Addressing Parent Employment as an Essential Issue in Child Health.

Abstract

In this issue of Pediatrics, Foster et al1 address the often unseen and pressing reality of the economic impact that having a child with special health care needs (CSHCN) has on families. Using data from the 2016–2017 National Survey of Children’s Health, the authors specifically address foregone family employment (FFE) and lost earnings.The numbers reported are sobering: FFE occurs in 14.5% of employed families of CSHCNs and skyrockets to 40.9% for those who have children with intellectual disability, seeming to correlate to the number of hours families raising CSHCNs must dedicate to caring for their child. Viewed through an equity lens, the authors’ findings become even more pointed. Those who have public insurance, are of Hispanic ethnicity, or whose children are younger, have functional limitations, or medical complexity seem particularly vulnerable.We know from the existing literature, well referenced by the authors, that social determinants of health (SDOHs), including family income, can directly impact health outcomes for a child.2,3 The estimated annual household loss of $18 000 among families caring for CSHCNs calculated by Foster et al1 may affect family stability in ways that resonate beyond the specific day-to-day care of the child affected, driving additional key concerns such as food insecurity and access to shelter, increasing the risk of negative health outcomes. The national aggregate lost income is staggering, estimated at $9 to $19 billion annually. However, the consequences of FFE are not confined to loss of income.4 They include decreased contributions to Social Security, lack of access to private health insurance, reduced asset acquisition, and opportunity costs related to career advancement. Because women are more likely than men to leave work to care for a CSHCN, they experience these negative impacts disproportionately. The numbers and trends Foster et al1 identify should spark further discussion about how our health care system can both better identify those families raising CSHCNs at risk for economic strain and, by extension, better support them.5The study has important implications for public policy and practice change. Strategies for policy makers may include the following6: Although policy change must be prioritized, health care providers can also address FFE from a boots-on-the-ground perspective within local practice constructs and communities.7–10 Some families may be reluctant to declare or seek help. This may be because of perceived or actual discrimination. At the level of individual patient care, the study’s findings suggest that providers consider each of the following: Foster et al1 have shined a light on an important, often overlooked stressor for families of CSHCNs. Even if providers screen diligently for SDOHs, only half of the current SDOH tools include FFE,11 further reflecting the invisible threat of FFE and calling for modification to existing tools. If we can improve our capacity to identify FFE in families caring for CSHCNs and implement the policy and practice recommendations outlined above, it is possible to imagine positive downstream effects on parent and child health, quality of life, wellness, functional outcomes, and even decreased health care system burdens as children are cared for more effectively in their communities and caregivers are able to work.