Disadvantaged Children

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By Ellen L. Lipman and David R. Offord
32                 Disadvantaged Children
                     Prepared by Ellen L. Lipman, MD, FRCPC1 and David R. Offord,
                     MD, FRCPC2

                                 Identification of disadvantaged children as an at-risk group
                          for the Periodic Health Examination is very appropriate since
                          there are currently over a million economically disadvantaged
                          children in Canada. These children are at increased risk of
                          morbidity and mortality, and may experience lifelong difficulties.
                          Physician contact with disadvantaged children and their families
                          is inevitable in most family practices, providing opportunities for
                          health maintenance, detection of high-risk conditions, and
                          appropriate interventions. Few studies have specifically examined
                          primary care health maintenance among poor children. This
                          chapter reviews the associations between socio-economic
                          disadvantage and increased health risks and the evidence for
                          effectiveness of selected interventions including public advocacy
                          and multi-agency initiatives.

                          Burden of Suffering
                                  The term disadvantage, as used here, refers principally to
                          economic disadvantage or poverty. By definition, a child living in
                          poverty in Canada lives in a family whose income is at or below the
                          Statistics Canada low income cut-off.<1> In 1991, this definition
                          identified those families spending greater than 58.5% of their income
                          on food, shelter or clothing. The absolute value of the low income
                          cutoff or poverty line varies with the size of the family and the place of
                          residence. In addition to families below the low-income cutoff, there is
                          a group of children living in families who are near poor, whose
                          incomes fall only 10-20% above the Statistics Canada low income cut-
                          off, and who differ little from those at the poverty line. Not all studies
                          examining poor children use this poverty line, but instead may use
                          more general measures such as level of income, area of residence, or
                          eligibility for subsidies.
                                  In Canada, the rates of child poverty have remained at the
                          significant level of 16% over a 15-year span (1973-1988).<2> In 1988,
                          this was estimated to represent over a million children under 18 years
With over one million     of age.<2> More recent figures suggest the current rate may be even
children in Canada,
the burden of                   Children who grow up in economically disadvantaged
suffering is              circumstances are at increased risk for morbidity and
substantial for current   mortality.<2,4-7> The mortality rate among children in the lowest
and future morbidity
                              Assistant Professor of Psychiatry, McMaster University, Hamilton, Ontario
                              Professor of Psychiatry, McMaster University, Hamilton, Ontario

income quintile is twice that of those in the highest income
quintile.<2> The increased morbidity among these economically
disadvantaged children includes physical, emotional, social and
educational health deficits.
       Higher rates of chronic health problems have been found in
children from poor families (i.e., whose income fell below the official
Statistics Canada poverty line).<4> High morbidity and mortality rates
have also been documented for treatable diseases such as asthma in
children living in poor inner city areas.<5>
       A significant association between economic disadvantage
(measured by low income or parental welfare status) and child
psychiatric disorders has also been demonstrated.<6,7> The risk of a
poor boy, aged 6 to 11 years, having one or more psychiatric
difficulties such as attention deficit hyperactivity disorder, conduct
disorder or emotional disorder, was four times that of a non-poor boy
(33 of 82 welfare boys with psychiatric difficulties vs. 187/1348 non-
welfare boys).<6>
      Similar associations have been demonstrated in the educational
and social spheres,<7> including poor school readiness,<8> low math
concept skills in the early grades<9> and later difficulties such as failing
a grade or use of special education services.<7>
       Disadvantaged children are clearly at increased risk for a wide
range of health and psychosocial morbidities. A poor child may have
difficulties in any of the physical, emotional, social or educational
domains. Having any single deficit increases the likelihood of having
other difficulties, so poor children tend to have multiple morbidities.
       While the term “disadvantaged child” is being used
interchangeably with “poor child” in this document, the actual
disadvantage goes beyond a simple lack of money to include the
context in which the child grows up. This includes such features as the
characteristics of the family, neighbourhood and schools and the
availability of preschool or recreational facilities. Characteristics of
poor families include a family head with relatively little formal
education, younger family heads, single parents, especially single
mothers, and unemployed parents. Poor parents also have increased
rates of physical or mental health problems. In terms of environmental
circumstances, inadequate housing, unsafe neighbourhoods,
neighbourhoods lacking in community resources or good schools, and
homes lacking material resources or stimulation may be consequences
of poverty. Each of these circumstances may have a negative impact on
child growth and development. In turn, there is evidence that early
interventions for children, such as an excellent preschool program,
may have long-term beneficial effects that last into adulthood.<10>
      The societal burden of suffering associated with child poverty in
Canada is enormous, and continues to diminish opportunities for poor
children as they grow. The mental and physical difficulties they

                         experience do not necessarily resolve as they grow up. Instead, they
                         may become adults with impairments in the physical, emotional, social,
                         and occupational spheres. For example, approximately 40% of children
                         with conduct disorder continue to experience serious psychosocial
                         difficulties into adulthood.<11> This substantial lifelong impairment
                         experienced by some poor children amounts to a large cost to society
                         in areas such as physical and mental health costs, decreased
                         occupational productivity, or use of social services.
                                Three maneuvers for assisting disadvantaged children will be
                         discussed: contact in the family practitioners’ office, referrals made by
                         family physicians for child and parent assistance in the home and
                         community, and advocacy by physicians and multi-agency initiatives.

                         Office Contact
                                Physician contact with disadvantaged children and their families
                         is inevitable in most family practices. Office visits will likely be the most
                         regular source of contact. Primary care contacts provide the
Family physicians        opportunity for health maintenance, detection of high-risk conditions
can provide
                         and intervention from infancy through the life span. Issues arising
children with
                         during office encounters discussed in this section are considered in
preventive               terms of developmental stages of the child, and the context or
interventions known      environment in which the child lives.
to be effective in the
general population
                         Developmental Stages
                                There is no evidence that risk factors among poor children have
                         different effects than they do among other children in the general
                         population. However, exposure to multiple risk factors is more
                         prevalent among poor children, thereby increasing associated
                         detrimental outcomes. Maintaining an awareness of general risk factors
                         as well as those with increased prevalence among disadvantaged
                         populations will allow a family doctor to provide optimal care. Selected
                         risk factors that are more prevalent among poor children are discussed

                         Prenatal Care
                                Adequate prenatal care for a poor mother is the first step in
                         promoting the health of the disadvantaged child-to-be. Low-income
                         mothers who have received inadequate prenatal care frequently give
                         birth to low birth weight babies. Low birth weight is a major
                         determinant of infant mortality, and can have major health
                         consequences for babies who survive including serious illnesses,
                         developmental disorders and lifelong handicapping conditions such as

birth defects, mental retardation, cerebral palsy, and seizure
disorders.<12> In addition to inadequate prenatal care, factors
influencing low birth weight include poor nutrition, maternal prenatal
stress, insufficient weight gain during pregnancy, drug and alcohol
abuse, smoking, and obstetrical complications. Low birth weight is
largely preventable, with an estimated 80% of women at risk
identifiable at the first prenatal visit, allowing interventions to begin
then to decrease the risks to the unborn child and mother.<12>
Separate chapters on smoking during pregnancy (Chapter 3),
prevention of low birth weight (Chapter 4) and preeclampsia
(Chapter 13) are included in this volume but these reviews do not
target the poor population specifically.

       Proper nutrition may be an issue in poor families due to such
factors as inadequate funds for food, or poor knowledge of nutrition.
Both types of growth disturbance, growth failure and obesity, have
been documented among poor children.<13,14> Discussion of
nutritional issues and monitoring of growth parameters is important,
although mixed evidence has been presented regarding the association
of poverty and retarded somatic growth.<13,14> In a case series of
82 children where anthropometric measures were found to be related
to poor academic achievement, it was thought that environmental
influences affected both the development of thought processes, and
nutrient intake and therefore growth.<13> In 1979 the Canadian Task
Force on the Periodic Health Examination found good evidence for
prevention and treatment of malnutrition in high-risk populations, but
poor children were not specifically studied as a high-risk population.
The evidence for screening and treatment of another possible
consequence of poor nutrition, iron-deficiency anemia, was fair in
disadvantaged infants (also see Chapters 6 and 23).
       Increased attention to preventable diseases should be maintained
for low-income children and families. Increased morbidity from acute
illnesses, such as asthma or infectious diseases, and maintenance of
regular immunizations may be issues. There is good evidence from
randomized control trials for effective prevention for immunizable
infectious diseases by immunization (Chapter 33).<15> Prevention and
treatment of hearing and vision problems (Chapter 27) should also be
considered, although the general evidence for the effectiveness of
prevention and treatment of these difficulties is less rigorous in general
populations. Effectiveness specifically in poor populations has not been
reviewed. Chronic medical illness has also been associated with
poverty in children,<4> although this association has not been
consistently demonstrated world-wide.<14>

      Context (Environment)
             Homelessness, or exposure to marginal or aged housing poses
      risks associated with inadequate shelter, or overcrowding. As well,
      specific health risks exist such as exposure to lead (e.g., through
      exposure to lead-based paint; see Chapter 25) with its hematologic
      and potential neurologic sequelae despite an asymptomatic clinical
             Evaluation of a poor child necessitates an understanding and
      appreciation of the context in which the child lives. Knowledge of the
      family and demographic history may alert the physician to possible
      problems. For example, chronic sociodemographic disadvantage, low
      maternal education, low family income, and poor family functioning
      have been shown to be associated with developmental delay, and
      psychosocial problems such as psychiatric, chronic health, social and
      educational difficulties.<7,17> Awareness that a family has these risk
      factors should increase vigilance for any of the above listed difficulties.
             Careful attention to a poor child’s family, and especially the
      primary caregiver, is needed. In a study of 155 children of single
      mothers recruited through social services and a local school in the
      U.S., economic hardship was found to be unrelated directly to child
      psychological functioning, but was related to mother’s psychological
      functioning which was in turn related to their child’s psychological
      functioning.<18> This highlights the need to assist poor mothers as
      well as their children since children are highly sensitive to their
      parents’ emotional states. Other maternal difficulties which may
      influence the child, and also may necessitate maternal interventions
      include psychiatric disorders, tobacco and other drug and alcohol use.
      Current evidence for the effectiveness of prevention and treatment of
      psychiatric disorders and substance use as part of the Periodic Health
      Examination, with the exception of problem drinking (Chapter 42) and
      tobacco use (Chapter 43), is poor, and these areas are considered
      research priorities.
             Three further points should be made. First, attention to language
      used, the nature of explanations given, reading material given, and
      attitude is important since all influence transmittal of information.
      Parents of disadvantaged children may themselves have low educational
      levels. Such parents require clear verbal explanations and literature
      written in easily understandable terms. There is evidence from the U.S.
      that poor families were more likely not to be completely satisfied with
      the primary care they received, and in particular, with the
      communication with the health care professional.<19> Second,
      consideration of drug costs, and whether medications are covered
      under drug plans such as those offered by welfare or family assistance,
      is important. Third, many poor parents do not feel comfortable in
      more formal or institutional settings such as a doctor’s or a school
      principal’s office. Primary practitioners can encourage parents to be

advocates for their children and to feel empowered to seek optimal
health and educational services for their children. There is evidence
that by bridging the social and cultural gaps between home and school,
a child’s academic achievement can be enhanced.<20>

Child and Parental Assistance in the Home or
       Studies in this area have focused on home- or community-based
programs aimed at assisting families with children deemed to be at high
risk for cognitive difficulties or developmental delay. Children have
been identified as being at high risk based on disadvantaged intellectual,
educational or social characteristics of the family.

Public Advocacy/Multi-Agency Initiatives
        Public advocacy for disadvantaged children or involvement in
multi-agency initiatives is beyond the scope of practice for many family
physicians. However, as more municipalities focus on community
initiatives for this (and other) disadvantaged populations, opportunities
for multi-agency involvement will increase. As the awareness of the
scope of morbidity, both immediate and long-term, for poor children
increases, the importance of public advocacy on behalf of these
children also increases.

Effectiveness of Treatment
Child and Parental Assistance in the Home or
       The strongest evidence available to support a parental assistance
program is found for community-based assistance to the parent and
child. In one of only two randomized controlled trials available,
65 high-risk families were randomly allocated to one of three groups at      There is good
                                                                             evidence to support
the time of their child’s birth.<21> Risk categorization was determined
based on parental age and education, family income, maternal IQ,             specialized day care
absence of father, poor school performance of siblings and other             or preschool
factors. One group were assigned to a Child Development Centre, a            programs for poor
day care setting with a systematic developmental curriculum                  children
specialized in addressing cognitive and social difficulties, and family
education, a home-based program to help parents foster appropriate
cognitive and social development of their child. Notably the Child
Development Centre also reserved spaced for non-high-risk children
to have a socioeconomically diverse program. The Child Development
program also had low teacher/child ratios, staff with considerable
child-care experience, and provided staff training. An emphasis was put

      on intellectual/creative and social/emotional activities, and language
      stimulation. The second group of families received family education
      only, and the third acted as a control group. Follow-up of over 90% of
      enrolled families covered 54 months. Children in the group receiving
      combined educational day care and family education did significantly
      better (p<0.05) in cognitive performance than those with either of the
      other interventions (Bayley Scales of Infant Development at 12 and
      18 months, Stanford-Binet Intelligence Test at 24, 36 and 48 months
      and the McCarthy Scales of Children’s Abilities at 30, 42 and
      54 months). Family education alone was not felt to be a sufficient
      intervention. The observed lack of effectiveness of family education
      alone is in contrast with results of other work, and the authors suggest
      that this difference may be related to factors such as intensity of
      training for home visitors and number of visits, or that short-term
      follow-up may not have detected potential later benefits. A weakness
      of this study is the lack of clarity about how families were recruited.
             Martin and colleagues<22> estimated the effects of an
      experimental educational day-care program in the intellectual
      development of 86 preschoolers from high-risk families in a
      randomized controlled trial. High-risk status was determined by an
      index of risk factors for intellectual impairment. Children were
      allocated to the experimental or control groups between 6 and
      12 weeks of age and remained in day care to 54 months (80% follow-
      up). The experimental program was designed to promote social and
      cognitive growth in an orderly, friendly environment. The IQs of
      experimental program children ranged from 8 to 20 points higher than
      those of control children and were higher on average (when maternal
      mental retardation and home environment were controlled p<0.0001).
      At 54 months, 93% of the experimental children and 69% of the
      control children had IQs within the normal range. There was an
      especially strong apparent effect on the IQs of children born to
      mentally retarded mothers, with none of the experimental children of
      retarded mothers having a subnormal IQ, but 6 of 7 control children of
      retarded mothers having subnormal IQ. Teenaged mothers in the
      experimental group were also found to be significantly more likely to
      have graduated from high school and to be self-supporting at the
      54-month evaluation than were mothers in the control group.
             Lee and co-workers<23> examined the longitudinal effects of an
      enriched preschool program aimed at disadvantaged black children
      (Head Start) vs. no preschool or other preschool programs for
      disadvantaged children using data from the National Longitudinal Study
      of Youth. Immediately after the program (one year follow-up), Head
      Start gains were favourable to both comparison groups. Beneficial
      effects were sustained into kindergarten and grade 1 for the Head
      Start program. These benefits were more pronounced when Head
      Start children were compared with children with no preschool
      experience, than when they were compared with children in other
      preschool programs. The authors suggest that this showed a beneficial

effect of any preschool experience as compared to no preschool
experience, rather than a benefit of Head Start per se.
       Two other studies, including the only Canadian work identified
from the MEDLINE search, provided descriptions of program
development for home visiting or outreach programs for
disadvantaged pregnant women<24> or low income mothers and
infants.<25> Unfortunately, neither provided data evaluating
outcomes. However, home visiting has been shown to prevent child
maltreatment in American studies and is recommended by the Task
Force during the perinatal period through infancy for families of low
socioeconomic status, single parenthood or teenaged parenthood
(A Recommendation – Chapter 29).
       Halpern,<26> in a descriptive paper, outlined the need to
address contextual factors impinging on parenting and child
development, and warned not to expect parenting interventions to
alter significantly the life chances of low income children. He noted,
however, that there was evidence of a positive effect of parenting
interventions. In some cases, increasingly positive parent-child relations
were prompted through such programs.

Public Advocacy/Multi-Agency Initiatives
       A series of descriptive and discussion papers supports the need
for public advocacy and multi-agency initiatives. Recommendations for
successful interventions include use of socioeconomic/cultural
models vs. a purely medical model, assisting poor families to change         There is an
                                                                             increasing interest in
their economic, and cultural beliefs and attitudes about health, linking
                                                                             public advocacy and
educational and day care issues with access to preventive care, use of       multi-agency
flexibility and collaborative spirit in these initiatives, providing         initiatives to assist
programs for poor children and their families together, and changing         disadvantaged
government funding and policy around issues related to poor children         children
and families. A strong plea has also gone out for increased funding of
rigorous research to contribute to the solution of the medicosocial
problems of these children.<27>
      Schorr<28> provides evidence of improved child outcome for
children from programs that cut across traditional professional and
bureaucratic boundaries, emphasize relationships of trust and respect,
are deeply rooted in the community, are family focused, and that
recognize the distinctive needs of those most at risk. In her discussion
of the “cycle of disadvantage” she provides specific examples of
successful U.S. programs that seem to meet these criteria. No
systematic or scientific evaluation of similar Canadian programs was
encountered in the literature reviewed. The Sparrow Lake Alliance in
Ontario is working actively toward improving consultation and
integration of children’s services in the province. Its members include
medical, community and government personnel. Initiatives promoted
by the Alliance include an inner city outreach program which includes

      school, psychiatric and educational involvement, and a joining of
      personnel working in the adult addictions field and in the child care
      area to work with substance-using women and their children. No
      systematic evaluation of this program is available to date.

      Recommendations of Others
            Several advocacy groups have disadvantaged children as a specific
      focus. In Canada, these include the Child Poverty Action Group, and
      Campaign 2000, a nonpartisan national initiative to end child poverty in
      Canada by the year 2000. A number of other advocacy and research
      groups have an interest in this important area including, among others,
      the Canadian Academy of Child Psychiatry, the Canadian Pediatric
      Society, the Canadian Council on Children and Youth, the Canadian
      Council on Social Development, Canadian Child Welfare Association
      and the Centre for Studies of Children at Risk.
              Most of the above agencies or groups have not made specific
      recommendations pertaining to the health and well-being of poor
      children. An exception is Campaign 2000, with its stated goal to
      eliminate child poverty. The only specific recommendations
      encountered came from the Society for Pediatric Research in the U.S.
      which outlined an 11-point plan to help solve health and other
      problems of poor children, and which included recognition of the
      importance of research, especially funding for long-term research

      Conclusions and Recommendations
             No specific studies have examined the effectiveness of preventive
      interventions during regular office contact between family physicians
      and disadvantaged children. Evidence from the general population
      exists to support efforts to prevent low birth weight, malnutrition in
      pregnant mothers and children, promote immunization, and identify
      hearing and vision problems. Awareness of other health risks such as
      homelessness, chronic medical problems and maternal difficulties
      should prompt efforts to prevent subsequent problems for children.
      These issues, however, have not been specifically studied among poor
      children (C Recommendation).
            There is good evidence to support recommendations for
      specialized day care or preschool programs for disadvantaged
      children, particularly programs specially designed for this group
      (A Recommendation). There is insufficient evidence to recommend for
      or against home-based parenting programs for disadvantaged children
      and families (C Recommendation).
             There is an increasing interest in public advocacy for
      disadvantaged children, and in developing multi-agency initiatives to
      assist these children. While individual family physicians may take an

interest in such initiatives, these lie outside the context of the Periodic
Health Examination.

Unanswered Questions (Research Agenda)
The following have been identified as research priorities:
 1.   Evaluating the effectiveness of specific screening interventions
      (e.g., for lead poisoning) in poor children.
 2.   Evaluating specific interventions for a disadvantaged child’s
      mother (e.g., treatment of psychiatric disorder) in terms of its
      effect on the child.
 3.   Evaluating the effectiveness of other community-based
      interventions aimed at poor children (e.g., recreation programs
      or after-school programs).
 4.   Developing new and identifying pre-existing multi-agency
      collaborative programs involving physicians and government or
      educational personnel, and evaluating the effectiveness of these
      programs on the health and well-being of disadvantaged children.

      The literature was identified with a MEDLINE search from
January 1984 to December 1992 using the following key words:
unemployment, poverty, medical indigency, minority groups.
     This review was initiated in January 1994 and the
recommendations finalized by the Task Force in March 1994.

      Ellen Lipman was supported by a Research Training Fellowship
from the Ontario Mental Health Foundation. David Offord was
supported by a National Health Scientist Award from Health Canada.
The Task Force thanks Sarah Shea, MD, FRCPC, Assistant Professor,
Department of Pediatrics, Dalhousie University, Halifax, NS, for
reviewing the draft report.

Selected References
 1.   Statistics Canada low income cut-offs. Income distribution by
      size in Canada (Cat. No. 13-207), Statistics Canada, Ottawa,
      1983: 32
 2.   Ross D, Shillington R: Children in poverty: toward a better
      future. Ottawa: Standing Senate Committee on Social Affairs,
      Science and Technology, 1991

       3.   Health and Welfare Canada: Countdown to the year
            2000 Healthy Canada. Maclean’s 1993; 106, Supplement: 8
       4.   Cadman D, Boyle MH, Offord DR, et al : Chronic illness and
            functional limitations in Ontario children: findings of the Ontario
            Child Health Study. Can Med Assoc J 1986; 135: 761-767
       5.   Weiss KB, Gergen PJ, Crain EF: Inner-city asthma. The
            epidemiology of an emerging US public health concern. Chest
            1992; 101(6 Suppl): 3625-3675
       6.   Offord DR, Boyle MH, Jones BR: Psychiatric disorder and poor
            school performance among welfare children in Ontario. Can
            J Psychiatry 1987; 32: 518-525
       7.   Lipman EL, Offord DR, Boyle MH: Economic disadvantage and
            child psychosocial morbidity. Can Med Assoc J 1994;
            151: 431-437
       8.   Hinshaw SP: Externalizing behaviour problems and academic
            underachievement in childhood and adolescence: causal
            relationships and underlying mechanisms. Psychol Bull 1992;
            111: 127-155
       9.   Entwisle DR, Alexander KL: Beginning school math
            competence: minority and majority comparisons. Child Dev
            1990; 61: 454-471
      10.   Schweinhart L, Weikart D, Lamer M: Consequences of three
            preschool curriculum models through age 15. Early Childhood
            Res Quarterly 1986; 1: 15-45
      11.   Offord DR, Bennet K: Prevention and treatment of conduct
            disorder: a critical review. J Am Acad Child Adolesc Psychiatry
            (In press)
      12.   Oberg CN: Medically uninsured children in the United States: a
            challenge to public policy. J Sch Health 1990; 60: 493-500
      13.   Karp R, Martin R, Sewell T, et al : Growth and academic
            achievement in inner-city kindergarten children. The relationship
            of height, weight, cognitive ability and neurodevelopmental
            level. Clin Pediatr Phila 1992; 31: 336-340
      14.   Carmichael A, Williams HE, Picot SG: Growth patterns, health
            and illness in preschool children from a multi-ethnic, poor socio-
            economic status municipality of Melbourne. J Paediatr Child
            Health 1990; 26: 136-141
      15.   Canadian Task Force on the Periodic Health Examination:
            The periodic health examination. Can Med Assoc J 1979;
            121: 1193-1254
      16.   Landrigan PJ: Health effects of environmental toxins in deficient
            housing. Bull NY Acad Med 1990; 66: 491-499
      17.   Najman JM, Bor W, Morrison J, et al : Child developmental
            delay and socio-economic disadvantage in Australia: a
            longitudinal study. Soc Sci Med 1992; 34: 829-835
      18.   McLoyd VC, Wilson L: Maternal behaviour, social support and
            economic conditions as predictors of distress in children. New
            Dir Child Dev 1990; 16: 49-69

19.   Wood DL, Corey C, Freeman HE, et al : Are poor families
      satisfied with the medical care their children receive? Pediatrics
      1992; 90: 66-70
20.   Comer JP: Educating poor minority children. Scientific American
      1988; 259: 42-48
21.   Wasik BH, Ramey CT, Bryant DM, et al : A longitudinal study of
      two early intervention strategies: Project CARE. Child Dev
      1990; 61: 1682-1696
22.   Martin SL, Ramey CT, Ramey S: The prevention of intellectual
      impairment in children of impoverished families: findings of a
      randomized trial of educational day care. Am J Public Health
      1990; 80: 844-847
23.   Lee VE, Brooks-Gunn J, Schnur E, et al : Are Head Start effects
      sustained? A longitudinal follow-up comparison of
      disadvantaged children attending Head Start, no preschool, and
      other preschool programs. Child Dev 1990; 61: 495-507
24.   Woodard GRB, Edouard L: Reaching out: a community initiative
      for disadvantaged pregnant women. Can J Public Health 1992;
      83: 188-190
25.   Poland ML, Giblin PT, Waller JB, et al : Development of a
      paraprofessional home visiting program for low-income mothers
      and infants. Am J Prev Med 1991; 7: 204-207
26.   Halpern R: Poverty and early childhood parenting: toward a
      framework for intervention. Am J Orthopsychiatry 1990;
      60: 6-18
27.   Kohl S: The challenge of care for the poor child: The research
      agenda. Am J Dis Child 1991; 145: 542-543
28.   Schorr LB: Children, families and the cycle of disadvantage.
      Can J Psychiatry 1991; 36: 437-441

        S    U   M   M      A   R Y         T   A    B     L   E     C   H   A   P     T   E   R     3 2

                                   Disadvantaged Children

  MANEUVER                      EFFECTIVENESS                  LEVEL OF EVIDENCE           RECOMMENDATION
  Office contact with the       Routine primary care                                       Poor evidence to
  primary care physician        has not been                                               include or exclude
  with a focus on risk          evaluated. No studies                                      specific maneuvers for
  factors for                   with a specific focus                                      poor children (C)*
  disadvantaged children        on disadvantaged

  Child and family              Enrolment in day care          Randomized controlled       Good evidence to
  assistance in the home        or preschool program           trials<21,22> (I)           include
  or community                  helpful, particularly in                                   recommendations for
                                specialized program                                        day care or preschool
                                for disadvantaged.                                         program for poor
                                                                                           children in periodic
                                                                                           health examination (A)

                                Home-based parenting           Comparisons between         Insufficient evidence
                                education program              places<21,23> (II-2)        to recommend for or
                                appears insufficient on                                    against home-based
                                its own, although                                          parenting
                                long-term evaluation                                       programs (C)

  *    Other Task Force recommendations on preventive health care for the general population should
       be followed (see Pediatric Preventive Care and Immunizations of Children and Adults). Also
       consider whether the children are at risk for iron deficiency anemia (Chapter 23), lead
       exposure (Chapter 25), or child maltreatment (Chapter 29).