Poverty & People with
Intellectual Disabilities
Eric Emerson
Institute for Health Research
Lancaster University
eric.emerson@lancaster.ac.uk
The Plan



What is poverty?
Why should we be concerned about poverty
and people with intellectual disabilities?
What are the implications for research, policy
& practice?
The Plan



What is poverty?
Why should we be concerned about poverty
and people with intellectual disabilities?
What are the implications for research, policy
& practice?
Absolute Poverty

‘A condition
characterised by severe
deprivation of basic
human needs, including
food, safe drinking
water, sanitation
facilities, health, shelter,
education and
information’
UN World Summit for Social
Development, Copenhagen
1995
Moderate & Severe Stunting
(Under 5s)
Pakistan
Mali
Niger
Bangladesh
Cambodia
Angola
India
Madagascar
Nepal
Ethiopia
Yemen
Afghanistan
0%
10%
20%
30%
40%
50%
60%
Relative Poverty

‘The inability, due to
lack of resources, to
participate in society
and to enjoy a standard
of living consistent with
human dignity and
social decency’
Child Poverty & Per Capita Gross
National Income in Rich Countries
25%
$60,000
Child Poverty
GNI (PC)
$50,000
20%
$40,000
15%
$30,000
10%
$20,000
5%
$10,000
Denmark
Finland
Norway
Sweden
France
Netherlands
Germany
Spain
Japan
Australia
Canada
UK
Ireland
Italy
$0
USA
0%
Rise & Fall in Child Poverty:
UK 1978-2005
40
35
25
20
15
10
5
04
02
00
98
96
94
92
90
88
86
84
82
80
0
78
% children
30
Poverty
Defined:
Living in
household
with less
than 60%
national
median
household
income
(after
housing
costs)
Poverty …

‘Fundamentally, poverty is a denial of choices
and opportunities, a violation of human
dignity. It means lack of basic capacity to
participate effectively in society.’
- UN Economic & Social Council (1998)
The Plan



What is poverty?
Why should we be concerned about poverty
and people with intellectual disabilities?
What are the implications for research, policy
& practice?
In General …

Poverty is related to





Mortality
General health
Mental health
Educational attainment
Life experiences and
opportunities
http://www.who.int/social_determinants/en/
average age at death 1838-1841
150 Years Ago …..
50
40
30
20
10
0
Liverpool Manchester
Leeds
Labourers
Farmers & Tradesmen
Gentry & Professionals
And Now …….
Male Life Expectancy by Occupational Status
England & Wales 1972-876 & 1997-2001
85
Social
Class
80
V
IV
IIIm
IIInm
II
I
75
70
65
60
55
1972-76
1997-01
Equivalised Household Income & Child
Mental Health in Britain 1999 & 2004
Conduct Disorder
Emotional Disorder
Anxiety Disorder
Depression
Specific Phobia
OCD
ADHD
PTSD
6
OR
5
4
3
2
1
1
2
3
4
Equivalised Income Quintile
5
What Processes Mediate & Moderate
the Link Between SEP and Health?
Accumulated
Risk of Exposure
Across the
Lifecourse
Physical Hazards
SEP
(cold/damp housing,
pollution, toxins,
poor nutrition)
Psychosocial
Hazards
(low status & control,
uncertainty,
‘life events’)
Health
Status
Poverty and Risk of Exposure
to Housing Hazards
Odds ratios >
overcrowding
cold
rising damp
mice/rats
condensation
water getting in
mould
1
2
3
4
Poverty and Risk of Exposure to
Potentially Adverse Life Events
Odds ratios > 1
Parental separation
Parental trouble with police
Bad fire
Saw severe domestic violence
Sexual abuse
Saw relative assaulted
Parent or sibling died
Serious assault
Child’s close friend died
Witnessed sudden death
Serious accident
2
3
4
What Processes Mediate & Moderate
the Link Between SEP and Health?
Accumulated
Risk of Exposure
Across the
Lifecourse
Physical Hazards
SEP
(cold/damp housing,
air pollution, toxins,
accidents, nutrition
arduous work)
Psychosocial
Hazards
(low status & control,
uncertainty,
‘life events’)
Vulnerability &
Resilience
Biological
(embedded organ or
system
weaknesses)
Psychosocial
(human capital,
social affiliations
& social capital)
Health Care
(including prevention)
Health
Status
The Plan



What is poverty?
Why should we be concerned about poverty
and people with intellectual disabilities?
What are the implications for research, policy
& practice?
Poverty and Intellectual
Disability

In high income
economies there is a
clear association
between poverty and the
incidence and
prevalence of
mild/moderate (but not
severe) intellectual
disability
Leonard, H., & Wen, X. (2002).
The epidemiology of mental
retardation: challenges and
opportunities in the new
millennium. Mental Retardation
and Developmental Disabilities
Research Reviews, 8, 117-134.
Leonard, H. et al., (2005).
Association of sociodemographic
characteristics of children with
intellectual disability in Western
Australia. Social Science &
Medicine, 60, 1499-1513.
Area Deprivation & Identification
of Developmental Disability
12%
Prevalence
10%
8%
MID
SID
PMID
ASD
6%
4%
2%
0%
1
2
3
4
5
6+
English Index of Depivation 2004 National Deciles
In General …

Intellectual
disability
Poverty is related to





Mortality
General health
Mental health
Educational attainment
Life experiences and
opportunities
http://www.who.int/social_determinants/en/
Equivalised Household Income & Conduct
Disorder Among British Children with
Intellectual Disabilities 1999 & 2004
40%
30%
20%
10%
1
2
3
4
Equivalised Income Quintile
5
Life Events & Emotional
Disorder
30%
No Life Event
1 Type of Life Event
2+ Types of Life Event
25%
20%
15%
10%
5%
0%
ID+ASD
ID noASD
no ID
http://www.ic.nhs.uk/pubs/learndiff2004
Poverty & Neighbourhood
Deprivation














Living in unsuitable
accommodation
Having less privacy at home
Unemployment
Not having a voluntary job
Not having enjoyed school
Being bullied at school
Not taking a course
Not attending a day centre
Not having control over money
Less likely to see members of
their family
Being an unpaid carer
Seeing friends less often
Doing a smaller range of
community activities
Not having voted














Not knowing about local
advocacy groups
Feeling unsafe
Being bullied
Being a victim of crime
Having poor health
Having a long-standing illness
or disability
Smoking
Not being happy
Being sad or worried
Feeling left out
Feeling helpless
Not feeling confident
Having unmet needs
Having wanted to complain
about the support they receive
Area Deprivation & Self-Rated Health
Adults with Intellectual Disability, England 2003/4
Health 'Not Good'
25%
20%
15%
10%
5%
0%
1
2
3
4
Area Deprivation Quintile
5
Attributable Risk

Controlling for increased
risks of exposure to potential
hazards accounts for



20-35% of the increased risk of
poor child health and mental
health
100% of the increased risk of
maternal unhappiness
50%+ of the increased risk of
maternal low self-esteem and
self-efficacy
Emerson, E., & Hatton, C. (in
press). American Journal on
Mental Retardation.
Emerson, E., & Hatton, C. (in
press). Journal of Intellectual
Disability Research
Emerson, E., Hatton, C., Blacher,
J., Llewellyn, G. & Graham, H.
(2006). Socio-economic position,
household composition, health
status and indicators of the wellbeing of mothers of children with
and without intellectual disability.
Journal of Intellectual Disability
Research 50, 862-873.
Obesity Among Women
45%
40%
35%
30%
25%
20%
15%
Women with ID
10%
Women
5%
Poorest 20% of Women
0%
16-24
25-34
35-44
45-54
55-64
65-74
75+
Obesity Among Women (in poverty)
45%
40%
35%
30%
25%
20%
15%
Women with ID
10%
Women
5%
Poorest 20% of Women
0%
16-24
25-34
35-44
45-54
55-64
65-74
75+
The Plan



What is poverty?
Why should we be concerned about poverty
and people with intellectual disabilities?
What are the implications for research, policy
& practice?


Delivery
Conceptualisation & design of ‘interventions’
Inequity of ‘Need’
% of British Children with Intellectual Disabilities &
Mental Health Problems by Family Circumstances
100%
Couple, not in poverty
75%
Lone parent, not in
poverty
Couple living in poverty
50%
25%
Lone parent living in
poverty
0%
British Families
British Familes with
Child with ID +
Conduct Disorder
Delivery Implications



Resource allocation
‘Goodness of fit’
Differential efficacy, effectiveness and
efficiency of interventions

Does this intervention reduce (or exacerbate)
inequalities?
‘financial disadvantage was the most salient moderator of outcomes’
of group-based behavioural parent training
Lundahl, B, Risser, H J, Lovejoy, M C (2006). A meta-analysis of parent
training: Moderators and follow-up effects. Clinical Psychology Review 26
(2006) 86– 104
Conceptualisation & Design
Accumulated
Risk of Exposure
Across the
Lifecourse
Physical Hazards
SEP
(cold/damp housing,
air pollution, toxins,
accidents, nutrition)
Psychosocial
Hazards
(low status & control,
uncertainty,
‘life events’)
Vulnerability &
Resilience
Biological
(embedded organ
weaknesses, fitness)
Psychosocial
(human capital,
social affiliations
& social capital)
Health Care
(including prevention)
Health
Status
Interventions

Generic risk reduction


Poverty reduction
Specific risk reduction
(mediating variables)



Housing quality
Parenting practices
Child protection
‘The reforms outlined in the Child
Poverty Review must be implemented
to end child deprivation and therefore
reduce risk factors for mental health
problems.’
Conceptualisation & Design
Accumulated
Risk of Exposure
Across the
Lifecourse
Physical Hazards
SEP
(cold/damp housing,
air pollution, toxins,
accidents, nutrition)
Psychosocial
Hazards
(low status & control,
uncertainty,
‘life events’)
Vulnerability &
Resilience
Biological
(embedded organ
weaknesses, fitness)
Psychosocial
(human capital,
social affiliations
& social capital)
Health Care
(including prevention)
Health
Status
Interventions:
Building Resilience



Individual
Family
Community









Nurturing, affectionate and secure
relationships with parent
Supportive relationship with other
adult
Positive, rewarding school
environments
Sense of ‘connectedness’ to the
school and/or local community
Positive personal achievements
Involvement in pro-social peer
groups
Positive ‘temperament’
Problem solving
Sense of meaning
In Conclusion ….


The health & social inequalities faced by people with
intellectual disabilities are, in part, the result of
poverty (rather than intellectual disability)
To address these inequalities we need to think
beyond social & clinical interventions and directly
address the social factors that generate inequality
eric.emerson@lancaster.ac.uk