid and similar state-funded programs, Start Healthy, Stay Healthy seeks to reduce the number of children who are uninsured or underinsured. The problem of uninsurance or underinsur- ance becomes increasingly significant under welfare reform, as fewer children are ex- pected to qualify for cash assistance pro- grams. More families are likely to be work . . . . . . . . 1ng in low-wage fobs without insurance. Strict new rules may disqualify other fami- lies from receiving aid through their state's TANF block grant program. The delinking of cash assistance and Medicaid, as well as other changes in welfare, place children at risk of losing Medicaid even though they are likely to remain eligible based on July 1 996 rules or poverty level coverage. Questions remain about whether these children will find their way into the Medicaid program. Eligibility for other benefit programs (such as child and adult care food programs, subsi dized child care, Head Start, WIC, food stamps, energy assistance, and the school . . ~ lunch program' can signal Medicaid eligibil- ity. Start Healthy, Stay Healthy trains staff of community-based organizations to recog- n1ze such signals and incorporate Medicaid . . . 40 .. .. ... . . . . . . ellgl~lllty screening into their routine 1n- take procedures. Families with children likely to be eligible are referred to Medicaid . .. . . . Or given correct help in applying for the pro As the project is being carried out nation- wide, those involved say that providing information about Medicaid to low-income families is not sufficient. Establishing an easy, accessible application process is key to facilitating enrollment in the program. The project encourages state Medicaid agencies to facilitate the enrollment of children by eliminating assets tests, shortening and sim- plifying applications and verification re- quirements, instituting mail-in applications, and "outstationing" (processing applications at sites other than the Medicaid office). The Start Healthy, Stay Healthy project is funded by the Ford Foundation, the Annie E. Casey Foundation, the Freddie Mac Foundation, and the Packard Foundation. Opening Doors on Chicago's West Side The Westside Health Authority, a consor- tium of community organizations on the west side of Chicago, in collaboration with university sociologists, conducted research on the sociocultural barriers to health care for low-income, minority women and their children living on Chicago's west side. Dur- ing the project, conducted from 1995 to 1997, trained community residents observed

sociocultural barriers to providing any re- ceiving good care that face clinics any pa- tients in the Austin and West Garfielu Park communities of Chicago (Kohrman, 1997~. The project was funueu by the Robert Woou Johnson Founuation's any the Kaiser Family Founuation's initiative, Opening Doors: Reducing Sociocultural Barriers to Health Care. Using observation, interviews, and focus groups, the trained community residents documented barriers created by the clinics and by patient beliefs and behaviors, incluu- ing: Clinics provided inadequate privacy, time, information, and facilities for waiting children. Parents often failed to keep ap- pointments coming only when children . . O , had symptoms aid not understand how to . .. . give medications, misunderstood and mis- useu generic drugs, and failed to tell medical providers all the symptoms and their con cerns. Researchers made a number of recommen- uations, including training health educators and advocates from the community to re auce misunderstandings. Healthy Communities In more than 1,200 locations States, communities are addressing issues of how to get well and stay healthy through a movement called Healthy Communities (also known as Healthy Cities). The goal of these local multi-sector partnerships is to in the United build healthier communities based on a vision of well-being for the total community (Coalition for Healthier Cities and Com- munities, 1 997; Flower, 1 995~. Those in- volvea in the initiative believe a healthy community is not an outcome, but a process that accommodates changing conditions and promotes improvement in the quality of life of its members. A key element of the Healthy Communities concept, which was pioneered in Europe in the 1 980s, is the use of a collaborative prob- lem-solving process. That process allows a broad spectrum of stakeholuers including citizens and representatives from the pri- vate, public, and nonprofit sectors to cre- ate a vision of well-being and implement a plan to turn the vision into reality. Using collaborative approaches, communities in- volveu in the project work to improve eau- cation, housing, job transportation, envi- ronment, health, and quality of life in a manner that benefits all segments of society. Each community's process is unique and is affected by the particular character of the community, local priorities, the resources available, and the participants. A patchwork of local public and private monies funds most of the work of Healthy Communities. Some of the communities have begun to engage in informal and for- mal evaluations. Interest in the initiative has been driven by a number of forces, including a reduction in fee-for-service health care, rising competi 41

tion in both pricing and quality, a shift to- warc3 wellness anc3 preventive care, anc3 a recognition of the need to change behaviors linked to health outcomes. Those involved with the initiative believe these pressures will focus attention on areas outside the traditional realm of health care, such as education, the environment, anc3 the economy. The Asset-Based Community Development Institute Established in 1995, the Asset-Basec3 Com- munity Development Institute (ABCD) seeks to disseminate two clecacles of research on capacity-builcling community clevelop- ment (Asset-Basec3 Community Develop- ment Institute, 1997~. A major focus of the program, which is located at Northwestern University's Institute for Policy Research, has been to produce resources anc3 tools for community builders involved in capacity- basec3 initiatives, helping them identify, nurture, anc3 mobilize neighborhood assets. 42 The Institute works on several health- relatec3 projects. Rather than focusing on neighborhoods' needs anc3 deficiencies, the Institute's founders use research showing that the re- sources of inclivicluals, associations, anc3 local institutions are the most effective tools for regenerating both urban anc3 rural com- munities. The Institute is funclec3 by grants from the Chicago Community Trust anc3 the W.K. Kellogg Foundation. Current projects include advising Healthy Communities initiatives anc3 working with Grantmakers in Health in Chicago anc3 in South Benc3, Indiana. The Institute also conducts research on how local associations affect economic development, how local governments can assist asset-basec3 initia- tives, new media stanciarcis in neighborhood coverage, anc3 evaluation approaches appro- priate for community-builcling efforts. The institute holds conferences anc3 publishes material for practitioners, anc3 holds training programs for targeted constituencies.

APPENDIX B MONITORING THE EFFECTS OF WELFARE REFORM The Personal Responsibility and Work Op- portunity Act of 1996 replaced the entitle- ment status of Aid to Families with Depen- dent Children (AFDC) with the TANF (Temporary Assistance to Needy Families) block grant, providing states an annual lump-sum payment and a maximum five- year limit on benefits. The new law changes not only the principles and policies of the country's welfare system, but also the nature of efforts to evaluate the new pro grams and services. Under the new law, the Secretary of the U.S. Department of Health and Human Services (HHS) is directed to encourage states to continue evaluating their waivers through random sampling, control groups, and other accepted experimental methods; the law also authorizes $15 million annually for research activities (from fiscal vear 1997 . 1 1 r ~1 ~ , through fiscal year 2002), half of which HHS is to allocate for federally initiated research and half for state-level evaluations. Thus, the quality, scope, and existence of welfare reform research and evaluation ef- forts are left to the discretion of individual states, researchers, and advocates. A number of projects are monitoring the effects of TANF on low-income children and youth and their families (few monitor or measure child health and nutrition out- comes related to welfare reform1. Thev . ~ ~ ~ ~ ~ . ~. . ~1 include the following tall sponsoring organi- zations or agencies are located in Washing- ton, D.C., unless otherwise indicated): Assessing the New Federalism, the Urban Prostitute Arid Child Trends, uric.: One of the largest monitoring projects, this three- to five-year initiative seeks to docu- ment, analyze, and report on changes in the social safety net resulting from the decen- tralization of social programs in this country and their effects on the wellbeing of chid . . ~ ... ctren ancr tamales. The project will also attempt to measure links between changes in government programs and changes in a set of indicators of well-being. Funding is from the Annie E. Casey Foundation and a consortium of other foundations. · JOBS Child Outcomes Study, Child Trends, Irlc.: Since 1989, Child Trends has conducted a study of the impact of the fed 1 ~ ITS Cal / - r- -- eral JtJ~ program ta welfare-to-work pro- gram) on children's health, cognitive devel- opment, adjustment, and school outcomes in three sites across the country. (The study is part of a larger evaluation of the eco- nomic impact of JOBS being carried out by the Manpower Demonstration Research Corporation under contract with HHS.) In a separate but related work, Child Trends is directing in Atlanta an in-depth, multi-year study on how mandatory maternal narticina . . . ~ ~ ~ , lion in j()~6i affects mother-child interac 43

· Mortitorirtg Child arid Family Social Program Outcomes Before arid After Welfare Reform ire Four States, Choirs Hall Center for Childrert, Urtiversity of Chicago: This project will create a multi-state database to track anc3 analyze the ways children anc3 families use social services in California, Illinois, Massachusetts, anc3 North Carolina. Initial funding is from the Edna McConnell Clark Foundations the first of a series of five an- nual reports is anticipated in late 1998. · Mortitorirtg Project, Childrert's Defense Fairly: This project encourages community- level information- gathering anc3 monitoring of how the welfare law affects the well-being ~ ~ ... . . ... Ottam~esanctch~ictren. The Chilciren's ~ ~ ~ 1 / ~\ 1 Recense tuner Aim nopes to collect baseline information about families anc3 children on welfare to compare with infor- mation on the status of children after the implementation of TANF. The Coalition on Human Needs is working with CDF in distributing client survey packets to na- tional groups. · Multi City Stubbly of the Effects of Welt fare Reform ort Childrert arid Families, Johrts Hopkins University (Baltimore, Mc3.~: A multidisciplinary study of the effects of wel- fare reform on children anc3 youth, this five- year project is gathering anc3 analyzing lon- gituclinal data in Baltimore, Boston, anc3 Chicago. The study is funclec3 by the Robert Wood Johnson Foundation, the Annie E. Casey Foundation, anc3 others. · Project orb Child Care Employment arid 44 Trairlirlg Programs for Welfare Recipients, National Center for the Early Childhood Workforce: As states anc3 communities cle- velop or consider programs to encourage welfare recipients to become child care pro- viclers, this survey aims for a better uncler- stancling of the conditions uncler which such programs can create good work opportuni- ties anc3 good child care. and how different , models achieve or fail in these goals. The survey is supported by the Carnegie Corpo- ration of New York. · Project on Devolutiorl arl`1 Urbarl Charge, Manpower Demor~stratior~ Research Corporation (New York City): This project will examine how states, urban counties, and large cities restructure social welfare .. . I-. programs over the next live years, and deter mine what difference these policies make in . .. lo. the lives or tow-~ncome Americans. Re- search is being conducted in Cleveland, I-os Angeles, Miami, and Philadelphia. The project is funded by a number of founda- tions. · Project on State-I-evel Child Outcomes: Er~har~cir~g Measurement of Child Outcomes ire State Welfare Evaluations, U.S. Department of Health arl`1 Human Services (HHS) (A`1- mirlistratiorl for Chiller arl`1 Families/Office of the Assistant Secretary for Plarlrlirlg arl`1 Evalu- atiorl): HHS has added child well-being measures to several existing impact evalua- tions required by the federal government as part of the welfare waiver process. In addi- tion, the National Institute of Child Health and Human Development (NICHD) Family

anc3 Child Well' Being Research Network (with Child Trencis taking the leac3) is working with a number of states to research how welfare reform has affected children anc3 youth. · Projecting outcomes from state welfare Claris, Mathematica Policy Research, frtc.: Mathematica is creating a dynamic microsimulation model to project costs, caseloads, distribution impacts, employ' meet, and other outcomes of state welfare plans. The model will build on the Simula' tion of Trencis in Employment, Welfare, anc3 Related Dynamics (STEWARD) models the database will be prepared from Survey of Income anc3 Program Participation (SIPP) data. The projectisfuncleciby the Smith Richardson Foundation anc3 the U.S. De' partment of Agriculture's Food anc3 Con' Ssumer erv1ce. · Research Forum ore Chiller, Families, arid the New Federalism, National Center for Childrert irt Poverty, Columbia University (New York City): This project will coorcli- nate a range of research projects, program evaluations, anc3 assessment efforts, anc3 function as an information clearinghouse for such programs as welfare reform. Using 8 1 studies related to Revolution, the Forum anc3 the Institute for Research on Poverty pro' clucec3 a list of involved states anc3 major areas of investigation. The project is funclec3 by the Annie E. Casey, Edna McConnell Clark, anc3 Russell Sage Foundations. . State Documerltatiorl Project, Center for Law arid Social Policy arid Center ort Bud' get arid Policy Priorities: Using "reporters" at the state level, this project will monitor, document, anc3 analyze how the 50 states restructure their welfare policies, cash assis' tance programs for poor families, anc3 food stamp anc3 Meclicaic3 programs, anc3 assess policy trencis around the country. The project, which was expected to yield data in early 1998, is funclec3 by the Annie E. Casey Foundation. · A Stubbly of State Capacity, Rockefeller Prostitute of Goverr~mer~t, State University of New York at Albany (Albany, N.Y.~: This study examines the management systems states use to carry out their welfare, Meclic- aic3, anc3 workforce development programs to determine what policies are being imple- mentec3. The project, which will continue through 2000, is funclec3 by the W. K. Kellogg Foundation, the Edna McConnell Clark Foundation, St. I-uke's Charitable Health Trust, the Flinn Foundation, the Gunc3 Foundation, the Fund for New Jersey, anc3 the Schumann Fund for New Jersey. · Survey of Program Dynamics, Census Bureau, U.S. Department of Commerce: This survey is clesignec3 to help policy mak- ers evaluate the effect of welfare reform by examining the long-term effects of the re- forms on the U.S. welfare system as well as on families, adults, children, anc3 youth. HHS has asked the NICHD Network to assist the Census Bureau in identifying child anc3 family outcomes to be aciclec3 to this longitudinal study. 45

. Testing welfare demonstration projects, Abt Associates (Besthesda, Md., and Cam- bridge, Mass.~: This private consulting firm is currently testing separate welfare demon stration projects for Arizona, Delaware, Indiana, and Michigan, and recently com- pleted similar studies of projects in Ala- bama, Illinois, New York, and Ohio. The projects compare the performance of those participating in the welfare demonstration projects with those who remain on the regu lar welfare plan on measures such as em ployment and earnings, welfare participa- tion and payments, child support payments, and participation in employment and train 1ng. . Welfare Irtformatiort Network: A national consortium for state and commu- nity-based welfare reform, this project serves as an information clearinghouse, gathering and disseminating information on research and evaluation activities. The Welfare Information Network is a special project of the Finance Project, a national initiative to improve the effectiveness, efficiency, and equity of public financing for education and other services for children and youth. Welfare Policy Center, Hudsort Irtsti- tute (Indianapolis, Inky: This project con- ducts research and provides technical assis 46 lance on welfare reform, including a Mil- waukee survey to determine what has hap- pened to welfare recipients who have left the program after reform was initiated there. The project is supported in part by the I-ynde and Harry Bradley and Charles Stewart Mott Foundations. · Welfare reform analysis, Center for Child arid Family Policy Research, School of Public Policy arid Social Research, University of California at I-os Ar~geles: This center, which conducts and promotes research, . . . . . training, and community service programs to inform policy and develop programs for children and families, has is analyzing two welfare reform programs in California. . Welfare Reform Research Coordir~atior~ Project, Institute for Womerl's Policy Research: This project, which uses state-level researchers to develop a consistent set of indicators to assess the effects of welfare Revolution on the well-being of low-income women and their children, aims to produce a model research and education program for welfare practitioners, advocates, and re- searchers. The project is funded by the Joyce Foundation, the Charles Stewart Mott Foundation, and the John D. and Catherine T. MacArthur Foundation.

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Wilde, Parke 1997 A Monthly Cycle in Food Use by Food Stamp Recipients. Paper presented at research briefing, Board on Children, Youth, and Families, May 19-20, 1997. Cornell University. Wilde, Parke, and Christine Ranney 1997 A Monthly Cycle in Food Expenditure and Intake by Participants in the U.S. Food Stamp Program. Working Paper 97-04. Department of Agricultural, Resource, and Managerial Economics, Cornell University, March. Wilkinson, Richard G. 1996 Unhealthy Societies: The Afflictions of Ir~- equality. New York: Routledge. Willis, E., R.M. Kliegman, I.R. Meurer, and I.M. Perry 1997 Welfare reform and food insecurity: Influ- ence on children. Archives of Pediatric Adolescent Medicine 151:871 -875. Wise, P., and A. Meyers 1988 Poverty and child health. Pediatric Clinics of North America 35:1169-1186. Yip, R., I. Parvanta, K. Scanlon, E.W. Borland, C.M. Russell, and F.L. Trowhridge 1992 Pediatric nutrition surveillance system- United States, 1980-1991. Morbidity arid Mortality Weekly Report 41 (ss-7~:1-24. Yudkowsky, B.K., I.D. Cartland, and S.S. Flint 1990 Pediatrician participation in Medicaid, 1978 to 1989. Pediatrics 85:567-577. Further Reading on Child Health and Nutrition Board on Children, Youth, and Families and Board on Health Promotion and Disease Prevention 1996 Paying Atter~tior~ to Chillers ire a Charging Health Care System: Summaries of Work- shops. National Research Council and Institute of Medicine. Washington, D.C.: National Academy Press. Dallek, Geraldine 1996 Learning the Lessons of Medicaid Managed Care. December. Washington, D.C.: Families USA. Athttp://epn.org/families/ medaid.html; July 18, 1997. Division of Health Care Services 1994 America's Health ire Trar~sitior~: Protecting arid Improving Quality. Institute of Medi- cine. Washington,D.C.: NationalAcad- emy Press. Earl, Robert, and Catherine E. Wotecki, eds. 1994 Iron Deficiency Anemia: Recommended Guidelines for the Preverltiorl, Detection, arid Marlagemerlt Among U.S. Children arid Women of Childbearing Age. Committee on the Prevention, Detection, and Manage- ment of Iron Deficiency Anemia Among U.S. Children and Women of Childbearing Age, Institute of Medicine. Washington, D.C.: National Academy Press. Edmunds, Margaret, Richard Frank, Michael Hogan, Dennis McCarty, Rhonda Robinson-Beale, and Constance Weisner, eds. 1997 Marlagirlg Managed Care: Quality Improve- merlt in Behavioral Health. Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care, Division of Neuroscience and Behav- ioral Health, Division of Health Care Ser- vices, Institute of Medicine. Washington, D.C.: National Academy Press. Green, M., ed. 1994 Bright Futures: Guidelines for Preventive Services for Irlfarlts, Children, arid Adoles- cer~ts. Arlington,Va.: NationalCenter for Education in Matemal and Child Health. Holahan, John 1997 Expanding Insurance Coverage for Chil- dren. May 1997. Washington, D.C.: Ur- banInstitute. Athttp:///www.urban.org/ family/expanding.htm; July 11, 1997. 53

Koppelman, Jane 1997 Reaching Ur~ir~sured Chillers Eligible for Medicaid arid Other Publicly Forged Ir~surar~ce Programs: Federal arid State Issues. Issue Brief. Washington, D.C.: National Health Policy Forum. Lewit, Eugene, and Linda Schuurmann Baker 1995 Health insurance coverage. The Future of Chillers 5 (3 ~ winter: 1 - 13. Milman, M., ed. 1993 Access to Health Care ire America. Commit- tee on Monitoring Access to Personal Health Care Services, Institute of Medicine. Washington,D.C.: NationalAcademy Press. Newacheck, Paul W., Dana C. Hughes, and Miriam Cisternas 1995 Children and health insurance: An over- view of recent trends. Health Affairs 14(1 spring:244-254. Newacheck, Paul W., Dana C. Hughes, and Jeffrey I. Stoddard 1996 Children's access to care: Differences by race, income, and insurance status. Pediat rics 97~1~Ianuary:26-32. Newacheck, Paul W., Jeffrey I. Stoddard, Dana C. Hughes, and Michelle Pearl 1997 Children's access to health care: The role of social and economic factors. Pp. 53-76 in Ruth E.K. Stein, ea., Health Care for Chil- drer~: What's Right, What's Wrong, What's Next. New York: United Hospital Fund. Perrin, Edward B., and Jeffrey I. Koshel, eds. 1997 Assessment of Performance Measures for Public Health, Substance Abuse, arid Mental Health. Panel on Performance Measures and Data for Public Health Performance Partnership Grants, Committee on National Statistics, National Research Council. Washington,D.C.: NationalAcademy Press. 54 Schneider, Andy 1997 Reducing the Number of Ur~ir~sured Chillers: Building Sport Medicaid Coverage is a Better Approach Third Creating a New Block Grant totheStates. Washington,D.C.: Center on Budget and Policy Priorities, June 5. Wise, Paul H. 1993 Confronting racial disparities in infant mortality: Reconciling science and politics. In Diane Rowley and Heather Tosteston, eds., American ;Iourr~al of Preventive Medicine Supplement to Vol. 9~6)November/Decem- ber. Oxford University Press. Further Reading on Income and Poverty Aber, Lawrence I., Jeanne Brooks-Gunn, and Rebecca A. Maynard 1995 EEects of welfare reform on teenage parents and their children. The Future of Childrer 5 ~ 2 Summer/fall 1995:53 - 71. Bane, Mary Jo 1992 How much does poverty matter? Pp.37-44 in P.N. Van de Water and L.B. Schorr, eds., Security for America's Children: Proceedings of the Fourth Corlfererlce of the National Academy of Social Ir~surar~ce. Dubuque, Iowa: Kendall/Hunt. Bane, Mary Jo, and David Ellwood 1994 Welfare Realities: From Rhetoric to Reform. Cambridge, Mass: Harvard University Press. Chase-Lansdale, P. Lindsay, and Jeanne Brooks- Gunn, eds. 1995 Escape from Poverty: What Makes a Differ er~ce for Children. New York: Cambridge University Press.

Citro, Constance A., and Robert T. Michael, eds. 1995 Measuring Poverty: A New Approach. Panel on Poverty and Family Assistance: Con cepts, Information Needs and Measurement Mead, Lawrence M. Methods, Committee on National Statistics, National Research Council. Washington, D.C.: National Academy Press. Danziger, Sheldon H., Gary D. Sandefur, and Daniel H. Weinberg, eds. 1994 Cor~fror~tir~g Poverty: Prescriptions for Charge. New York: Russell Sage Founda tion, and Cambridge, Mass.: Harvard Uni versity Press. Duncan, Greg I., and Jeanne Brooks-Gunn, eds. 1997 Cor~sequer~ces of Growing Up Poor. New York: Russell Sage. Duncan, Greg I., Jeanne Brooks-Gunn, and Pamela Klebanov 1994 Economic deprivation and early childhood 1997 development. Child Development 65:296 318. Duncan, Greg I., Wei-Jun Young, Jeanne Brooks Gunn, and Judith Smith 1996 Does Childhood Poverty Affect the Life Chances of Children? Unpublished paper. Department of Education and Social Policy, Northwestem University. Edin, Kathryn, and Christopher Jencks 1992 Reforming welfare. Pp. 204-234 in Christo pher Jencks, ea., Rethir~kir~g Social Policy: Race, Poverty, arid the Underclass. Cam bridge, Mass.: Harvard University Press. Huston, Aletha C., ed. 1994 Childrer~ir~Poverty. New York: Cambridge University Press. Huston, Aletha C., Vonnie C. McLoyd, and Cynthia Garcia Coll 1994 Children and poverty: Issues in contempo rary research. Child Development 65~2)April:275-282. Korenman, S., and I. Miller 1995 Long-Term Poverty and Child Develop ment in the United States: Results from the NLSY. Institute for Research on Poverty Discussion Paper 1044-94. Madison: Uni- versity of Wisconsin. 1992 The New Politics of Poverty: The Norlworkirlg Poor ire America. New York: Basic Books. Moore, Kristin A., Donna Ruane Morrison, Martha Zaslow, and Dana A. Glei 1995 Ebbing and Flowing, Learning and Growing: Family Economic Resources and Children's Development. Unpublished paper. Wash- ington, D.C.: Child Trends, Inc. Phillips, Deborah, and Anne Bridgman, eds. 1995 New Fir~dir~gs ore Children, Families, arid Economic Self-Sufficier~cy: Summary of a Research Briefing. Board on Children, Youth, and Families, National Research Council and Institute of Medicine. Wash- ington, D.C.: National Academy Press. New Firldirlgs on Welfare arid Childrerl's Development: Summary of a Research Brief- ir~g. Board on Children, Youth, and Fami- lies, National Research Council and Insti- tute of Medicine. Washington, D.C.: Na- tional Academy Press. Rainwater, Lee, and Timothy M. Smeeding 1995 Doing Poorly: The Reallr~comeofAmericar~ Children in a Comparative Perspective. Work- ing paper #127. Department of Economics, Syracuse University. Shinn, Marybeth, Beth C. Weitzman, Rachel Becker-Klein, Kirsten Cowal, Lisa Duchon, Yvonne Rafferty, Nancy Bialo, and Judith Schteingart 1997 NYU Studies of Homeless Families. Paper presented at research briefing, Board on Children, Youth, and Families, May 19-20, 1997. Department of Psychology, New York University. U.S. Department of Health and Human Services 1996 Indicators of Welfare Deperlderlce arid Well- Beirlg: Interim Report to Congress. Washing- ton, D.C.: U.S. Department of Health and Human Services, October. 55

56

BOARD ON CHILDREN, YOUTH, AND FAMILIES JACK P. SHONKOFF (Chair), Heller Graduate School, Brandeis University DAVID V.B. BRITT, Children's Television Workshop, New York City LARRY BUMPASS, Center for Demography and Ecology, University of Wisconsin FERNANDO A. GUERRA, San Antonio Metropolitan Health District, Texas BERNARD GUYER, Department of Maternal and Child Health, Johns Hopkins University AI-ETHA C. HUSTON, Department of Human Ecology, University of Texas, Austin RENEE JENKINS, Department of Pediatrics and Child Health, Howard University Hospital SARA McI-ANAHAN, Office of Population Research, Princeton University ROBERT MICHAEI-, Harris Graduate School of Public Policy Studies, University of Chicago PANIC NEWACHECK, Institute of Health Policy Studies and Department of Pediatrics, University of California, San Francisco MARTHA PHII-I-IPS, The Concord Coalition, Washington, D.C. JULIUS B. RICHMOND, Department of Social Medicine, Harvard University Medical School TIMOTHY M. SANDOS, TCI Central, Inc., Denver, Colorado DEBORAH STIPEK, Graduate School of Education, University of California, I-os Angeles DIANA TAYLOR, Women's Health Program, Department of Family Health Care Nursing, University of California, San Francisco GAIL WII-ENSKY, Project Hope, Bethesda, Maryland EVAN CHARNEY (Liaison), Council, Institute of Medicine RUTH T. GROSS (Liaison), Board on Health Promotion and Disease Prevention, Institute of Medicine ELEANOR E. MACCOBY (Liaison), Commission on Behavioral and Social Sciences and Education DEBORAH A. PHII-I-IPS, Director ANNE BRIDGMAN, Program Officer for Commur~icatiorts DRUSII-I-A BARNES, Admir~istrative Associate NANCY GEYEI-IN, Project Assistant KAREN KUHI-THAU, Cor~sultar~t 57

PARTICIPANTS, RESEARCH BRIEFING ON POVERTY AND CHILDREN'S HEALTH AND NUTRITION WILLIAM G. BITHONEY, Brookciale University Hospital, State University of New York Health Sciences Center NTRA BONDER, Office of Chilciren's Health, Maryland Department of Health anc3 Mental Hygiene JEANNE BROOKS'GUNN,* Center for Children anc3 Families, Teachers College, Columbia University PATRICK CASEY, Center for Applied Research anc3 Evaluation anc3 Department of Pediatrics, University of Arkansas for Medical Sciences SUSAN CASTELLANO, Maternal anc3 Chilc3 Health Assurance, Minnesota Department of Human Services SALLY DAVIS, Center for Health Promotion, University of New Mexico BARBARA DEVANEY, Mathematica Policy Research, Inc. JEFFREY EVANS,* National Institute of Chilc3 Health anc3 Human Development, U.S. Department of Health anc3 Human Services AMY FINE, Association of Maternal anc3 Chilc3 Health Programs HARRIETTE FOX, Fox Health Policy Consultants DEBORAH FRANK, Growth anc3 Development Program, Boston Medical Center RUTH T. GROSS, Department of Pediatrics (Emerita), Stanford University School of Medicine BERNARD GUYER, Department of Maternal anc3 Chilc3 Health, Johns Hopkins University KATHLEEN MULLAN HARRIS, Carolina Population Center, University of North Carolina at Chapel Hill JAY HIRSCHMAN, Food anc3 Consumer Service, U.S. Department of Agriculture ANDREA KANE, National Governors' Association ROBERT KARP, Pediatric Resource Center of Kings County Hospital Center anc3 Chilciren's Medical Center of State University of New York Health Science Center at Brooklyn CLAIRE KOHRMAN. Department of Pediatrics, University of Chicago BETSY LOZOFF, Center for Human Growth anc3 Development, University of Michigan CINDY MANN, Center on Budget anc3 Policy Priorities MARIE McCORMICK, Department of Maternal anc3 Chilc3 Health, Harvard School of Public Health anc3 Department of Pediatrics, Harvard Medical School * Members, Family and Child Well-Being Research Network, NICHD 58

MICHAEL McGINNIS, National Research Council (Scholar~in'Residence) PEGGY McMANUS, McManus Health Policy, Inc. KRISTIN A. MOORE,* Child Trends, Inc. SUSAN NALDER, Maternal Child Health Epidemiology, Public Health Division, New Mexico Department of Health PAUL NEWACHECK, Institute of Health Policy Studies and Department of Pediatrics, University of California at San Francisco ERNESTO POLLITT, Department of Pediatrics, University of California at Davis, and Visiting Scholar, The World Bank JAMES RESCHOVSKY, Center for Studying Health System Change MARYBETH SHINN, Department of Psychology, New York University MARIAN SIGMAN, Department of Psychiatry, University of California at Los Angeles THEODORE WACHS, Department of Psychological Sciences, Purdue University JAMES WELSH, Division of Planning and Policy and Resource Development, New York State Department of Health KATHY WIBBERLY, Office of Health Policy, Virginia Department of Health K.A.S. WICKRAMA, Center for Family Research, Iowa State University PARKE WILDE, Department of Agricultural Resource and Managerial Economics, Cornell University PAUL H. WISE, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Children's Hospital, Harvard Medical School KATHRYN TAAFFE YOUNG, The Commonwealth Fund Other members of the network are: GREG J. DUNCAN, Institute for Policy Research, Northwestern University ELIZABETH PETERS, Department of Consumer Economics and Housing, Cornell University DESMOND K. RUNYAN, Department of Social Medicine, University of North Carolina JAY D. TEACHMAN, Department of Human Development, Washington State University ARLAND THORNTON, Institute for Social Research, University of Michigan * Members, Family and Child Well'Being Research Network, NICHD 59

Other Reports from the Board on Children, Youth, and Families Educatir~gLar~guage-Mirrority Chit~rerr (1998) Violence ire Families: Assessing Prever~tiorr Arid Treatment Programs (1998) Improving Schooling for L-arlguage-Mirlority Chimer: A Research Agenda (1997) New Firrdir~gs or Welfare Arid Chit~rer`'s Development: Summary of a Research Briefing ~ 1997 ~ Youth Development arid Neighborhood frlfuerlces: Challenges arid Opportunities: Summary of a Workshop (1996) Paying Atter~tiorr to Chit~rerr ire a Chart g Health Care System: Summaries of a Workshop (with the Board on Health Promotion and Disease Prevention of the Institute of Meclicine) (1996) Beyond the Blueprint: Directions for Research or Head Start's Families: Report of Three Rourrdtable Meetings ~ 1996) Child Care for Low-Ir~come Families: Directions for Research: Summary of a Workshop (1996) Service Provider Perspectives or Family Violence Ir~terver~tior~s: Proceedings of a Workshop (1995) "Immigrant Children and Their Families: Issues for Research and Policy" in The Future of Chit- drerr (1995) Ir~tegratir~g Federal Statistics or Chit~rerr (with the Committee on National Statistics of the Na- tional Research Council) ~1995) Child Care for Low-Ir~come Families: Summary of Two Workshops (1995) New Firrdir~gs or Chit~rerr, Families, Arid Economic Self-Sufficier~cy: Summary of a Research Briefing (1995) The Impact of War or Child Health ire the Countries of the Former Yugoslavia: A Workshop Sum- mary (with the Institute of Medicine and the Office of International Affairs of the National Research Council) ~1995) 60

Cultural Diversity Arid Early Education: Report of a Workshop (1994) Benefits Arid Systems of Care for Maternal Arid Child Health: Workshop Highlights (with the Board on Health Promotion and Disease Prevention of the Institute of Meclicine) (1994) Protecting and Improving the Quality of Care for Children Under Health Care Reform: Workshop Highlights (with the Board on Health Promotion and Disease Prevention of the Institute of Meclicine) (1994) America's Fathers Arid Public Policy: Report of a Workshop (1994) Violence Arid the American Family: Report of a Workshop (1994) 61

The National Academy of Sciences is a private, nonprofit, self~perpetuating society of distin' guished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the char- ter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the Na' tional Academy of Sciences, as a parallel organization of outstanding engineers. It is autono' mous in its administration and in the selection of its members, sharing with the National Acad- emy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and educa- tion. Dr. Kenneth T. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in I 9 1 6 to associate the broad community of science and technology with the Academy's purposes of fur' thering knowledge and advising the federal government. Functioning in accordance with gen- eral policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering commu- nities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council. 62

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