When low-income parents enroll in Medicaid through the Affordable Care Act (ACA) state expansion program, their children have considerably better odds of receiving annual preventive care pediatrician visits, according to a new analysis by the University of Pittsburgh Graduate School of Public Health and Johns Hopkins University.
This “spillover effect,” explained in a study published online today and scheduled for the December issue of the journal Pediatrics, demonstrates that the potential benefits of Medicaid expansion extend beyond the newly covered adults.
“These findings are of great significance given the current uncertainty surrounding the future of the ACA and Medicaid expansions authorized by the law,” said senior author Eric T. Roberts, Ph.D., assistant professor in Pitt Public Health’s Department of Health Policy and Management. “Lawmakers crafting policy proposals that could curtail Medicaid benefits or eligibility should recognize that such efforts would not just limit the receipt of health care services by low-income adults, but also by their children.”
The ACA provided states the opportunity to expand Medicaid coverage to all low-income people at or below 138 percent of the federal poverty level. So far, 31 states and the District of Columbia have expanded Medicaid coverage.
Roberts and his colleagues identified 50,622 parent-child pairs from data collected in the 2001 through 2013 Medical Expenditure Panel Surveys, a nationally representative survey administered by the U.S. Department of Health & Human Services that includes detailed information on family structure and demographics, including health insurance status and health care use.
They discovered that children of parents who had recently enrolled in Medicaid had a 29 percent higher probability than children of unenrolled parents of receiving their well child visit, which is recommended annually for children age 3 and older, and more frequently for infants and toddlers.
During the visits, the children are examined for growth and development and given immunizations, and their caregivers are guided on proper nutrition and child behaviors. Studies have shown that children who get well child visits are more likely to receive all their immunizations and less likely to have avoidable hospitalizations. The U.S. has persistently low rates of well child visits, particularly in low-income families.
“There are many reasons that parental Medicaid coverage increases the likelihood of well child visits for their children,” said Roberts. “It could be that insurance enhances the parents’ ability to navigate the health care system for themselves and their children, increasing their comfort in scheduling well child visits. Medicaid enrollment could be a sort of ‘welcome mat,’ in which eligible but previously uninsured children are enrolled after their parents gain coverage. It also could be that parental Medicaid coverage frees up more money to provide preventive services to their children, because even copays can be a deterrent to medical care among low-income people.”
Maya Venkataramani, M.D., is lead author on this research, and Craig Evan Pollack, M.D., M.H.S., is a coauthor. Both are from the Johns Hopkins University School of Medicine.
Single Father Adopts Five Siblings from Foster Care System
Back in October of 2020, single father Robert Carter adopted a set of five siblings so that they would never again be separated by the foster care system. Robert became inspired to foster after being split up from many of his own brothers and sisters when he entered the system at the age of 12. Following his emancipation, Robert became legally responsible for two of his siblings, which inspired him to continue to expand his family. He became a foster father to three of the five siblings and quickly realized that it was his purpose to adopt all five children.
A Systemic Issue
There are currently over 400,000 children in the foster care system, two-thirds of whom have a sibling in the system as well. Many of these children are separated from their siblings for reasons including a lack of families able to foster sibling groups, diverse needs of children and lack of resources for finding placements. Other siblings may be more likely to be separated by social workers due to myths that sibling sets will not integrate as well into a new family dynamic or that it is in the best interests of a parentified older child to be removed from their siblings.
Sibling separations, like Carter and his children experienced, often compounds the trauma that children in the system endure. In a foster care system where 63% of children are removed from their homes due to parental neglect, sibling relationships help to provide much needed stability and emotional support. These sustained relationships allow sibling sets to have greater success in school, better relationships with foster parents, more successful permanency outcomes, and better mental health. Yet, until the last couple of decades, the advantages of keeping siblings together were largely ignored from a policy perspective.
In 2008 this changed when keeping siblings together became national priority when the Fostering Connections to Success and Increasing Adoptions Act was passed. This Act “requires a state plan to provide for reasonable efforts for joint placement of siblings in the same foster care, kinship guardianship, or adoptive placement unless it would be contrary to the safety or wellbeing of any of them.” This act also requires that children who are unable to be placed with their siblings be allowed frequent visits with their other siblings.
While sibling placement is defined as a priority on the federal level, states may interpret the implementation of a plan differently. As of 2018, only 37 states have statutes requiring these reasonable efforts to keep siblings together during the placement process. States may often vary in their definition of “sibling” as well. While children often define their siblings as those who grew up with them, including step-siblings, often state laws only define sibling relationships in terms of blood relations.
Certain states, such as Oregon, have a Sibling Bill of Rights to help protect children in the foster care system. Some of these rights include being able “to live in the same home as (their) sibling if possible” and “to live with foster parents who are trained on the importance of sibling relationships.” Bills like these offer children autonomy and protection when entering the system so that they can advocate for themselves.
As laws continue to evolve to protect children in foster care like Robert and his kids, Robert hopes that foster and adoptive parents will step up to help keep families together. Here’s what he said in an interview with Aol.com:
“A lot of people think you have to be married to adopt or be a foster parent. I want people to know: No matter the situation, as long as you have the means to take care of a child [you can] become a foster parent,” he explains. “We have so many kids still in custody, there are 400 kids in Ohio waiting on forever homes. And I am happy that I was able to help encourage and inspire other people to step up.”
Currently, over 100,000 children are to be adopted, many of which risk being separated from their siblings. You can help to keep these children together by becoming a foster parent for a sibling set and learning more about the adoption process.
If you are unable to adopt or foster right now, research your state’s sibling protection measures and help advocate for policies that support sibling reunification.
Protecting Children from Harm in the Context of Distance Learning
The nation saw an uptick in domestic violence calls in the midst of the pandemic and the shutdown. The convergence of social isolation, economic pressure, and psychological stress created favorable conditions for abuse to occur. Adults are not the only victims of abuse in the home. Children, too, are vulnerable. History shows that violence against children and child exploitation intensify under conditions of isolation and economic pressure. While the pandemic may be temporary, child abuse often has long-term consequences.
School systems play a vital role in intervening in the lives of vulnerable children. In fact, schools make 21% of the reports to child protective services according to The Washington Post. When COVID-19 forced the schools to close, states saw a drastic drop in the number of children being referred to CPS. Unfortunately, this reduction did not mean that the incidence of abuse decreased. Indeed, as reports to CPS dropped, ER doctors saw a rise in more severe cases of abuse. Child abuse not only persisted, but it went unchecked during the shutdown. Without school personnel, community workers, medical and dental personnel, and other mandated reporters, there was no watchdog to report the abuse until children sustained injuries severe enough to warrant medical attention.
Clearly, schools serve a vital function in protecting children from harm. Now more than ever, they need to be alert and responsive to abuse as children return to school virtually. Distance learning presents unique opportunities and challenges that should be addressed proactively. Social workers can and should play a leadership role in adapting child welfare protocols for distance learning and retraining school personnel to identify and report suspicions of child abuse and neglect. This article outlines a proposed curriculum for child abuse and neglect reporting in the context of distance learning.
School personnel should be well-equipped to spot signs of child abuse and neglect in the context of distance learning. Asynchronous instruction affords teachers a glimpse into students’ homes. In addition to any disclosures of abuse, teachers should be especially attentive to:
- Verbal threats of harm, hidden, unexplained, suspicious, and/or repeated injuries
- Suicidal ideation in students
- Sexually inappropriate behaviors or images
- Weariness when an adult is present or approaches the student
- Excessive dirtiness or lack of proper hygiene in the home or the student
- Illegal substances or evidence of impairment in the caregiver
- Evidence of malnourishment in the student
School staff should also note that it is illegal under most state laws for children to be home alone unless they have demonstrated sufficient maturity, and there are safety structures in place. Young children should not be home alone. Furthermore, children with a record of behavior or emotional problems (e.g. frequent suspensions) should not be in the home unattended. Children who are able to be home alone should be able to access safe adults in case of an emergency, and there should not be hazardous conditions or items present. Children who can take care of themselves may not be mature enough or capable of taking care of younger children. School staff members play a critical role in monitoring these conditions. Clear steps should be outlined for reporting any safety concerns or suspicions in a timely and accurate manner to school personnel (e.g. principal, guidance counselor) and child protective services.
Because teachers will be exposed to the live conditions of the home, they have to be prepared to respond to crisis situations. Crisis management in the context of distance learning is different from that in more traditional settings because the staff person is physically distant from the student, and there may not be another adult present with the child for reinforcement. As a result, they are at a disadvantage in terms of their ability to intervene.
Still, there are measures staff can take to manage the crisis from afar. In the event of an imminent threat to the safety of a student, staff can adapt telehealth protocols such as:
(1) call local 911/EMS while maintaining contact with the student
(2) identify bystanders who may be able to assist by providing information, monitoring the student, and/or intervening, as appropriate
(3) obtain the student’s physical location, an alternate contact in case of a disconnection or other technical issue, and contact information for the student’s caregiver
(4) while maintaining contact with the student, contact the caregiver to advise him/her of the situation
School personnel has an important responsibility in monitoring student attendance. Countless children can be lost to human trafficking and exploitation if schools falter in this duty. As such, the onus is on the schools to locate children who do not report for school. Students should be expected, at a minimum, to check in occasionally so that school personnel can check on their well-being.
Finally, school administrators should be cognizant of the increased risk of exploitation by school staff when supervision and monitoring are lacking. Clear codes of conduct should be put in place or adapted to guide online interactions between students and school staff. Outside meetups should be prohibited unless they occur at school during school hours with proper supervision. Administrators should ‘‘float’’ from class to class to monitor interactions and conduct in the virtual classrooms. Caregivers should also be encouraged to monitor online learning. An adult should be present at all times during synchronous sessions to supervise and provide support.
Schools play a critical role in protecting our most vulnerable population. Critical attention should be given to adapting child welfare protocols for distance learning so that school personnel can make the necessary efforts to be effective in this capacity under these unprecedented conditions. Social workers should proactively address this issue and retrain school staff in child welfare protocols.
Normal Childhood Behaviour Misconstrued and How Assessments Are Helpful
There is a quote attributed to Sigmund Freud, “Sometimes a cigar is just a cigar”. So too of childhood behaviour and incidents; they may be simply within the range of normal childhood life. However, in the context of high conflict separated parents, the simple explanation can get transplanted with extraordinary suspicions and theories.
Normal childhood development has toddler-age children exploring their bodies, discovering the genitals and anus and taking pleasure from self-touching. They are at the toilet training stage of life and hence are drawn by normal parenting behaviour to attend to these body parts. In intact families as children are observed to engage in self-stimulation and genital play, they are simply redirected to either stop or to engage privately at appropriate time and place. In the context of high conflict separated parents, there is a risk to ascribe these childhood behaviours to sinister behaviour on the part of one of the parents. So a parent may inadvertently bring greater attention to the child’s behaviour and thus actually reinforce the concerning behaviour themselves while at the same time alleging sexual abuse at the hands of the other parent.
As preschoolers, children take flight on playground equipment. They may be learning to ride their two-wheeler. Hence this is a time of childhood injuries, particularly bruises, bumped heads and broken arms. In the context of high conflict separated parents, a parent may be suspicious of child-abuse in view of injuries and use the situation to allege physical abuse or at least neglect. However, and again, even in intact families, children can get hurt; bump their heads and fall from bikes and playground equipment.
As school-age children try to get their own way, they naturally try to pit parents against each other. They will use whatever strategy works. Kids may tell you that other kids are getting or doing what is desired or they may tell you that the “other parent” let’s them do as requested. In intact families, parents simply call their children on manipulative behaviour or at least check with the other parent to determine if what the child is saying is true. However, in the context of high conflict separated parents, a parent may take what a child says at face value and believe that the other parent is undermining their own parenting or the values of the child.
In intact families or even between separated parents with good communication, normal childhood events tend not to escalate with suspicion and drama. Issues are nipped in the bud and children are redirected to appropriate behaviour. Injuries are attended to without additional fanfare. A parent may feel guilty for a child’s injury, but not blamed per se.
In the context of high conflict separated parents, normal childhood behaviour and incidents can take on epic proportions. Otherwise, normal behaviour can lead to suspicion or be used against a parent to undermine care and custody. As one parent cries foul, the other cries parental alienation syndrome. The fight is on and heats up to the point of boiling over. The child is caught in the middle and their behaviour escalates as a result. Both parents then use the child’s behaviour as evidence of their own claim against the other.
Here is where a good assessment is so necessary. The assessor will tease out normal from abnormal childhood behaviour and incidents and determine how much of a child’s behaviour is attributable to just the conflict between the parents versus truly sinister behaviour deliberately aimed at harming or neglecting a child.
Parents beware though. Sometimes a cigar is just a cigar, despite suspicion.
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